WP-29576-ABCBS Second Quarter 2014 Small Group Rates

Transcription

Second Quarter 2014
Small Group Rate Tables
Table of Contents
Click on plan to navigate to page.
Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Anthem Premier Plans – PPO
Anthem Premier DirectAccess – gwaa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Anthem Premier DirectAccess – gyaa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Anthem Premier Plans – POS
Anthem HealthKeepers Premier DirectAccess – gwaa. . . . . . . . . . . . . . . . . . . . . . . . 0SN9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Anthem HealthKeepers Premier DirectAccess – gyaa . . . . . . . . . . . . . . . . . . . . . . . . 0SN2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Anthem Preferred Plans – PPO
Anthem Preferred DirectAccess – gjba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SN7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Anthem Preferred DirectAccess – ghfa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Anthem Preferred DirectAccess – gkfa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SN5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Anthem Preferred DirectAccess – gcga. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Anthem Preferred DirectAccess – gtga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Anthem Preferred DirectAccess – gyha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SNJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Anthem Preferred DirectAccess – gzha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SMY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Anthem Preferred DirectAccess – gbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SN0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Anthem Preferred DirectAccess – gaaf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Anthem Preferred DirectAccess – gpqa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Anthem Preferred DirectAccess – gqqa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SN6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Anthem Preferred DirectAccess – grqa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SP7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Anthem Preferred Plans – POS
Anthem HealthKeepers Preferred Guided Access Plus w/Dental – gtoa . . . . . . . . .0VUA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Anthem HealthKeepers Preferred Guided Access Plus – gtoa . . . . . . . . . . . . . . . . . 0W2U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Anthem HealthKeepers Preferred Guided Access Plus – gnbf . . . . . . . . . . . . . . . . . 0SN4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Anthem HealthKeepers Preferred DirectAccess – gjba . . . . . . . . . . . . . . . . . . . . . . . 0SN8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Anthem HealthKeepers Preferred DirectAccess – ghfa . . . . . . . . . . . . . . . . . . . . . . . 0SNC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Anthem HealthKeepers Preferred DirectAccess – gkfa . . . . . . . . . . . . . . . . . . . . . . . 0SND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Anthem HealthKeepers Preferred DirectAccess – gcga. . . . . . . . . . . . . . . . . . . . . . . 0SNF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Anthem HealthKeepers Preferred DirectAccess – gtga . . . . . . . . . . . . . . . . . . . . . . . 0SNH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Anthem HealthKeepers Preferred DirectAccess – gyha . . . . . . . . . . . . . . . . . . . . . . . 0SMZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Anthem HealthKeepers Preferred DirectAccess – gzha . . . . . . . . . . . . . . . . . . . . . . . 0SN3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Anthem HealthKeepers Preferred DirectAccess – gbia . . . . . . . . . . . . . . . . . . . . . . . 0SNK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Anthem HealthKeepers Preferred DirectAccess – gaaf . . . . . . . . . . . . . . . . . . . . . . . 0SNV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Anthem HealthKeepers Preferred DirectAccess – gpqa . . . . . . . . . . . . . . . . . . . . . . 0SNZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Anthem HealthKeepers Preferred DirectAccess – gqqa . . . . . . . . . . . . . . . . . . . . . . .0SP6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Anthem HealthKeepers Preferred DirectAccess – grqa . . . . . . . . . . . . . . . . . . . . . . . .0SP8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Anthem Preferred Plans – CDHP/PPO
Anthem Preferred DirectAccess w/HSA – gxqa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Anthem Preferred DirectAccess w/HRA – ggra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SP0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Anthem Preferred DirectAccess w/HRA – ghra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SP2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Anthem Preferred DirectAccess w/HRA – gmra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SP4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Anthem Preferred DirectAccess w/HSA – gtqa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SP9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Anthem Preferred Plans – CDHP/POS
Anthem HealthKeepers Preferred Guided Access Plus w/HSA – gsab . . . . . . . . . . 0W35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Anthem HealthKeepers Preferred Guided Access Plus w/HSA – gvab . . . . . . . . . . 0W36 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Anthem HealthKeepers Preferred Guided Access Plus w/HRA – gbbb . . . . . . . . . 0W37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Anthem HealthKeepers Preferred DirectAccess w/HSA – gxqa . . . . . . . . . . . . . . . 0SNX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Anthem HealthKeepers Preferred DirectAccess w/HRA – ggra . . . . . . . . . . . . . . . . .0SP1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Anthem HealthKeepers Preferred DirectAccess w/HRA – ghra . . . . . . . . . . . . . . . .0SP3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Anthem HealthKeepers Preferred DirectAccess w/HRA – gmra . . . . . . . . . . . . . . . .0SP5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Anthem HealthKeepers Preferred DirectAccess w/HSA – gtqa . . . . . . . . . . . . . . . .0SPA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Table of Contents
Click on plan to navigate to page.
Anthem Essential Plans – PPO
Anthem Essential DirectAccess – gvia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Anthem Essential DirectAccess – ghia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Anthem Essential Plans – POS
Anthem HealthKeepers Essential Guided Access Plus – gyoa . . . . . . . . . . . . . . . . . 0W2V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Anthem HealthKeepers Essential Guided Access Plus – gbpa . . . . . . . . . . . . . . . . . 0W2W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Anthem HealthKeepers Essential Guided Access Plus w/Dental – gcpa . . . . . . . . 0VUB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Anthem HealthKeepers Essential Guided Access Plus – gcpa . . . . . . . . . . . . . . . . . 0W2X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Anthem HealthKeepers Essential Guided Access Plus – gobf . . . . . . . . . . . . . . . . . 0W2Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Anthem HealthKeepers Essential DirectAccess – ghia . . . . . . . . . . . . . . . . . . . . . . . 0SNP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Anthem HealthKeepers Essential DirectAccess – gvia . . . . . . . . . . . . . . . . . . . . . . . 0SNM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Anthem Essential Plans – CDHP/PPO
Anthem Essential DirectAccess w/HSA – gjsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SPB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Anthem Essential DirectAccess w/HSA – gpsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Anthem Essential DirectAccess w/HRA – ggta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Anthem Essential DirectAccess w/HSA – gjta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Anthem Essential DirectAccess w/HSA – gkta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0SPK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Anthem Essential DirectAccess w/HSA – gdsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SPM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Anthem Essential Plans – CDHP/POS
Anthem HealthKeepers Essential Guided Access Plus w/HSA – gzeb . . . . . . . . . . 0W33 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Anthem HealthKeepers Essential Guided Access Plus w/HSA – gqeb . . . . . . . . . . 0W34 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Anthem HealthKeepers Essential Guided Access Plus w/HSA – gybb . . . . . . . . . . 0W38 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Anthem HealthKeepers Essential Guided Access Plus w/HRA – gpcb . . . . . . . . . . 0W39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Anthem HealthKeepers Essential DirectAccess w/HSA – gjsa . . . . . . . . . . . . . . . . 0SPC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Anthem HealthKeepers Essential DirectAccess w/HSA – gpsa . . . . . . . . . . . . . . . .0SPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Anthem HealthKeepers Essential DirectAccess w/HRA – ggta . . . . . . . . . . . . . . . . 0SPG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Anthem HealthKeepers Essential DirectAccess w/HSA – gjta . . . . . . . . . . . . . . . . .0SPJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Anthem HealthKeepers Essential DirectAccess w/HSA – gkta . . . . . . . . . . . . . . . . .0SPL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Anthem HealthKeepers Essential DirectAccess w/HSA – gdsa . . . . . . . . . . . . . . . 0SN1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Anthem Core Plans – POS
Anthem HealthKeepers Core Guided Access Plus – gznb . . . . . . . . . . . . . . . . . . . . . 0YQJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Anthem HealthKeepers Core Guided Access Plus – gwnb . . . . . . . . . . . . . . . . . . . . 0W2S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Anthem Core Plans – CDHP/PPO
Anthem Core DirectAccess w/HSA – gmua . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Anthem Core DirectAccess w/HSA – gyua . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0SNQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Anthem Core Plans – CDHP/POS
Anthem HealthKeepers Core DirectAccess w/HSA – gmua . . . . . . . . . . . . . . . . . . . .0SNT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Anthem HealthKeepers Core DirectAccess w/HSA – gyua . . . . . . . . . . . . . . . . . . . 0SNR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Anthem HealthKeepers Core Guided Access Plus w/HSA – ggdb . . . . . . . . . . . . . . 0YQK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Anthem HealthKeepers Core Guided Access Plus w/HSA – ghdb . . . . . . . . . . . . . . 0W30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Anthem HealthKeepers Core Guided Access Plus w/HSA – gkdb . . . . . . . . . . . . . . 0W31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Anthem HealthKeepers Core Guided Access Plus w/Dental w/HSA – gkdb . . . . . 0VUC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Anthem HealthKeepers Core Guided Access Plus w/HSA – grgb . . . . . . . . . . . . . . 0W32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Anthem SHOP Exchange Plans
Anthem HealthKeepers Gold Guided Access Plus – groa ..............................................OYQH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Anthem HealthKeepers Silver Guided Access Plus – gvoa .............................................105T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Anthem HealthKeepers Bronze Guided Access Plus w/HSA – gjdb ...........................OYQG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Anthem VA Vision Plans
Blue View VisionSM Monthly Rates – Voluntary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Blue View VisionSM Monthly Rates – Non-Voluntary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Anthem Dental Essential Plans
Anthem Dental Essential Pediatric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
Anthem Dental Essential Adult & Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Instructions
1
Small Group Rate Sheets
New Business effective dates
Renewal dates
Second Quarter 2014
04/01/2014 – 06/15/2014
04/01/2014 – 06/01/2014
How to Use the Rate Sheets to Estimate Premium
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Rates are effective only for Second Quarter 2014 for effective dates of April 1, 2014
through June 15, 2014. Rate sheets will be updated quarterly.
Rate sheets display per member per month rates, by age band, for each of the 80
ACA compliant Off Exchange/Marketplace medical products and the 3 core SHOP
products offered for 2014. All products assume a Calendar Year Benefit period.
Most products are also available with a Plan Year benefit period at the same rates.
All products and rates exclude coverage for bariatric surgery.
All 2014 plans are member-rated by age. You will need the full census of all employees
and all covered dependents including the age and tobacco use of each. Brokers may
use the Policy Search on the Broker Services page of the Virginia legacy portal to find
the full group census including a listing of members and their dates of birth.
To calculate the estimated monthly premium for a group:
1. Determine the rating area based on the employer’s physical location.
SHOP Marketplace products and rates can be quoted by contacting your Anthem
Account Executive or Account Manager.
2. Determine the rate for each employee by adding the rate for the employee’s age
and the age rates for all dependents. For children age 20 and younger, add the
rates for no more than 3 children. For children ages 21 and over, add the age rates
for all children.
Rates displayed apply only for non-Tobacco users. Tobacco users will be billed
higher rates.
3. Sum the total rates for all employees (including their dependent rates) to produce
the estimated monthly premium for the group.
Rates for all of the 12 Virginia rating areas are listed for each product.
The Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. service area
is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area
east of State Route 123. The 12 rating areas represent the 11 MSAs (metropolitan
statistical areas) plus one for all other non-MSA cities and counties.
Note: If you do not have a full census for a group, it is recommended you use these
rules to estimate the census:
The rates apply to both new and renewal business.
Rating Area
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
Rating Area Description
Blacksburg MSA
Charlottesville MSA
Danville MSA
Harrisonburg MSA
Bristol MSA
Lynchburg MSA
Richmond MSA
Roanoke MSA
VA Beach-Norfolk MSA
Wash/Arl/Alex MSA
Winchester MSA
All other non-MSA cities and counties
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Employee – use the employee’s age
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Employee/Child – use the employee’s age and 1 child under age 20
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Employee/Children – use the employee’s age and 2 children under age 20
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Employee/Spouse – use the employee’s age for both the employee and for the spouse
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Employee/Family – use the employee’s age for both the employee and the spouse
and 2 children under age 20
Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and BlueShield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association.
®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
2
0SMT
Rates effective 4/1/2014 to 6/15/2014
16064VA1210001
Anthem Premier DirectAccess gwaa
Anthem Health Plans PPO
Calendar Year
Off Exchange
N
Disclosure: Due to rounding differences in the calculations, billed rates may vary
slightly from the rates shown in this presentation
Rates provided apply to non-tobacco use members.
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 235.85
371.42
371.42
371.42
371.42
372.91
380.33
389.25
403.73
415.62
421.56
430.48
439.39
444.96
450.90
453.88
456.85
459.82
462.79
468.73
474.67
483.59
492.13
504.02
518.87
536.33
557.13
580.53
607.27
633.64
663.36
692.70
725.01
757.70
792.98
828.27
866.52
905.15
946.38
966.81
1,008.03
1,043.69
1,067.09
1,096.43
1,114.26
1,114.26
$ 215.11
338.76
338.76
338.76
338.76
340.12
346.89
355.02
368.23
379.07
384.49
392.62
400.75
405.83
411.25
413.96
416.67
419.38
422.09
427.52
432.94
441.07
448.86
459.70
473.25
489.17
508.14
529.48
553.87
577.92
605.03
631.79
661.26
691.07
723.25
755.43
790.33
825.56
863.16
881.79
919.39
951.92
973.26
1,000.02
1,016.28
1,016.28
$ 229.44
361.33
361.33
361.33
361.33
362.78
370.00
378.67
392.77
404.33
410.11
418.78
427.45
432.87
438.65
441.55
444.44
447.33
450.22
456.00
461.78
470.45
478.76
490.32
504.78
521.76
542.00
564.76
590.77
616.43
645.34
673.88
705.32
737.11
771.44
805.77
842.98
880.56
920.67
940.54
980.65
1,015.34
1,038.10
1,066.65
1,083.99
1,083.99
$ 214.59
337.93
337.93
337.93
337.93
339.28
346.04
354.15
367.33
378.14
383.55
391.66
399.77
404.84
410.25
412.95
415.65
418.36
421.06
426.47
431.87
439.98
447.76
458.57
472.09
487.97
506.90
528.18
552.52
576.51
603.54
630.24
659.64
689.38
721.48
753.58
788.39
823.54
861.05
879.63
917.14
949.58
970.87
997.57
1,013.79
1,013.79
$ 222.80
350.86
350.86
350.86
350.86
352.26
359.28
367.70
381.38
392.61
398.23
406.65
415.07
420.33
425.94
428.75
431.56
434.36
437.17
442.79
448.40
456.82
464.89
476.12
490.15
506.64
526.29
548.39
573.66
598.57
626.64
654.35
684.88
715.75
749.09
782.42
818.56
855.05
893.99
913.29
952.23
985.92
1,008.02
1,035.74
1,052.58
1,052.58
$ 211.84
333.61
333.61
333.61
333.61
334.94
341.62
349.62
362.63
373.31
378.65
386.65
394.66
399.66
405.00
407.67
410.34
413.01
415.68
421.02
426.35
434.36
442.03
452.71
466.05
481.73
500.42
521.43
545.45
569.14
595.83
622.18
651.21
680.56
712.26
743.95
778.31
813.01
850.04
868.39
905.42
937.44
958.46
984.82
1,000.83
1,000.83
$ 234.80
369.76
369.76
369.76
369.76
371.24
378.63
387.51
401.93
413.76
419.68
428.55
437.43
442.97
448.89
451.85
454.80
457.76
460.72
466.64
472.55
481.43
489.93
501.76
516.55
533.93
554.64
577.93
604.56
630.81
660.39
689.60
721.77
754.31
789.44
824.56
862.65
901.11
942.15
962.49
1,003.53
1,039.03
1,062.32
1,091.53
1,109.28
1,109.28
$ 226.89
357.30
357.30
357.30
357.30
358.73
365.88
374.45
388.39
399.82
405.54
414.11
422.69
428.05
433.76
436.62
439.48
442.34
445.20
450.91
456.63
465.20
473.42
484.86
499.15
515.94
535.95
558.46
584.19
609.55
638.14
666.36
697.45
728.89
762.84
796.78
833.58
870.74
910.40
930.05
969.71
1,004.01
1,026.52
1,054.75
1,071.90
1,071.90
$ 237.34
373.76
373.76
373.76
373.76
375.26
382.73
391.70
406.28
418.24
424.22
433.19
442.16
447.76
453.74
456.73
459.72
462.71
465.70
471.69
477.67
486.64
495.23
507.19
522.14
539.71
560.64
584.19
611.10
637.63
667.54
697.06
729.58
762.47
797.98
833.48
871.98
910.85
952.34
972.90
1,014.38
1,050.27
1,073.81
1,103.34
1,121.28
1,121.28
$ 227.44
358.17
358.17
358.17
358.17
359.60
366.77
375.36
389.33
400.79
406.52
415.12
423.72
429.09
434.82
437.68
440.55
443.41
446.28
452.01
457.74
466.34
474.58
486.04
500.36
517.20
537.26
559.82
585.61
611.04
639.69
667.99
699.15
730.67
764.69
798.72
835.61
872.86
912.62
932.32
972.07
1,006.46
1,029.02
1,057.32
1,074.51
1,074.51
$ 214.88
338.40
338.40
338.40
338.40
339.75
346.52
354.64
367.84
378.67
384.08
392.21
400.33
405.40
410.82
413.52
416.23
418.94
421.65
427.06
432.48
440.60
448.38
459.21
472.74
488.65
507.60
528.92
553.28
577.31
604.38
631.12
660.56
690.34
722.48
754.63
789.49
824.68
862.24
880.86
918.42
950.90
972.22
998.96
1,015.20
1,015.20
$ 228.67
360.11
360.11
360.11
360.11
361.55
368.75
377.40
391.44
402.96
408.72
417.37
426.01
431.41
437.17
440.05
442.94
445.82
448.70
454.46
460.22
468.86
477.15
488.67
503.07
520.00
540.17
562.85
588.78
614.35
643.16
671.61
702.93
734.62
768.83
803.05
840.14
877.59
917.56
937.37
977.34
1,011.91
1,034.60
1,063.04
1,080.33
1,080.33
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM, and Lumenos are registered trademarks of Anthem Insurance Companies, Inc. The Blue Cross and
Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
3
0SNA
16064VA1210002
Anthem Premier DirectAccess gyaa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 246.58
388.32
388.32
388.32
388.32
389.87
397.64
406.96
422.10
434.53
440.74
450.06
459.38
465.21
471.42
474.53
477.63
480.74
483.85
490.06
496.27
505.59
514.52
526.95
542.48
560.73
582.48
606.94
634.90
662.47
693.54
724.22
758.00
792.17
829.06
865.95
905.95
946.34
989.44
1,010.80
1,053.90
1,091.18
1,115.64
1,146.32
1,164.96
1,164.96
$ 224.90
354.17
354.17
354.17
354.17
355.59
362.67
371.17
384.98
396.32
401.98
410.48
418.98
424.30
429.96
432.80
435.63
438.46
441.30
446.96
452.63
461.13
469.28
480.61
494.78
511.42
531.26
553.57
579.07
604.21
632.55
660.53
691.34
722.51
756.15
789.80
826.28
863.11
902.43
921.90
961.22
995.22
1,017.53
1,045.51
1,062.51
1,062.51
$ 239.89
377.78
377.78
377.78
377.78
379.29
386.85
395.91
410.65
422.74
428.78
437.85
446.91
452.58
458.62
461.65
464.67
467.69
470.71
476.76
482.80
491.87
500.56
512.65
527.76
545.51
566.67
590.47
617.67
644.49
674.72
704.56
737.43
770.67
806.56
842.45
881.36
920.65
962.58
983.36
1,025.29
1,061.56
1,085.36
1,115.21
1,133.34
1,133.34
$ 224.35
353.30
353.30
353.30
353.30
354.71
361.78
370.26
384.04
395.34
401.00
409.47
417.95
423.25
428.91
431.73
434.56
437.39
440.21
445.86
451.52
460.00
468.12
479.43
493.56
510.17
529.95
552.21
577.65
602.73
630.99
658.90
689.64
720.73
754.30
787.86
824.25
860.99
900.21
919.64
958.86
992.77
1,015.03
1,042.94
1,059.90
1,059.90
$ 232.93
366.82
366.82
366.82
366.82
368.29
375.62
384.43
398.73
410.47
416.34
425.14
433.95
439.45
445.32
448.25
451.19
454.12
457.06
462.93
468.80
477.60
486.04
497.77
512.45
529.69
550.23
573.34
599.75
625.79
655.14
684.12
716.03
748.31
783.16
818.01
855.79
893.94
934.66
954.83
995.55
1,030.76
1,053.87
1,082.85
1,100.46
1,100.46
$ 221.48
348.79
348.79
348.79
348.79
350.19
357.16
365.53
379.13
390.30
395.88
404.25
412.62
417.85
423.43
426.22
429.01
431.80
434.59
440.17
445.75
454.12
462.15
473.31
487.26
503.65
523.19
545.16
570.27
595.04
622.94
650.49
680.84
711.53
744.67
777.80
813.73
850.00
888.72
907.90
946.62
980.10
1,002.07
1,029.63
1,046.37
1,046.37
$ 245.48
386.59
386.59
386.59
386.59
388.14
395.87
405.15
420.22
432.59
438.78
448.06
457.34
463.13
469.32
472.41
475.51
478.60
481.69
487.88
494.06
503.34
512.23
524.60
540.07
558.24
579.89
604.24
632.07
659.52
690.45
720.99
754.62
788.64
825.37
862.10
901.91
942.12
985.03
1,006.29
1,049.21
1,086.32
1,110.67
1,141.21
1,159.77
1,159.77
$ 237.21
373.56
373.56
373.56
373.56
375.05
382.53
391.49
406.06
418.01
423.99
432.96
441.92
447.52
453.50
456.49
459.48
462.47
465.46
471.43
477.41
486.38
494.97
506.92
521.86
539.42
560.34
583.87
610.77
637.29
667.18
696.69
729.19
762.06
797.55
833.04
871.52
910.37
951.83
972.38
1,013.84
1,049.70
1,073.24
1,102.75
1,120.68
1,120.68
$ 248.14
390.77
390.77
390.77
390.77
392.33
400.15
409.53
424.77
437.27
443.52
452.90
462.28
468.14
474.39
477.52
480.65
483.77
486.90
493.15
499.40
508.78
517.77
530.27
545.91
564.27
586.16
610.77
638.91
666.65
697.92
728.79
762.78
797.17
834.29
871.42
911.67
952.31
995.68
1,017.17
1,060.55
1,098.06
1,122.68
1,153.55
1,172.31
1,172.31
$ 237.78
374.46
374.46
374.46
374.46
375.96
383.45
392.43
407.04
419.02
425.01
434.00
442.99
448.60
454.59
457.59
460.59
463.58
466.58
472.57
478.56
487.55
496.16
508.14
523.12
540.72
561.69
585.28
612.24
638.83
668.79
698.37
730.95
763.90
799.47
835.05
873.62
912.56
954.12
974.72
1,016.28
1,052.23
1,075.82
1,105.41
1,123.38
1,123.38
$ 224.66
353.79
353.79
353.79
353.79
355.21
362.28
370.77
384.57
395.89
401.55
410.04
418.53
423.84
429.50
432.33
435.16
437.99
440.82
446.48
452.14
460.63
468.77
480.09
494.24
510.87
530.69
552.97
578.45
603.57
631.87
659.82
690.60
721.73
755.34
788.95
825.39
862.19
901.46
920.92
960.19
994.15
1,016.44
1,044.39
1,061.37
1,061.37
$ 239.08
376.50
376.50
376.50
376.50
378.01
385.54
394.57
409.26
421.30
427.33
436.36
445.40
451.05
457.07
460.08
463.10
466.11
469.12
475.14
481.17
490.20
498.86
510.91
525.97
543.67
564.75
588.47
615.58
642.31
672.43
702.17
734.93
768.06
803.83
839.60
878.37
917.53
959.32
980.03
1,021.82
1,057.97
1,081.68
1,111.43
1,129.50
1,129.50
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
4
0SN9
88380VA0740023
Anthem HealthKeepers Premier DirectAccess gwaa
HealthKeepers Traditional
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 222.62
350.58
350.58
350.58
350.58
351.98
358.99
367.41
381.08
392.30
397.91
406.32
414.74
419.99
425.60
428.41
431.21
434.02
436.82
442.43
448.04
456.46
464.52
475.74
489.76
506.24
525.87
547.96
573.20
598.09
626.14
653.83
684.33
715.18
748.49
781.79
817.90
854.36
893.28
912.56
951.47
985.13
1,007.22
1,034.91
1,051.74
1,051.74
$ 203.03
319.73
319.73
319.73
319.73
321.01
327.40
335.08
347.55
357.78
362.89
370.57
378.24
383.04
388.15
390.71
393.27
395.83
398.38
403.50
408.61
416.29
423.64
433.87
446.66
461.69
479.60
499.74
522.76
545.46
571.04
596.30
624.11
652.25
682.62
713.00
745.93
779.18
814.67
832.26
867.75
898.44
918.58
943.84
959.19
959.19
$ 210.25
331.10
331.10
331.10
331.10
332.42
339.05
346.99
359.91
370.50
375.80
383.74
391.69
396.66
401.96
404.60
407.25
409.90
412.55
417.85
423.15
431.09
438.71
449.30
462.55
478.11
496.65
517.51
541.35
564.86
591.34
617.50
646.31
675.44
706.90
738.35
772.46
806.89
843.64
861.85
898.61
930.39
951.25
977.41
993.30
993.30
$ 202.54
318.96
318.96
318.96
318.96
320.24
326.62
334.27
346.71
356.92
362.02
369.67
377.33
382.11
387.22
389.77
392.32
394.87
397.42
402.53
407.63
415.29
422.62
432.83
445.59
460.58
478.44
498.53
521.50
544.15
569.66
594.86
622.61
650.68
680.98
711.28
744.13
777.31
812.71
830.25
865.66
896.28
916.37
941.57
956.88
956.88
$ 206.17
324.67
324.67
324.67
324.67
325.97
332.46
340.25
352.92
363.31
368.50
376.29
384.08
388.95
394.15
396.75
399.34
401.94
404.54
409.73
414.93
422.72
430.19
440.58
453.56
468.82
487.01
507.46
530.84
553.89
579.86
605.51
633.76
662.33
693.17
724.01
757.46
791.22
827.26
845.12
881.15
912.32
932.78
958.43
974.01
974.01
$ 206.15
324.64
324.64
324.64
324.64
325.94
332.43
340.22
352.88
363.27
368.47
376.26
384.05
388.92
394.11
396.71
399.31
401.90
404.50
409.70
414.89
422.68
430.15
440.54
453.52
468.78
486.96
507.41
530.79
553.84
579.81
605.45
633.70
662.27
693.11
723.95
757.39
791.15
827.18
845.04
881.07
912.24
932.69
958.34
973.92
973.92
$ 214.76
338.20
338.20
338.20
338.20
339.55
346.32
354.43
367.62
378.45
383.86
391.97
400.09
405.16
410.57
413.28
415.99
418.69
421.40
426.81
432.22
440.34
448.12
458.94
472.47
488.36
507.30
528.61
552.96
576.97
604.03
630.74
660.17
689.93
722.06
754.19
789.02
824.19
861.73
880.33
917.87
950.34
971.65
998.37
1,014.60
1,014.60
$ 214.16
337.26
337.26
337.26
337.26
338.61
345.35
353.45
366.60
377.39
382.79
390.88
398.98
404.04
409.43
412.13
414.83
417.53
420.23
425.62
431.02
439.11
446.87
457.66
471.15
487.00
505.89
527.14
551.42
575.37
602.35
628.99
658.33
688.01
720.05
752.09
786.83
821.90
859.34
877.89
915.32
947.70
968.95
995.59
1,011.78
1,011.78
$ 208.78
328.78
328.78
328.78
328.78
330.10
336.67
344.56
357.38
367.90
373.17
381.06
388.95
393.88
399.14
401.77
404.40
407.03
409.66
414.92
420.18
428.07
435.63
446.15
459.31
474.76
493.17
513.88
537.56
560.90
587.20
613.17
641.78
670.71
701.95
733.18
767.04
801.24
837.73
855.81
892.31
923.87
944.58
970.56
986.34
986.34
$ 225.97
355.86
355.86
355.86
355.86
357.28
364.40
372.94
386.82
398.21
403.90
412.44
420.98
426.32
432.01
434.86
437.71
440.55
443.40
449.10
454.79
463.33
471.51
482.90
497.14
513.86
533.79
556.21
581.83
607.10
635.57
663.68
694.64
725.95
759.76
793.57
830.22
867.23
906.73
926.30
965.80
999.97
1,022.39
1,050.50
1,067.58
1,067.58
$ 206.98
325.95
325.95
325.95
325.95
327.25
333.77
341.60
354.31
364.74
369.95
377.78
385.60
390.49
395.70
398.31
400.92
403.53
406.13
411.35
416.56
424.39
431.88
442.31
455.35
470.67
488.93
509.46
532.93
556.07
582.15
607.90
636.25
664.94
695.90
726.87
760.44
794.34
830.52
848.45
884.63
915.92
936.45
962.20
977.85
977.85
$ 209.63
330.12
330.12
330.12
330.12
331.44
338.04
345.97
358.84
369.40
374.69
382.61
390.53
395.48
400.77
403.41
406.05
408.69
411.33
416.61
421.89
429.82
437.41
447.97
461.18
476.69
495.18
515.98
539.75
563.18
589.59
615.67
644.39
673.44
704.81
736.17
770.17
804.50
841.15
859.30
895.95
927.64
948.43
974.51
990.36
990.36
HealthKeepers, Inc, is an independent licensee of the Blue Cross and Blue Shield Association.
and Blue Shield Association.
®
ANTHEMand 360ºHealth® are registered trademarks of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
5
0SN2
88380VA0740024
Anthem HealthKeepers Premier DirectAccess gyaa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 232.91
366.78
366.78
366.78
366.78
368.25
375.58
384.39
398.69
410.43
416.30
425.10
433.90
439.40
445.27
448.21
451.14
454.07
457.01
462.88
468.74
477.55
485.98
497.72
512.39
529.63
550.17
573.28
599.69
625.73
655.07
684.04
715.95
748.23
783.08
817.92
855.70
893.84
934.56
954.73
995.44
1,030.65
1,053.76
1,082.73
1,100.34
1,100.34
$ 212.41
334.51
334.51
334.51
334.51
335.85
342.54
350.57
363.61
374.32
379.67
387.70
395.73
400.74
406.10
408.77
411.45
414.12
416.80
422.15
427.50
435.53
443.23
453.93
467.31
483.03
501.77
522.84
546.92
570.67
597.43
623.86
652.96
682.40
714.18
745.96
780.41
815.20
852.33
870.73
907.86
939.97
961.05
987.47
1,003.53
1,003.53
$ 219.96
346.40
346.40
346.40
346.40
347.79
354.71
363.03
376.54
387.62
393.16
401.48
409.79
414.99
420.53
423.30
426.07
428.84
431.61
437.16
442.70
451.01
458.98
470.06
483.92
500.20
519.60
541.42
566.36
590.96
618.67
646.04
676.17
706.66
739.56
772.47
808.15
844.18
882.63
901.68
940.13
973.38
995.21
1,022.57
1,039.20
1,039.20
$ 211.90
333.70
333.70
333.70
333.70
335.03
341.71
349.72
362.73
373.41
378.75
386.76
394.77
399.77
405.11
407.78
410.45
413.12
415.79
421.13
426.47
434.48
442.15
452.83
466.18
481.86
500.55
521.57
545.60
569.29
595.99
622.35
651.38
680.75
712.45
744.15
778.52
813.23
850.27
868.62
905.66
937.70
958.72
985.08
1,001.10
1,001.10
$ 215.70
339.68
339.68
339.68
339.68
341.04
347.83
355.98
369.23
380.10
385.54
393.69
401.84
406.94
412.37
415.09
417.81
420.52
423.24
428.68
434.11
442.26
450.08
460.95
474.53
490.50
509.52
530.92
555.38
579.49
606.67
633.50
663.06
692.95
725.22
757.49
792.47
827.80
865.50
884.19
921.89
954.50
975.90
1,002.74
1,019.04
1,019.04
$ 215.67
339.64
339.64
339.64
339.64
341.00
347.79
355.94
369.19
380.06
385.49
393.64
401.79
406.89
412.32
415.04
417.76
420.47
423.19
428.63
434.06
442.21
450.02
460.89
474.48
490.44
509.46
530.86
555.31
579.43
606.60
633.43
662.98
692.87
725.13
757.40
792.38
827.70
865.40
884.08
921.78
954.39
975.79
1,002.62
1,018.92
1,018.92
$ 224.68
353.83
353.83
353.83
353.83
355.25
362.32
370.81
384.61
395.94
401.60
410.09
418.58
423.89
429.55
432.38
435.21
438.04
440.87
446.53
452.19
460.69
468.82
480.15
494.30
510.93
530.75
553.04
578.51
603.63
631.94
659.89
690.68
721.81
755.43
789.04
825.49
862.28
901.56
921.02
960.29
994.26
1,016.55
1,044.51
1,061.49
1,061.49
$ 224.05
352.84
352.84
352.84
352.84
354.25
361.31
369.78
383.54
394.83
400.47
408.94
417.41
422.70
428.35
431.17
433.99
436.82
439.64
445.28
450.93
459.40
467.51
478.80
492.92
509.50
529.26
551.49
576.89
601.95
630.17
658.05
688.74
719.79
753.31
786.83
823.18
859.87
899.04
918.44
957.61
991.48
1,013.71
1,041.58
1,058.52
1,058.52
$ 218.42
343.97
343.97
343.97
343.97
345.35
352.23
360.48
373.90
384.90
390.41
398.66
406.92
412.08
417.58
420.33
423.08
425.83
428.59
434.09
439.59
447.85
455.76
466.77
480.53
496.69
515.96
537.63
562.39
586.81
614.33
641.50
671.43
701.70
734.38
767.05
802.48
838.25
876.44
895.35
933.53
966.56
988.23
1,015.40
1,031.91
1,031.91
$ 236.41
372.30
372.30
372.30
372.30
373.79
381.24
390.17
404.69
416.60
422.56
431.50
440.43
446.02
451.97
454.95
457.93
460.91
463.89
469.84
475.80
484.73
493.30
505.21
520.10
537.60
558.45
581.90
608.71
635.14
664.93
694.34
726.73
759.49
794.86
830.23
868.58
907.30
948.62
969.10
1,010.42
1,046.16
1,069.62
1,099.03
1,116.90
1,116.90
$ 216.55
341.02
341.02
341.02
341.02
342.38
349.20
357.39
370.69
381.60
387.06
395.24
403.43
408.54
414.00
416.73
419.45
422.18
424.91
430.37
435.82
444.01
451.85
462.76
476.40
492.43
511.53
533.01
557.57
581.78
609.06
636.00
665.67
695.68
728.08
760.47
795.60
831.07
868.92
887.68
925.53
958.27
979.75
1,006.69
1,023.06
1,023.06
$ 219.32
345.38
345.38
345.38
345.38
346.76
353.67
361.96
375.43
386.48
392.01
400.30
408.58
413.77
419.29
422.05
424.82
427.58
430.34
435.87
441.40
449.68
457.63
468.68
482.50
498.73
518.07
539.83
564.70
589.22
616.85
644.13
674.18
704.58
737.39
770.20
805.77
841.69
880.03
899.02
937.36
970.52
992.28
1,019.56
1,036.14
1,036.14
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
6
0SN7
16064VA1210003
Anthem Preferred DirectAccess gjba
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 217.61
342.70
342.70
342.70
342.70
344.07
350.92
359.15
372.51
383.48
388.96
397.19
405.41
410.55
416.04
418.78
421.52
424.26
427.00
432.49
437.97
446.20
454.08
465.04
478.75
494.86
514.05
535.64
560.31
584.65
612.06
639.14
668.95
699.11
731.66
764.22
799.52
835.16
873.20
892.05
930.09
962.99
984.58
1,011.65
1,028.10
1,028.10
$ 198.48
312.57
312.57
312.57
312.57
313.82
320.07
327.57
339.76
349.77
354.77
362.27
369.77
374.46
379.46
381.96
384.46
386.96
389.46
394.46
399.46
406.97
414.16
424.16
436.66
451.35
468.86
488.55
511.05
533.24
558.25
582.94
610.14
637.64
667.34
697.03
729.23
761.73
796.43
813.62
848.31
878.32
898.01
922.71
937.71
937.71
$ 211.71
333.40
333.40
333.40
333.40
334.73
341.40
349.40
362.41
373.07
378.41
386.41
394.41
399.41
404.75
407.41
410.08
412.75
415.42
420.75
426.09
434.09
441.76
452.42
465.76
481.43
500.10
521.10
545.11
568.78
595.45
621.79
650.80
680.14
711.81
743.48
777.82
812.50
849.50
867.84
904.85
936.85
957.86
984.20
1,000.20
1,000.20
$ 197.99
311.80
311.80
311.80
311.80
313.05
319.28
326.77
338.93
348.90
353.89
361.38
368.86
373.54
378.53
381.02
383.51
386.01
388.50
393.49
398.48
405.96
413.14
423.11
435.58
450.24
467.70
487.34
509.79
531.93
556.87
581.51
608.63
636.07
665.69
695.31
727.43
759.86
794.47
811.62
846.23
876.16
895.80
920.43
935.40
935.40
$ 205.57
323.73
323.73
323.73
323.73
325.02
331.50
339.27
351.89
362.25
367.43
375.20
382.97
387.83
393.01
395.60
398.19
400.78
403.37
408.55
413.73
421.50
428.94
439.30
452.25
467.47
485.60
505.99
529.30
552.28
578.18
603.76
631.92
660.41
691.16
721.92
755.26
788.93
824.86
842.67
878.60
909.68
930.08
955.65
971.19
971.19
$ 195.47
307.82
307.82
307.82
307.82
309.05
315.21
322.60
334.60
344.45
349.38
356.76
364.15
368.77
373.69
376.16
378.62
381.08
383.54
388.47
393.39
400.78
407.86
417.71
430.02
444.49
461.73
481.12
503.29
525.14
549.77
574.08
600.86
627.95
657.20
686.44
718.14
750.16
784.33
801.26
835.42
864.97
884.37
908.68
923.46
923.46
$ 216.65
341.18
341.18
341.18
341.18
342.54
349.37
357.56
370.86
381.78
387.24
395.43
403.62
408.73
414.19
416.92
419.65
422.38
425.11
430.57
436.03
444.22
452.06
462.98
476.63
492.66
511.77
533.26
557.83
582.05
609.35
636.30
665.98
696.01
728.42
760.83
795.97
831.46
869.33
888.09
925.96
958.72
980.21
1,007.16
1,023.54
1,023.54
$ 209.35
329.68
329.68
329.68
329.68
331.00
337.59
345.50
358.36
368.91
374.19
382.10
390.01
394.96
400.23
402.87
405.51
408.14
410.78
416.06
421.33
429.24
436.83
447.38
460.56
476.06
494.52
515.29
539.03
562.43
588.81
614.85
643.54
672.55
703.87
735.19
769.14
803.43
840.02
858.16
894.75
926.40
947.17
973.22
989.04
989.04
$ 218.99
344.86
344.86
344.86
344.86
346.24
353.14
361.41
374.86
385.90
391.42
399.69
407.97
413.14
418.66
421.42
424.18
426.94
429.70
435.21
440.73
449.01
456.94
467.98
481.77
497.98
517.29
539.02
563.85
588.33
615.92
643.16
673.17
703.51
736.28
769.04
804.56
840.42
878.70
897.67
935.95
969.06
990.78
1,018.03
1,034.58
1,034.58
$ 209.85
330.48
330.48
330.48
330.48
331.80
338.41
346.34
359.23
369.81
375.09
383.03
390.96
395.92
401.20
403.85
406.49
409.13
411.78
417.07
422.35
430.28
437.89
448.46
461.68
477.21
495.72
516.54
540.33
563.80
590.24
616.35
645.10
674.18
705.57
736.97
771.01
805.38
842.06
860.24
896.92
928.65
949.47
975.58
991.44
991.44
$ 198.27
312.24
312.24
312.24
312.24
313.49
319.73
327.23
339.40
349.40
354.39
361.89
369.38
374.06
379.06
381.56
384.06
386.55
389.05
394.05
399.04
406.54
413.72
423.71
436.20
450.87
468.36
488.03
510.51
532.68
557.66
582.33
609.49
636.97
666.63
696.30
728.46
760.93
795.59
812.76
847.42
877.39
897.07
921.73
936.72
936.72
$ 210.99
332.27
332.27
332.27
332.27
333.60
340.24
348.22
361.18
371.81
377.13
385.10
393.08
398.06
403.38
406.03
408.69
411.35
414.01
419.32
424.64
432.62
440.26
450.89
464.18
479.80
498.41
519.34
543.26
566.85
593.43
619.68
648.59
677.83
709.40
740.96
775.19
809.74
846.62
864.90
901.78
933.68
954.61
980.86
996.81
996.81
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
7
0SNB
16064VA1210010
Anthem Preferred DirectAccess ghfa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 191.59
301.71
301.71
301.71
301.71
302.92
308.95
316.19
327.96
337.61
342.44
349.68
356.92
361.45
366.28
368.69
371.10
373.52
375.93
380.76
385.59
392.83
399.77
409.42
421.49
435.67
452.57
471.57
493.30
514.72
538.85
562.69
588.94
615.49
644.15
672.81
703.89
735.27
768.76
785.35
818.84
847.81
866.81
890.65
905.13
905.13
$ 174.74
275.18
275.18
275.18
275.18
276.28
281.78
288.39
299.12
307.93
312.33
318.93
325.54
329.67
334.07
336.27
338.47
340.67
342.87
347.28
351.68
358.28
364.61
373.42
384.43
397.36
412.77
430.11
449.92
469.46
491.47
513.21
537.15
561.37
587.51
613.65
641.99
670.61
701.16
716.29
746.84
773.26
790.59
812.33
825.54
825.54
$ 186.39
293.52
293.52
293.52
293.52
294.69
300.56
307.61
319.06
328.45
333.15
340.19
347.23
351.64
356.33
358.68
361.03
363.38
365.73
370.42
375.12
382.16
388.91
398.31
410.05
423.84
440.28
458.77
479.91
500.75
524.23
547.41
572.95
598.78
626.67
654.55
684.78
715.31
747.89
764.03
796.61
824.79
843.28
866.47
880.56
880.56
$ 174.31
274.50
274.50
274.50
274.50
275.60
281.09
287.68
298.38
307.17
311.56
318.15
324.73
328.85
333.24
335.44
337.64
339.83
342.03
346.42
350.81
357.40
363.71
372.50
383.48
396.38
411.75
429.04
448.81
468.30
490.26
511.94
535.82
559.98
586.06
612.14
640.41
668.96
699.43
714.52
744.99
771.35
788.64
810.32
823.50
823.50
$ 180.98
285.00
285.00
285.00
285.00
286.14
291.84
298.68
309.80
318.92
323.48
330.32
337.16
341.43
345.99
348.27
350.55
352.83
355.11
359.67
364.23
371.07
377.63
386.75
398.15
411.54
427.50
445.46
465.98
486.21
509.01
531.53
556.32
581.40
608.48
635.55
664.91
694.55
726.18
741.86
773.49
800.85
818.81
841.32
855.00
855.00
$ 172.08
270.99
270.99
270.99
270.99
272.07
277.49
284.00
294.57
303.24
307.57
314.08
320.58
324.65
328.98
331.15
333.32
335.49
337.65
341.99
346.33
352.83
359.06
367.73
378.57
391.31
406.49
423.56
443.07
462.31
483.99
505.40
528.97
552.82
578.56
604.31
632.22
660.40
690.48
705.39
735.47
761.48
778.55
799.96
812.97
812.97
$ 190.73
300.36
300.36
300.36
300.36
301.56
307.57
314.78
326.49
336.10
340.91
348.12
355.33
359.83
364.64
367.04
369.44
371.85
374.25
379.05
383.86
391.07
397.98
407.59
419.60
433.72
450.54
469.46
491.09
512.41
536.44
560.17
586.30
612.73
641.27
669.80
700.74
731.98
765.32
781.84
815.18
844.01
862.93
886.66
901.08
901.08
$ 184.30
290.24
290.24
290.24
290.24
291.40
297.21
304.17
315.49
324.78
329.42
336.39
343.35
347.71
352.35
354.67
357.00
359.32
361.64
366.28
370.93
377.89
384.57
393.86
405.47
419.11
435.36
453.65
474.54
495.15
518.37
541.30
566.55
592.09
619.66
647.24
677.13
707.31
739.53
755.49
787.71
815.57
833.86
856.79
870.72
870.72
$ 192.79
303.61
303.61
303.61
303.61
304.82
310.90
318.18
330.02
339.74
344.60
351.88
359.17
363.72
368.58
371.01
373.44
375.87
378.30
383.16
388.01
395.30
402.28
412.00
424.14
438.41
455.42
474.54
496.40
517.96
542.25
566.23
592.65
619.36
648.21
677.05
708.32
739.90
773.60
790.30
824.00
853.14
872.27
896.26
910.83
910.83
$ 184.75
290.94
290.94
290.94
290.94
292.10
297.92
304.91
316.25
325.56
330.22
337.20
344.18
348.55
353.20
355.53
357.86
360.18
362.51
367.17
371.82
378.80
385.50
394.81
406.44
420.12
436.41
454.74
475.69
496.34
519.62
542.60
567.91
593.52
621.16
648.80
678.76
709.02
741.32
757.32
789.61
817.54
835.87
858.85
872.82
872.82
$ 174.55
274.88
274.88
274.88
274.88
275.98
281.48
288.07
298.79
307.59
311.99
318.59
325.18
329.31
333.70
335.90
338.10
340.30
342.50
346.90
351.30
357.89
364.22
373.01
384.01
396.93
412.32
429.64
449.43
468.95
490.94
512.65
536.57
560.76
586.87
612.98
641.30
669.88
700.39
715.51
746.02
772.41
789.73
811.45
824.64
824.64
$ 185.75
292.52
292.52
292.52
292.52
293.69
299.54
306.56
317.97
327.33
332.01
339.03
346.05
350.44
355.12
357.46
359.80
362.14
364.48
369.16
373.84
380.86
387.59
396.95
408.65
422.40
438.78
457.21
478.27
499.04
522.44
545.55
571.00
596.74
624.53
652.32
682.45
712.87
745.34
761.43
793.90
821.98
840.41
863.52
877.56
877.56
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
8
0SN5
16064VA1210005
Anthem Preferred DirectAccess gkfa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 194.20
305.82
305.82
305.82
305.82
307.04
313.16
320.50
332.43
342.21
347.11
354.45
361.79
366.37
371.27
373.71
376.16
378.61
381.05
385.94
390.84
398.18
405.21
415.00
427.23
441.60
458.73
478.00
500.02
521.73
546.19
570.35
596.96
623.87
652.93
681.98
713.48
745.28
779.23
796.05
830.00
859.35
878.62
902.78
917.46
917.46
$ 177.12
278.93
278.93
278.93
278.93
280.05
285.62
292.32
303.20
312.12
316.59
323.28
329.97
334.16
338.62
340.85
343.08
345.32
347.55
352.01
356.47
363.17
369.58
378.51
389.67
402.77
418.40
435.97
456.05
475.85
498.17
520.20
544.47
569.02
595.52
622.01
650.74
679.75
710.71
726.05
757.02
783.79
801.37
823.40
836.79
836.79
$ 188.93
297.52
297.52
297.52
297.52
298.71
304.66
311.80
323.40
332.92
337.69
344.83
351.97
356.43
361.19
363.57
365.95
368.33
370.71
375.47
380.23
387.37
394.21
403.73
415.64
429.62
446.28
465.02
486.45
507.57
531.37
554.87
580.76
606.94
635.21
663.47
694.11
725.06
758.08
774.44
807.47
836.03
854.77
878.28
892.56
892.56
$ 176.69
278.25
278.25
278.25
278.25
279.36
284.93
291.61
302.46
311.36
315.81
322.49
329.17
333.34
337.80
340.02
342.25
344.47
346.70
351.15
355.60
362.28
368.68
377.59
388.72
401.79
417.38
434.90
454.94
474.69
496.95
518.94
543.14
567.63
594.06
620.50
649.16
678.10
708.98
724.28
755.17
781.88
799.41
821.39
834.75
834.75
$ 183.45
288.89
288.89
288.89
288.89
290.05
295.82
302.76
314.02
323.27
327.89
334.82
341.76
346.09
350.71
353.02
355.33
357.65
359.96
364.58
369.20
376.13
382.78
392.02
403.58
417.16
433.34
451.54
472.34
492.85
515.96
538.78
563.91
589.34
616.78
644.22
673.98
704.02
736.09
751.98
784.05
811.78
829.98
852.80
866.67
866.67
$ 174.43
274.69
274.69
274.69
274.69
275.79
281.28
287.88
298.59
307.38
311.77
318.37
324.96
329.08
333.47
335.67
337.87
340.07
342.26
346.66
351.05
357.65
363.96
372.75
383.74
396.65
412.04
429.34
449.12
468.62
490.60
512.30
536.19
560.37
586.46
612.56
640.85
669.42
699.91
715.02
745.51
771.88
789.18
810.88
824.07
824.07
$ 193.33
304.46
304.46
304.46
304.46
305.68
311.77
319.07
330.95
340.69
345.56
352.87
360.18
364.74
369.61
372.05
374.49
376.92
379.36
384.23
389.10
396.41
403.41
413.15
425.33
439.64
456.69
475.87
497.79
519.41
543.77
567.82
594.31
621.10
650.02
678.95
710.31
741.97
775.76
792.51
826.30
855.53
874.71
898.77
913.38
913.38
$ 186.82
294.20
294.20
294.20
294.20
295.38
301.26
308.32
319.80
329.21
333.92
340.98
348.04
352.45
357.16
359.51
361.87
364.22
366.57
371.28
375.99
383.05
389.82
399.23
411.00
424.82
441.30
459.83
481.02
501.91
525.44
548.68
574.28
600.17
628.12
656.07
686.37
716.97
749.62
765.80
798.46
826.70
845.24
868.48
882.60
882.60
$ 195.42
307.75
307.75
307.75
307.75
308.98
315.14
322.52
334.52
344.37
349.30
356.68
364.07
368.68
373.61
376.07
378.53
380.99
383.46
388.38
393.30
400.69
407.77
417.62
429.93
444.39
461.63
481.01
503.17
525.02
549.64
573.95
600.73
627.81
657.05
686.28
717.98
749.99
784.15
801.07
835.23
864.78
884.17
908.48
923.25
923.25
$ 187.27
294.91
294.91
294.91
294.91
296.09
301.99
309.07
320.57
330.00
334.72
341.80
348.88
353.30
358.02
360.38
362.74
365.10
367.46
372.18
376.89
383.97
390.76
400.19
411.99
425.85
442.37
460.94
482.18
503.12
526.71
550.01
575.66
601.62
629.63
657.65
688.03
718.70
751.43
767.65
800.39
828.70
847.28
870.57
884.73
884.73
$ 176.93
278.63
278.63
278.63
278.63
279.74
285.32
292.00
302.87
311.79
316.25
322.93
329.62
333.80
338.26
340.49
342.71
344.94
347.17
351.63
356.09
362.78
369.18
378.10
389.25
402.34
417.95
435.50
455.56
475.34
497.63
519.64
543.89
568.41
594.88
621.34
650.04
679.02
709.95
725.27
756.20
782.95
800.50
822.52
835.89
835.89
$ 188.28
296.51
296.51
296.51
296.51
297.70
303.63
310.74
322.31
331.79
336.54
343.66
350.77
355.22
359.96
362.34
364.71
367.08
369.45
374.20
378.94
386.06
392.88
402.36
414.22
428.16
444.77
463.45
484.79
505.85
529.57
552.99
578.79
604.88
633.05
661.22
691.76
722.59
755.51
771.82
804.73
833.19
851.87
875.30
889.53
889.53
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
9
0SNE
16064VA1210006
Anthem Preferred DirectAccess gcga
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 206.27
324.83
324.83
324.83
324.83
326.13
332.63
340.42
353.09
363.48
368.68
376.48
384.27
389.15
394.34
396.94
399.54
402.14
404.74
409.94
415.13
422.93
430.40
440.79
453.79
469.05
487.25
507.71
531.10
554.16
580.15
605.81
634.07
662.65
693.51
724.37
757.83
791.61
827.67
845.53
881.59
912.77
933.24
958.90
974.49
974.49
$ 188.13
296.26
296.26
296.26
296.26
297.45
303.37
310.48
322.03
331.51
336.26
343.37
350.48
354.92
359.66
362.03
364.40
366.77
369.14
373.88
378.62
385.73
392.54
402.02
413.88
427.80
444.39
463.05
484.39
505.42
529.12
552.52
578.30
604.37
632.52
660.66
691.17
721.99
754.87
771.16
804.05
832.49
851.15
874.56
888.78
888.78
$ 200.67
316.01
316.01
316.01
316.01
317.27
323.59
331.18
343.50
353.62
358.67
366.26
373.84
378.58
383.64
386.16
388.69
391.22
393.75
398.80
403.86
411.45
418.71
428.83
441.47
456.32
474.02
493.92
516.68
539.11
564.39
589.36
616.85
644.66
674.68
704.70
737.25
770.12
805.19
822.57
857.65
887.99
907.90
932.86
948.03
948.03
$ 187.67
295.54
295.54
295.54
295.54
296.72
302.63
309.73
321.25
330.71
335.44
342.53
349.62
354.06
358.79
361.15
363.51
365.88
368.24
372.97
377.70
384.79
391.59
401.05
412.87
426.76
443.31
461.93
483.21
504.19
527.83
551.18
576.89
602.90
630.98
659.05
689.49
720.23
753.04
769.29
802.10
830.47
849.09
872.43
886.62
886.62
$ 194.85
306.85
306.85
306.85
306.85
308.08
314.21
321.58
333.55
343.37
348.27
355.64
363.00
367.61
372.52
374.97
377.43
379.88
382.34
387.24
392.15
399.52
406.58
416.40
428.67
443.09
460.28
479.61
501.70
523.49
548.03
572.28
598.97
625.97
655.12
684.28
715.88
747.79
781.85
798.73
832.79
862.25
881.58
905.82
920.55
920.55
$ 185.27
291.76
291.76
291.76
291.76
292.93
298.76
305.76
317.14
326.48
331.15
338.15
345.15
349.53
354.20
356.53
358.86
361.20
363.53
368.20
372.87
379.87
386.58
395.92
407.59
421.30
437.64
456.02
477.03
497.74
521.08
544.13
569.52
595.19
622.91
650.62
680.68
711.02
743.40
759.45
791.84
819.85
838.23
861.28
875.28
875.28
$ 205.35
323.38
323.38
323.38
323.38
324.67
331.14
338.90
351.51
361.86
367.04
374.80
382.56
387.41
392.58
395.17
397.76
400.34
402.93
408.11
413.28
421.04
428.48
438.83
451.76
466.96
485.07
505.44
528.73
551.69
577.56
603.10
631.24
659.70
690.42
721.14
754.45
788.08
823.97
841.76
877.65
908.70
929.07
954.62
970.14
970.14
$ 198.42
312.48
312.48
312.48
312.48
313.73
319.98
327.48
339.67
349.67
354.66
362.16
369.66
374.35
379.35
381.85
384.35
386.85
389.35
394.35
399.35
406.85
414.04
424.04
436.53
451.22
468.72
488.41
510.90
533.09
558.09
582.78
609.96
637.46
667.14
696.83
729.02
761.51
796.20
813.39
848.07
878.07
897.76
922.44
937.44
937.44
$ 207.57
326.88
326.88
326.88
326.88
328.19
334.73
342.57
355.32
365.78
371.01
378.85
386.70
391.60
396.83
399.45
402.06
404.68
407.29
412.52
417.75
425.60
433.12
443.58
456.65
472.01
490.32
510.91
534.45
557.66
583.81
609.63
638.07
666.84
697.89
728.94
762.61
796.61
832.89
850.87
887.15
918.53
939.13
964.95
980.64
980.64
$ 198.91
313.24
313.24
313.24
313.24
314.49
320.76
328.28
340.49
350.52
355.53
363.05
370.56
375.26
380.27
382.78
385.29
387.79
390.30
395.31
400.32
407.84
415.04
425.07
437.60
452.32
469.86
489.59
512.15
534.39
559.45
584.19
611.44
639.01
668.77
698.53
730.79
763.37
798.14
815.36
850.13
880.20
899.94
924.68
939.72
939.72
$ 187.93
295.95
295.95
295.95
295.95
297.13
303.05
310.16
321.70
331.17
335.90
343.01
350.11
354.55
359.28
361.65
364.02
366.39
368.75
373.49
378.22
385.33
392.13
401.60
413.44
427.35
443.93
462.57
483.88
504.89
528.57
551.95
577.69
603.74
631.85
659.97
690.45
721.23
754.08
770.36
803.21
831.62
850.26
873.64
887.85
887.85
$ 199.99
314.94
314.94
314.94
314.94
316.20
322.50
330.06
342.34
352.42
357.46
365.02
372.57
377.30
382.34
384.86
387.38
389.90
392.42
397.45
402.49
410.05
417.30
427.37
439.97
454.77
472.41
492.25
514.93
537.29
562.48
587.36
614.76
642.48
672.40
702.32
734.76
767.51
802.47
819.79
854.75
884.98
904.82
929.70
944.82
944.82
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
10
0SNG
16064VA1210008
Anthem Preferred DirectAccess gtga
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 199.61
314.34
314.34
314.34
314.34
315.60
321.88
329.43
341.69
351.75
356.78
364.32
371.86
376.58
381.61
384.12
386.64
389.15
391.67
396.70
401.73
409.27
416.50
426.56
439.13
453.91
471.51
491.31
513.95
536.26
561.41
586.24
613.59
641.25
671.12
700.98
733.36
766.05
800.94
818.23
853.12
883.30
903.10
927.93
943.02
943.02
$ 182.05
286.69
286.69
286.69
286.69
287.84
293.57
300.45
311.63
320.81
325.39
332.27
339.15
343.45
348.04
350.34
352.63
354.92
357.22
361.80
366.39
373.27
379.86
389.04
400.51
413.98
430.04
448.10
468.74
489.09
512.03
534.68
559.62
584.85
612.08
639.32
668.85
698.66
730.49
746.25
778.08
805.60
823.66
846.31
860.07
860.07
$ 194.18
305.80
305.80
305.80
305.80
307.02
313.14
320.48
332.40
342.19
347.08
354.42
361.76
366.35
371.24
373.69
376.13
378.58
381.03
385.92
390.81
398.15
405.19
414.97
427.20
441.58
458.70
477.97
499.98
521.69
546.16
570.32
596.92
623.83
652.88
681.93
713.43
745.23
779.18
796.00
829.94
859.30
878.56
902.72
917.40
917.40
$ 181.60
285.99
285.99
285.99
285.99
287.13
292.85
299.72
310.87
320.02
324.60
331.46
338.33
342.62
347.19
349.48
351.77
354.06
356.34
360.92
365.50
372.36
378.94
388.09
399.53
412.97
428.99
447.00
467.59
487.90
510.78
533.37
558.25
583.42
610.59
637.76
667.21
696.96
728.70
744.43
776.18
803.63
821.65
844.24
857.97
857.97
$ 188.55
296.93
296.93
296.93
296.93
298.12
304.06
311.18
322.76
332.26
337.02
344.14
351.27
355.72
360.47
362.85
365.22
367.60
369.97
374.73
379.48
386.60
393.43
402.93
414.81
428.77
445.40
464.10
485.48
506.56
530.32
553.77
579.61
605.74
633.95
662.15
692.74
723.62
756.58
772.91
805.87
834.37
853.08
876.54
890.79
890.79
$ 179.29
282.34
282.34
282.34
282.34
283.47
289.12
295.89
306.90
315.94
320.46
327.23
334.01
338.24
342.76
345.02
347.28
349.54
351.80
356.31
360.83
367.61
374.10
383.14
394.43
407.70
423.51
441.30
461.63
481.67
504.26
526.56
551.13
575.97
602.80
629.62
658.70
688.06
719.40
734.93
766.27
793.38
811.16
833.47
847.02
847.02
$ 198.71
312.93
312.93
312.93
312.93
314.18
320.44
327.95
340.15
350.17
355.18
362.69
370.20
374.89
379.90
382.40
384.90
387.41
389.91
394.92
399.92
407.43
414.63
424.65
437.16
451.87
469.40
489.11
511.64
533.86
558.89
583.61
610.84
638.38
668.11
697.83
730.07
762.61
797.35
814.56
849.29
879.33
899.05
923.77
938.79
938.79
$ 192.02
302.39
302.39
302.39
302.39
303.60
309.65
316.90
328.70
338.37
343.21
350.47
357.73
362.26
367.10
369.52
371.94
374.36
376.78
381.62
386.45
393.71
400.67
410.34
422.44
436.65
453.59
472.64
494.41
515.88
540.07
563.96
590.27
616.88
645.60
674.33
705.48
736.92
770.49
787.12
820.69
849.72
868.77
892.66
907.17
907.17
$ 200.86
316.32
316.32
316.32
316.32
317.59
323.91
331.50
343.84
353.96
359.02
366.61
374.21
378.95
384.01
386.54
389.07
391.60
394.13
399.20
404.26
411.85
419.12
429.25
441.90
456.77
474.48
494.41
517.18
539.64
564.95
589.94
617.46
645.29
675.34
705.39
737.97
770.87
805.98
823.38
858.49
888.86
908.79
933.78
948.96
948.96
$ 192.48
303.12
303.12
303.12
303.12
304.33
310.39
317.67
329.49
339.19
344.04
351.32
358.59
363.14
367.99
370.41
372.84
375.26
377.69
382.54
387.39
394.66
401.63
411.33
423.46
437.71
454.68
473.78
495.60
517.12
541.37
565.32
591.69
618.36
647.16
675.96
707.18
738.70
772.35
789.02
822.67
851.77
870.86
894.81
909.36
909.36
$ 181.86
286.39
286.39
286.39
286.39
287.54
293.26
300.14
311.31
320.47
325.05
331.93
338.80
343.10
347.68
349.97
352.26
354.55
356.84
361.42
366.01
372.88
379.47
388.63
400.09
413.55
429.59
447.63
468.25
488.58
511.49
534.12
559.03
584.24
611.44
638.65
668.15
697.93
729.72
745.47
777.26
804.76
822.80
845.42
859.17
859.17
$ 193.53
304.77
304.77
304.77
304.77
305.99
312.08
319.40
331.28
341.04
345.91
353.23
360.54
365.11
369.99
372.43
374.87
377.31
379.74
384.62
389.50
396.81
403.82
413.57
425.76
440.09
457.16
476.36
498.30
519.94
544.32
568.40
594.91
621.73
650.68
679.64
711.03
742.72
776.55
793.32
827.15
856.40
875.60
899.68
914.31
914.31
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
11
0SNJ
16064VA1210007
Anthem Preferred DirectAccess gyha
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 213.69
336.52
336.52
336.52
336.52
337.87
344.60
352.67
365.80
376.57
381.95
390.03
398.10
403.15
408.54
411.23
413.92
416.61
419.30
424.69
430.07
438.15
445.89
456.66
470.12
485.93
504.78
525.98
550.21
574.10
601.02
627.61
656.89
686.50
718.47
750.44
785.10
820.10
857.45
875.96
913.32
945.62
966.82
993.41
1,009.56
1,009.56
$ 194.89
306.92
306.92
306.92
306.92
308.15
314.29
321.65
333.62
343.44
348.35
355.72
363.09
367.69
372.60
375.06
377.51
379.97
382.42
387.33
392.24
399.61
406.67
416.49
428.77
443.19
460.38
479.72
501.81
523.61
548.16
572.41
599.11
626.12
655.27
684.43
716.04
747.96
782.03
798.91
832.98
862.45
881.78
906.03
920.76
920.76
$ 207.89
327.38
327.38
327.38
327.38
328.69
335.24
343.09
355.86
366.34
371.58
379.43
387.29
392.20
397.44
400.06
402.68
405.30
407.92
413.15
418.39
426.25
433.78
444.25
457.35
472.74
491.07
511.69
535.27
558.51
584.70
610.56
639.05
667.86
698.96
730.06
763.78
797.83
834.16
852.17
888.51
919.94
940.56
966.43
982.14
982.14
$ 194.42
306.17
306.17
306.17
306.17
307.39
313.52
320.87
332.81
342.60
347.50
354.85
362.20
366.79
371.69
374.14
376.59
379.04
381.49
386.39
391.29
398.63
405.68
415.47
427.72
442.11
459.26
478.54
500.59
522.33
546.82
571.01
597.64
624.59
653.67
682.76
714.29
746.14
780.12
796.96
830.95
860.34
879.63
903.81
918.51
918.51
$ 201.86
317.89
317.89
317.89
317.89
319.16
325.52
333.15
345.55
355.72
360.81
368.43
376.06
380.83
385.92
388.46
391.00
393.55
396.09
401.18
406.26
413.89
421.20
431.38
444.09
459.03
476.84
496.86
519.75
542.32
567.75
592.86
620.52
648.50
678.70
708.89
741.64
774.70
809.98
827.47
862.75
893.27
913.30
938.41
953.67
953.67
$ 191.94
302.26
302.26
302.26
302.26
303.47
309.51
316.77
328.56
338.23
343.07
350.32
357.57
362.11
366.94
369.36
371.78
374.20
376.62
381.45
386.29
393.54
400.49
410.17
422.26
436.46
453.39
472.43
494.20
515.66
539.84
563.71
590.01
616.61
645.33
674.04
705.17
736.61
770.16
786.78
820.33
849.35
868.39
892.27
906.78
906.78
$ 212.73
335.01
335.01
335.01
335.01
336.35
343.05
351.09
364.16
374.88
380.24
388.28
396.32
401.34
406.70
409.38
412.06
414.74
417.42
422.78
428.14
436.18
443.89
454.61
468.01
483.75
502.52
523.62
547.74
571.53
598.33
624.79
653.94
683.42
715.25
747.07
781.58
816.42
853.61
872.03
909.22
941.38
962.48
988.95
1,005.03
1,005.03
$ 205.57
323.73
323.73
323.73
323.73
325.02
331.50
339.27
351.89
362.25
367.43
375.20
382.97
387.83
393.01
395.60
398.19
400.78
403.37
408.55
413.73
421.50
428.94
439.30
452.25
467.47
485.60
505.99
529.30
552.28
578.18
603.76
631.92
660.41
691.16
721.92
755.26
788.93
824.86
842.67
878.60
909.68
930.08
955.65
971.19
971.19
$ 215.04
338.64
338.64
338.64
338.64
339.99
346.77
354.89
368.10
378.94
384.36
392.48
400.61
405.69
411.11
413.82
416.53
419.24
421.95
427.36
432.78
440.91
448.70
459.53
473.08
489.00
507.96
529.29
553.68
577.72
604.81
631.56
661.03
690.83
723.00
755.17
790.05
825.27
862.85
881.48
919.07
951.58
972.91
999.67
1,015.92
1,015.92
$ 206.06
324.51
324.51
324.51
324.51
325.81
332.30
340.09
352.74
363.13
368.32
376.11
383.90
388.76
393.96
396.55
399.15
401.74
404.34
409.53
414.72
422.51
429.98
440.36
453.34
468.59
486.77
507.21
530.57
553.61
579.57
605.21
633.44
662.00
692.83
723.66
757.08
790.83
826.85
844.70
880.72
911.87
932.32
957.95
973.53
973.53
$ 194.69
306.60
306.60
306.60
306.60
307.83
313.96
321.32
333.27
343.09
347.99
355.35
362.71
367.31
372.21
374.67
377.12
379.57
382.02
386.93
391.83
399.19
406.25
416.06
428.32
442.73
459.90
479.22
501.29
523.06
547.59
571.81
598.48
625.46
654.59
683.72
715.30
747.18
781.22
798.08
832.11
861.55
880.86
905.08
919.80
919.80
$ 207.18
326.27
326.27
326.27
326.27
327.58
334.10
341.93
354.66
365.10
370.32
378.15
385.98
390.87
396.09
398.70
401.31
403.92
406.53
411.75
416.97
424.80
432.31
442.75
455.80
471.13
489.41
509.96
533.45
556.62
582.72
608.49
636.88
665.59
696.59
727.58
761.19
795.12
831.34
849.28
885.50
916.82
937.37
963.15
978.81
978.81
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
12
0SMY
16064VA1210004
Anthem Preferred DirectAccess gzha
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 194.86
306.86
306.86
306.86
306.86
308.09
314.22
321.59
333.56
343.38
348.29
355.65
363.02
367.62
372.53
374.98
377.44
379.89
382.35
387.26
392.17
399.53
406.59
416.41
428.68
443.11
460.29
479.62
501.72
523.50
548.05
572.29
598.99
625.99
655.15
684.30
715.90
747.82
781.88
798.76
832.82
862.28
881.61
905.85
920.58
920.58
$ 177.72
279.88
279.88
279.88
279.88
281.00
286.60
293.31
304.23
313.19
317.66
324.38
331.10
335.30
339.77
342.01
344.25
346.49
348.73
353.21
357.69
364.40
370.84
379.80
390.99
404.15
419.82
437.45
457.60
477.48
499.87
521.98
546.33
570.96
597.54
624.13
652.96
682.07
713.13
728.53
759.59
786.46
804.10
826.21
839.64
839.64
$ 189.57
298.53
298.53
298.53
298.53
299.72
305.69
312.86
324.50
334.06
338.83
346.00
353.16
357.64
362.42
364.80
367.19
369.58
371.97
376.74
381.52
388.69
395.55
405.11
417.05
431.08
447.80
466.60
488.10
509.29
533.17
556.76
582.73
609.00
637.36
665.72
696.47
727.52
760.65
777.07
810.21
838.87
857.68
881.26
895.59
895.59
$ 177.29
279.19
279.19
279.19
279.19
280.31
285.89
292.59
303.48
312.41
316.88
323.58
330.28
334.47
338.94
341.17
343.40
345.64
347.87
352.34
356.80
363.51
369.93
378.86
390.03
403.15
418.79
436.37
456.48
476.30
498.63
520.69
544.98
569.55
596.07
622.59
651.35
680.39
711.38
726.73
757.72
784.52
802.11
824.17
837.57
837.57
$ 184.07
289.87
289.87
289.87
289.87
291.03
296.83
303.78
315.09
324.36
329.00
335.96
342.92
347.26
351.90
354.22
356.54
358.86
361.18
365.82
370.45
377.41
384.08
393.35
404.95
418.57
434.81
453.07
473.94
494.52
517.71
540.61
565.83
591.33
618.87
646.41
676.27
706.41
738.59
754.53
786.71
814.53
832.80
855.70
869.61
869.61
$ 175.02
275.62
275.62
275.62
275.62
276.72
282.23
288.85
299.60
308.42
312.83
319.44
326.06
330.19
334.60
336.81
339.01
341.22
343.42
347.83
352.24
358.86
365.20
374.02
385.04
398.00
413.43
430.79
450.64
470.21
492.26
514.03
538.01
562.26
588.45
614.63
643.02
671.69
702.28
717.44
748.03
774.49
791.86
813.63
826.86
826.86
$ 193.99
305.49
305.49
305.49
305.49
306.71
312.82
320.15
332.07
341.84
346.73
354.06
361.39
365.98
370.86
373.31
375.75
378.20
380.64
385.53
390.42
397.75
404.77
414.55
426.77
441.13
458.24
477.48
499.48
521.17
545.61
569.74
596.32
623.20
652.22
681.24
712.71
744.48
778.39
795.19
829.10
858.43
877.67
901.81
916.47
916.47
$ 187.45
295.20
295.20
295.20
295.20
296.38
302.28
309.37
320.88
330.33
335.05
342.14
349.22
353.65
358.37
360.73
363.10
365.46
367.82
372.54
377.27
384.35
391.14
400.59
412.39
426.27
442.80
461.40
482.65
503.61
527.23
550.55
576.23
602.21
630.25
658.30
688.70
719.40
752.17
768.41
801.17
829.51
848.11
871.43
885.60
885.60
$ 196.08
308.79
308.79
308.79
308.79
310.03
316.20
323.61
335.65
345.54
350.48
357.89
365.30
369.93
374.87
377.34
379.81
382.28
384.75
389.69
394.63
402.04
409.15
419.03
431.38
445.89
463.19
482.64
504.87
526.80
551.50
575.89
602.76
629.93
659.27
688.60
720.41
752.52
786.80
803.78
838.06
867.70
887.15
911.55
926.37
926.37
$ 187.90
295.91
295.91
295.91
295.91
297.09
303.01
310.11
321.65
331.12
335.86
342.96
350.06
354.50
359.23
361.60
363.97
366.34
368.70
373.44
378.17
385.27
392.08
401.55
413.39
427.29
443.87
462.51
483.81
504.82
528.50
551.87
577.62
603.66
631.77
659.88
690.36
721.13
753.98
770.25
803.10
831.51
850.15
873.53
887.73
887.73
$ 177.53
279.58
279.58
279.58
279.58
280.70
286.29
293.00
303.90
312.85
317.32
324.03
330.74
334.94
339.41
341.65
343.88
346.12
348.36
352.83
357.30
364.01
370.44
379.39
390.57
403.71
419.37
436.98
457.11
476.96
499.33
521.42
545.74
570.34
596.90
623.46
652.26
681.34
712.37
727.75
758.78
785.62
803.23
825.32
838.74
838.74
$ 188.93
297.52
297.52
297.52
297.52
298.71
304.66
311.80
323.40
332.92
337.69
344.83
351.97
356.43
361.19
363.57
365.95
368.33
370.71
375.47
380.23
387.37
394.21
403.73
415.64
429.62
446.28
465.02
486.45
507.57
531.37
554.87
580.76
606.94
635.21
663.47
694.11
725.06
758.08
774.44
807.47
836.03
854.77
878.28
892.56
892.56
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
13
0SN0
16064VA1210009
Anthem Preferred DirectAccess gbia
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 208.48
328.32
328.32
328.32
328.32
329.63
336.20
344.08
356.88
367.39
372.64
380.52
388.40
393.33
398.58
401.21
403.83
406.46
409.09
414.34
419.59
427.47
435.02
445.53
458.66
474.09
492.48
513.16
536.80
560.11
586.38
612.32
640.88
669.77
700.96
732.15
765.97
800.12
836.56
854.62
891.06
922.58
943.26
969.20
984.96
984.96
$ 190.14
299.44
299.44
299.44
299.44
300.64
306.63
313.81
325.49
335.07
339.86
347.05
354.24
358.73
363.52
365.92
368.31
370.71
373.10
377.89
382.68
389.87
396.76
406.34
418.32
432.39
449.16
468.02
489.58
510.84
534.80
558.46
584.51
610.86
639.30
667.75
698.59
729.74
762.97
779.44
812.68
841.43
860.29
883.95
898.32
898.32
$ 202.82
319.40
319.40
319.40
319.40
320.68
327.07
334.73
347.19
357.41
362.52
370.18
377.85
382.64
387.75
390.31
392.86
395.42
397.97
403.08
408.19
415.86
423.21
433.43
446.20
461.21
479.10
499.22
522.22
544.90
570.45
595.68
623.47
651.58
681.92
712.26
745.16
778.38
813.83
831.40
866.85
897.51
917.64
942.87
958.20
958.20
$ 189.68
298.71
298.71
298.71
298.71
299.90
305.88
313.05
324.70
334.26
339.04
346.20
353.37
357.85
362.63
365.02
367.41
369.80
372.19
376.97
381.75
388.92
395.79
405.35
417.30
431.34
448.07
466.88
488.39
509.60
533.50
557.09
583.08
609.37
637.75
666.12
696.89
727.96
761.11
777.54
810.70
839.38
858.19
881.79
896.13
896.13
$ 196.94
310.14
310.14
310.14
310.14
311.38
317.58
325.03
337.12
347.05
352.01
359.45
366.90
371.55
376.51
378.99
381.47
383.95
386.43
391.40
396.36
403.80
410.94
420.86
433.27
447.84
465.21
484.75
507.08
529.10
553.91
578.41
605.39
632.69
662.15
691.61
723.56
755.81
790.24
807.29
841.72
871.49
891.03
915.53
930.42
930.42
$ 187.26
294.89
294.89
294.89
294.89
296.07
301.97
309.04
320.55
329.98
334.70
341.78
348.85
353.28
358.00
360.36
362.71
365.07
367.43
372.15
376.87
383.95
390.73
400.17
411.96
425.82
442.34
460.91
482.15
503.08
526.67
549.97
575.63
601.58
629.59
657.60
687.98
718.65
751.38
767.60
800.33
828.64
847.22
870.52
884.67
884.67
$ 207.55
326.85
326.85
326.85
326.85
328.16
334.69
342.54
355.29
365.75
370.97
378.82
386.66
391.57
396.80
399.41
402.03
404.64
407.26
412.48
417.71
425.56
433.08
443.54
456.61
471.97
490.28
510.87
534.40
557.61
583.75
609.58
638.01
666.77
697.82
728.88
762.54
796.53
832.81
850.79
887.07
918.45
939.04
964.86
980.55
980.55
$ 200.56
315.84
315.84
315.84
315.84
317.10
323.42
331.00
343.32
353.42
358.48
366.06
373.64
378.38
383.43
385.96
388.48
391.01
393.54
398.59
403.64
411.22
418.49
428.59
441.23
456.07
473.76
493.66
516.40
538.82
564.09
589.04
616.52
644.31
674.32
704.32
736.85
769.70
804.76
822.13
857.19
887.51
907.41
932.36
947.52
947.52
$ 209.80
330.39
330.39
330.39
330.39
331.71
338.32
346.25
359.13
369.71
374.99
382.92
390.85
395.81
401.09
403.74
406.38
409.02
411.67
416.95
422.24
430.17
437.77
448.34
461.55
477.08
495.59
516.40
540.19
563.65
590.08
616.18
644.92
674.00
705.38
736.77
770.80
805.16
841.83
860.01
896.68
928.40
949.21
975.31
991.17
991.17
$ 201.04
316.60
316.60
316.60
316.60
317.87
324.20
331.80
344.14
354.28
359.34
366.94
374.54
379.29
384.35
386.89
389.42
391.95
394.48
399.55
404.61
412.21
419.50
429.63
442.29
457.17
474.90
494.85
517.64
540.12
565.45
590.46
618.00
645.86
675.94
706.02
738.63
771.55
806.70
824.11
859.25
889.65
909.59
934.60
949.80
949.80
$ 189.95
299.13
299.13
299.13
299.13
300.33
306.31
313.49
325.15
334.73
339.51
346.69
353.87
358.36
363.14
365.54
367.93
370.32
372.72
377.50
382.29
389.47
396.35
405.92
417.88
431.94
448.70
467.54
489.08
510.32
534.25
557.88
583.90
610.23
638.64
667.06
697.87
728.98
762.18
778.64
811.84
840.56
859.40
883.03
897.39
897.39
$ 202.13
318.32
318.32
318.32
318.32
319.59
325.96
333.60
346.01
356.20
361.29
368.93
376.57
381.35
386.44
388.99
391.53
394.08
396.63
401.72
406.81
414.45
421.77
431.96
444.69
459.65
477.48
497.53
520.45
543.05
568.52
593.67
621.36
649.37
679.61
709.85
742.64
775.75
811.08
828.59
863.92
894.48
914.53
939.68
954.96
954.96
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
14
0SNU
16064VA1210016
Anthem Preferred DirectAccess gaaf
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 214.03
337.05
337.05
337.05
337.05
338.40
345.14
353.23
366.37
377.16
382.55
390.64
398.73
403.79
409.18
411.88
414.57
417.27
419.96
425.36
430.75
438.84
446.59
457.38
470.86
486.70
505.58
526.81
551.08
575.01
601.97
628.60
657.92
687.58
719.60
751.62
786.34
821.39
858.80
877.34
914.75
947.11
968.34
994.97
1,011.15
1,011.15
$ 195.21
307.41
307.41
307.41
307.41
308.64
314.79
322.17
334.15
343.99
348.91
356.29
363.67
368.28
373.20
375.66
378.11
380.57
383.03
387.95
392.87
400.25
407.32
417.16
429.45
443.90
461.12
480.48
502.62
524.44
549.03
573.32
600.06
627.12
656.32
685.52
717.19
749.16
783.28
800.19
834.31
863.82
883.19
907.47
922.23
922.23
$ 208.22
327.90
327.90
327.90
327.90
329.21
335.77
343.64
356.43
366.92
372.17
380.04
387.91
392.82
398.07
400.69
403.32
405.94
408.56
413.81
419.06
426.93
434.47
444.96
458.08
473.49
491.85
512.51
536.12
559.40
585.63
611.53
640.06
668.92
700.07
731.22
764.99
799.09
835.49
853.52
889.92
921.40
942.06
967.96
983.70
983.70
$ 194.73
306.66
306.66
306.66
306.66
307.89
314.02
321.38
333.34
343.15
348.06
355.42
362.78
367.38
372.29
374.74
377.19
379.65
382.10
387.00
391.91
399.27
406.32
416.14
428.40
442.82
459.99
479.31
501.39
523.16
547.69
571.92
598.60
625.59
654.72
683.85
715.44
747.33
781.37
798.24
832.28
861.71
881.03
905.26
919.98
919.98
$ 202.18
318.39
318.39
318.39
318.39
319.66
326.03
333.67
346.09
356.28
361.37
369.01
376.66
381.43
386.53
389.07
391.62
394.17
396.71
401.81
406.90
414.54
421.87
432.06
444.79
459.76
477.59
497.64
520.57
543.17
568.64
593.80
621.50
649.52
679.76
710.01
742.80
775.92
811.26
828.77
864.11
894.68
914.73
939.89
955.17
955.17
$ 192.24
302.74
302.74
302.74
302.74
303.95
310.01
317.27
329.08
338.77
343.61
350.88
358.14
362.68
367.53
369.95
372.37
374.79
377.21
382.06
386.90
394.17
401.13
410.82
422.93
437.16
454.11
473.18
494.98
516.47
540.69
564.61
590.95
617.59
646.35
675.11
706.29
737.78
771.38
788.03
821.64
850.70
869.77
893.69
908.22
908.22
$ 213.07
335.55
335.55
335.55
335.55
336.89
343.60
351.66
364.74
375.48
380.85
388.90
396.96
401.99
407.36
410.04
412.73
415.41
418.10
423.46
428.83
436.89
444.60
455.34
468.76
484.53
503.33
524.46
548.62
572.45
599.29
625.80
654.99
684.52
716.40
748.28
782.84
817.74
854.98
873.44
910.68
942.90
964.04
990.54
1,006.65
1,006.65
$ 205.89
324.24
324.24
324.24
324.24
325.54
332.02
339.80
352.45
362.82
368.01
375.79
383.58
388.44
393.63
396.22
398.82
401.41
404.00
409.19
414.38
422.16
429.62
439.99
452.96
468.20
486.36
506.79
530.13
553.15
579.09
604.71
632.92
661.45
692.25
723.06
756.45
790.17
826.16
844.00
879.99
911.11
931.54
957.16
972.72
972.72
$ 215.37
339.17
339.17
339.17
339.17
340.53
347.31
355.45
368.68
379.53
384.96
393.10
401.24
406.33
411.75
414.47
417.18
419.89
422.61
428.03
433.46
441.60
449.40
460.25
473.82
489.76
508.76
530.12
554.54
578.62
605.76
632.55
662.06
691.91
724.13
756.35
791.28
826.56
864.21
882.86
920.51
953.07
974.44
1,001.23
1,017.51
1,017.51
$ 206.39
325.02
325.02
325.02
325.02
326.32
332.82
340.62
353.30
363.70
368.90
376.70
384.50
389.37
394.57
397.17
399.77
402.37
404.97
410.18
415.38
423.18
430.65
441.05
454.05
469.33
487.53
508.01
531.41
554.48
580.49
606.16
634.44
663.04
693.92
724.79
758.27
792.07
828.15
846.03
882.10
913.31
933.78
959.46
975.06
975.06
$ 195.00
307.08
307.08
307.08
307.08
308.31
314.45
321.82
333.80
343.62
348.54
355.91
363.28
367.88
372.80
375.25
377.71
380.17
382.62
387.53
392.45
399.82
406.88
416.71
428.99
443.42
460.62
479.97
502.08
523.88
548.44
572.70
599.42
626.44
655.62
684.79
716.42
748.35
782.44
799.33
833.42
862.89
882.24
906.50
921.24
921.24
$ 207.51
326.79
326.79
326.79
326.79
328.10
334.63
342.48
355.22
365.68
370.91
378.75
386.59
391.49
396.72
399.34
401.95
404.57
407.18
412.41
417.64
425.48
433.00
443.45
456.53
471.88
490.19
510.77
534.30
557.50
583.65
609.46
637.89
666.65
697.70
728.74
762.40
796.39
832.66
850.63
886.91
918.28
938.87
964.68
980.37
980.37
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
15
0SNY
16064VA1210011
Anthem Preferred DirectAccess gpqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 215.00
338.59
338.59
338.59
338.59
339.94
346.72
354.84
368.05
378.88
384.30
392.43
400.55
405.63
411.05
413.76
416.47
419.17
421.88
427.30
432.72
440.84
448.63
459.47
473.01
488.92
507.89
529.22
553.59
577.63
604.72
631.47
660.93
690.72
722.89
755.06
789.93
825.14
862.73
881.35
918.93
951.44
972.77
999.52
1,015.77
1,015.77
$ 196.09
308.81
308.81
308.81
308.81
310.05
316.22
323.63
335.68
345.56
350.50
357.91
365.32
369.95
374.90
377.37
379.84
382.31
384.78
389.72
394.66
402.07
409.17
419.06
431.41
445.92
463.22
482.67
504.90
526.83
551.53
575.93
602.80
629.97
659.31
688.65
720.45
752.57
786.85
803.83
838.11
867.76
887.21
911.61
926.43
926.43
$ 209.17
329.40
329.40
329.40
329.40
330.72
337.31
345.21
358.06
368.60
373.87
381.77
389.68
394.62
399.89
402.53
405.16
407.80
410.43
415.70
420.97
428.88
436.46
447.00
460.17
475.65
494.10
514.85
538.57
561.96
588.31
614.33
642.99
671.98
703.27
734.56
768.49
802.75
839.31
857.43
893.99
925.61
946.37
972.39
988.20
988.20
$ 195.62
308.06
308.06
308.06
308.06
309.29
315.45
322.85
334.86
344.72
349.65
357.04
364.43
369.06
373.98
376.45
378.91
381.38
383.84
388.77
393.70
401.09
408.18
418.04
430.36
444.84
462.09
481.50
503.68
525.55
550.20
574.53
601.33
628.44
657.71
686.97
718.70
750.74
784.94
801.88
836.07
865.65
885.06
909.39
924.18
924.18
$ 203.10
319.84
319.84
319.84
319.84
321.12
327.52
335.19
347.67
357.90
363.02
370.69
378.37
383.17
388.29
390.84
393.40
395.96
398.52
403.64
408.76
416.43
423.79
434.02
446.82
461.85
479.76
499.91
522.94
545.65
571.23
596.50
624.33
652.47
682.86
713.24
746.19
779.45
814.95
832.54
868.05
898.75
918.90
944.17
959.52
959.52
$ 193.12
304.12
304.12
304.12
304.12
305.34
311.42
318.72
330.58
340.31
345.18
352.48
359.77
364.34
369.20
371.63
374.07
376.50
378.93
383.80
388.67
395.96
402.96
412.69
424.86
439.15
456.18
475.34
497.24
518.83
543.16
567.18
593.64
620.40
649.30
678.19
709.51
741.14
774.90
791.62
825.38
854.58
873.74
897.76
912.36
912.36
$ 214.05
337.08
337.08
337.08
337.08
338.43
345.17
353.26
366.41
377.19
382.59
390.68
398.77
403.82
409.22
411.91
414.61
417.31
420.00
425.39
430.79
438.88
446.63
457.42
470.90
486.74
505.62
526.86
551.13
575.06
602.02
628.65
657.98
687.64
719.67
751.69
786.41
821.46
858.88
877.42
914.84
947.19
968.43
995.06
1,011.24
1,011.24
$ 206.83
325.72
325.72
325.72
325.72
327.02
333.54
341.35
354.06
364.48
369.69
377.51
385.33
390.21
395.42
398.03
400.64
403.24
405.85
411.06
416.27
424.09
431.58
442.00
455.03
470.34
488.58
509.10
532.55
555.68
581.74
607.47
635.81
664.47
695.41
726.36
759.90
793.78
829.93
847.85
884.00
915.27
935.79
961.53
977.16
977.16
$ 216.36
340.72
340.72
340.72
340.72
342.08
348.90
357.07
370.36
381.27
386.72
394.89
403.07
408.18
413.63
416.36
419.09
421.81
424.54
429.99
435.44
443.62
451.45
462.36
475.99
492.00
511.08
532.55
557.08
581.27
608.53
635.44
665.09
695.07
727.44
759.81
794.90
830.33
868.15
886.89
924.71
957.42
978.89
1,005.81
1,022.16
1,022.16
$ 207.33
326.51
326.51
326.51
326.51
327.82
334.35
342.18
354.92
365.36
370.59
378.43
386.26
391.16
396.38
399.00
401.61
404.22
406.83
412.06
417.28
425.12
432.63
443.07
456.13
471.48
489.77
510.34
533.84
557.03
583.15
608.94
637.35
666.08
697.10
728.12
761.75
795.70
831.95
849.91
886.15
917.49
938.06
963.86
979.53
979.53
$ 195.89
308.49
308.49
308.49
308.49
309.72
315.89
323.30
335.33
345.20
350.14
357.54
364.94
369.57
374.51
376.97
379.44
381.91
384.38
389.31
394.25
401.65
408.75
418.62
430.96
445.46
462.74
482.17
504.38
526.28
550.96
575.33
602.17
629.32
658.63
687.93
719.71
751.79
786.03
803.00
837.24
866.86
886.29
910.66
925.47
925.47
$ 208.46
328.28
328.28
328.28
328.28
329.59
336.16
344.04
356.84
367.35
372.60
380.48
388.36
393.28
398.53
401.16
403.78
406.41
409.04
414.29
419.54
427.42
434.97
445.48
458.61
474.04
492.42
513.10
536.74
560.05
586.31
612.24
640.80
669.69
700.88
732.06
765.88
800.02
836.46
854.51
890.95
922.47
943.15
969.08
984.84
984.84
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
16
0SN6
16064VA1210012
Anthem Preferred DirectAccess gqqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 198.56
312.70
312.70
312.70
312.70
313.95
320.20
327.71
339.90
349.91
354.91
362.42
369.92
374.61
379.62
382.12
384.62
387.12
389.62
394.63
399.63
407.14
414.33
424.33
436.84
451.54
469.05
488.75
511.26
533.47
558.48
583.19
610.39
637.91
667.61
697.32
729.53
762.05
796.76
813.96
848.67
878.69
898.39
923.09
938.10
938.10
$ 181.10
285.20
285.20
285.20
285.20
286.34
292.04
298.89
310.01
319.14
323.70
330.55
337.39
341.67
346.23
348.51
350.80
353.08
355.36
359.92
364.49
371.33
377.89
387.02
398.42
411.83
427.80
445.77
466.30
486.55
509.37
531.90
556.71
581.81
608.90
636.00
665.37
695.03
726.69
742.38
774.03
801.41
819.38
841.91
855.60
855.60
$ 193.17
304.21
304.21
304.21
304.21
305.43
311.51
318.81
330.68
340.41
345.28
352.58
359.88
364.44
369.31
371.74
374.18
376.61
379.05
383.91
388.78
396.08
403.08
412.81
424.98
439.28
456.32
475.48
497.38
518.98
543.32
567.35
593.82
620.59
649.49
678.39
709.72
741.36
775.13
791.86
825.63
854.83
874.00
898.03
912.63
912.63
$ 180.66
284.51
284.51
284.51
284.51
285.65
291.34
298.17
309.26
318.37
322.92
329.75
336.58
340.84
345.40
347.67
349.95
352.22
354.50
359.05
363.60
370.43
376.98
386.08
397.46
410.83
426.77
444.69
465.17
485.37
508.13
530.61
555.36
580.40
607.43
634.46
663.76
693.35
724.93
740.58
772.16
799.47
817.40
839.87
853.53
853.53
$ 187.57
295.39
295.39
295.39
295.39
296.57
302.48
309.57
321.09
330.54
335.27
342.36
349.45
353.88
358.60
360.97
363.33
365.69
368.06
372.78
377.51
384.60
391.39
400.84
412.66
426.54
443.09
461.69
482.96
503.94
527.57
550.90
576.60
602.60
630.66
658.72
689.14
719.87
752.65
768.90
801.69
830.05
848.66
871.99
886.17
886.17
$ 178.35
280.87
280.87
280.87
280.87
281.99
287.61
294.35
305.31
314.29
318.79
325.53
332.27
336.48
340.98
343.22
345.47
347.72
349.96
354.46
358.95
365.69
372.15
381.14
392.38
405.58
421.31
439.00
459.22
479.16
501.63
523.82
548.26
572.97
599.66
626.34
655.27
684.48
715.66
731.10
762.28
789.24
806.94
829.13
842.61
842.61
$ 197.68
311.31
311.31
311.31
311.31
312.56
318.78
326.25
338.39
348.36
353.34
360.81
368.28
372.95
377.93
380.42
382.91
385.40
387.89
392.87
397.85
405.33
412.49
422.45
434.90
449.53
466.97
486.58
508.99
531.09
556.00
580.59
607.68
635.07
664.65
694.22
726.29
758.66
793.22
810.34
844.90
874.78
894.39
918.99
933.93
933.93
$ 191.02
300.82
300.82
300.82
300.82
302.02
308.04
315.26
326.99
336.62
341.43
348.65
355.87
360.38
365.20
367.60
370.01
372.42
374.82
379.63
384.45
391.67
398.59
408.21
420.25
434.38
451.23
470.18
491.84
513.20
537.26
561.03
587.20
613.67
642.25
670.83
701.81
733.10
766.49
783.03
816.43
845.30
864.26
888.02
902.46
902.46
$ 199.82
314.67
314.67
314.67
314.67
315.93
322.22
329.77
342.05
352.12
357.15
364.70
372.25
376.97
382.01
384.53
387.04
389.56
392.08
397.11
402.15
409.70
416.94
427.01
439.59
454.38
472.01
491.83
514.49
536.83
562.00
586.86
614.24
641.93
671.82
701.71
734.13
766.85
801.78
819.09
854.01
884.22
904.05
928.91
944.01
944.01
$ 191.48
301.55
301.55
301.55
301.55
302.76
308.79
316.02
327.78
337.43
342.26
349.50
356.73
361.26
366.08
368.49
370.91
373.32
375.73
380.56
385.38
392.62
399.55
409.20
421.27
435.44
452.33
471.32
493.03
514.44
538.57
562.39
588.63
615.16
643.81
672.46
703.52
734.88
768.35
784.93
818.41
847.36
866.35
890.18
904.65
904.65
$ 180.91
284.90
284.90
284.90
284.90
286.04
291.74
298.58
309.69
318.80
323.36
330.20
337.04
341.31
345.87
348.15
350.43
352.71
354.99
359.54
364.10
370.94
377.49
386.61
398.01
411.40
427.35
445.30
465.81
486.04
508.83
531.34
556.12
581.20
608.26
635.33
664.67
694.30
725.93
741.59
773.22
800.57
818.52
841.02
854.70
854.70
$ 192.52
303.18
303.18
303.18
303.18
304.39
310.46
317.73
329.56
339.26
344.11
351.39
358.66
363.21
368.06
370.49
372.91
375.34
377.76
382.61
387.46
394.74
401.71
411.42
423.54
437.79
454.77
473.87
495.70
517.23
541.48
565.43
591.81
618.49
647.29
676.09
707.32
738.85
772.50
789.18
822.83
851.94
871.04
894.99
909.54
909.54
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
17
0SP7
16064VA1210013
Anthem Preferred DirectAccess grqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 198.13
312.01
312.01
312.01
312.01
313.26
319.50
326.99
339.15
349.14
354.13
361.62
369.11
373.79
378.78
381.28
383.77
386.27
388.76
393.76
398.75
406.24
413.41
423.40
435.88
450.54
468.02
487.67
510.14
532.29
557.25
581.90
609.04
636.50
666.14
695.78
727.92
760.37
795.00
812.16
846.80
876.75
896.40
921.05
936.03
936.03
$ 180.70
284.57
284.57
284.57
284.57
285.71
291.40
298.23
309.33
318.43
322.99
329.82
336.65
340.91
345.47
347.74
350.02
352.30
354.57
359.13
363.68
370.51
377.06
386.16
397.54
410.92
426.86
444.78
465.27
485.48
508.24
530.72
555.48
580.52
607.56
634.59
663.90
693.50
725.08
740.74
772.32
799.64
817.57
840.05
853.71
853.71
$ 192.75
303.54
303.54
303.54
303.54
304.75
310.82
318.11
329.95
339.66
344.52
351.80
359.09
363.64
368.50
370.93
373.35
375.78
378.21
383.07
387.92
395.21
402.19
411.90
424.05
438.31
455.31
474.43
496.29
517.84
542.12
566.10
592.51
619.22
648.06
676.89
708.16
739.73
773.42
790.11
823.81
852.95
872.07
896.05
910.62
910.62
$ 180.26
283.88
283.88
283.88
283.88
285.02
290.69
297.51
308.58
317.66
322.20
329.02
335.83
340.09
344.63
346.90
349.17
351.44
353.71
358.26
362.80
369.61
376.14
385.23
396.58
409.92
425.82
443.70
464.14
484.30
507.01
529.44
554.13
579.12
606.08
633.05
662.29
691.82
723.33
738.94
770.45
797.70
815.59
838.01
851.64
851.64
$ 187.16
294.74
294.74
294.74
294.74
295.92
301.81
308.89
320.38
329.81
334.53
341.60
348.68
353.10
357.81
360.17
362.53
364.89
367.25
371.96
376.68
383.75
390.53
399.96
411.75
425.60
442.11
460.68
481.90
502.83
526.41
549.69
575.33
601.27
629.27
657.27
687.63
718.28
751.00
767.21
799.92
828.22
846.79
870.07
884.22
884.22
$ 177.96
280.25
280.25
280.25
280.25
281.37
286.98
293.70
304.63
313.60
318.08
324.81
331.54
335.74
340.22
342.47
344.71
346.95
349.19
353.68
358.16
364.89
371.33
380.30
391.51
404.68
420.38
438.03
458.21
478.11
500.53
522.67
547.05
571.71
598.33
624.96
653.82
682.97
714.08
729.49
760.60
787.50
805.16
827.30
840.75
840.75
$ 197.24
310.62
310.62
310.62
310.62
311.86
318.07
325.53
337.64
347.58
352.55
360.01
367.46
372.12
377.09
379.58
382.06
384.55
387.03
392.00
396.97
404.43
411.57
421.51
433.94
448.54
465.93
485.50
507.86
529.92
554.77
579.31
606.33
633.66
663.17
692.68
724.68
756.98
791.46
808.54
843.02
872.84
892.41
916.95
931.86
931.86
$ 190.60
300.15
300.15
300.15
300.15
301.35
307.35
314.56
326.26
335.87
340.67
347.87
355.08
359.58
364.38
366.78
369.18
371.59
373.99
378.79
383.59
390.80
397.70
407.30
419.31
433.42
450.23
469.13
490.75
512.06
536.07
559.78
585.89
612.31
640.82
669.33
700.25
731.47
764.78
781.29
814.61
843.42
862.33
886.04
900.45
900.45
$ 199.38
313.98
313.98
313.98
313.98
315.24
321.52
329.05
341.30
351.34
356.37
363.90
371.44
376.15
381.17
383.68
386.20
388.71
391.22
396.24
401.27
408.80
416.02
426.07
438.63
453.39
470.97
490.75
513.36
535.65
560.77
585.57
612.89
640.52
670.35
700.18
732.52
765.17
800.02
817.29
852.14
882.28
902.06
926.87
941.94
941.94
$ 191.06
300.88
300.88
300.88
300.88
302.08
308.10
315.32
327.06
336.68
341.50
348.72
355.94
360.45
365.27
367.68
370.08
372.49
374.90
379.71
384.52
391.75
398.67
408.29
420.33
434.47
451.32
470.28
491.94
513.30
537.37
561.14
587.32
613.80
642.38
670.96
701.95
733.24
766.64
783.19
816.59
845.47
864.43
888.20
902.64
902.64
$ 180.51
284.27
284.27
284.27
284.27
285.41
291.09
297.91
309.00
318.10
322.65
329.47
336.29
340.56
345.10
347.38
349.65
351.93
354.20
358.75
363.30
370.12
376.66
385.75
397.13
410.49
426.41
444.31
464.78
484.96
507.71
530.16
554.90
579.91
606.92
633.92
663.20
692.77
724.32
739.95
771.51
798.80
816.71
839.17
852.81
852.81
$ 192.09
302.51
302.51
302.51
302.51
303.72
309.77
317.03
328.83
338.51
343.35
350.61
357.87
362.41
367.25
369.67
372.09
374.51
376.93
381.77
386.61
393.87
400.83
410.51
422.61
436.82
453.77
472.82
494.60
516.08
540.28
564.18
590.50
617.12
645.86
674.60
705.76
737.22
770.80
787.43
821.01
850.05
869.11
893.01
907.53
907.53
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
18
0VUA
88380VA0740002
Anthem HealthKeepers Preferred Guided Access Plus w/Dental gtoa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 190.00
299.21
299.21
299.21
299.21
300.41
306.39
313.57
325.24
334.82
339.60
346.78
353.97
358.45
363.24
365.63
368.03
370.42
372.82
377.60
382.39
389.57
396.45
406.03
418.00
432.06
448.82
467.67
489.21
510.45
534.39
558.03
584.06
610.39
638.81
667.24
698.06
729.17
762.39
778.84
812.06
840.78
859.63
883.27
897.63
897.63
$ 159.51
251.20
251.20
251.20
251.20
252.20
257.23
263.26
273.05
281.09
285.11
291.14
297.17
300.94
304.96
306.97
308.98
310.99
313.00
317.01
321.03
327.06
332.84
340.88
350.93
362.73
376.80
392.63
410.71
428.55
448.64
468.49
490.34
512.45
536.31
560.18
586.05
612.17
640.06
653.87
681.76
705.87
721.70
741.54
753.60
753.60
$ 177.23
279.11
279.11
279.11
279.11
280.23
285.81
292.51
303.39
312.32
316.79
323.49
330.19
334.37
338.84
341.07
343.31
345.54
347.77
352.24
356.70
363.40
369.82
378.75
389.92
403.03
418.67
436.25
456.34
476.16
498.49
520.54
544.82
569.38
595.90
622.42
651.16
680.19
711.17
726.52
757.50
784.30
801.88
823.93
837.33
837.33
$ 172.28
271.31
271.31
271.31
271.31
272.40
277.82
284.33
294.91
303.60
307.94
314.45
320.96
325.03
329.37
331.54
333.71
335.88
338.05
342.39
346.73
353.25
359.49
368.17
379.02
391.77
406.97
424.06
443.59
462.85
484.56
505.99
529.60
553.47
579.25
605.02
632.97
661.18
691.30
706.22
736.34
762.38
779.47
800.91
813.93
813.93
$ 176.26
277.57
277.57
277.57
277.57
278.68
284.23
290.89
301.72
310.60
315.04
321.70
328.37
332.53
336.97
339.19
341.41
343.63
345.85
350.29
354.73
361.40
367.78
376.66
387.77
400.81
416.36
433.84
453.83
473.53
495.74
517.67
541.82
566.24
592.61
618.98
647.57
676.44
707.25
722.51
753.32
779.97
797.46
819.39
832.71
832.71
$ 177.83
280.05
280.05
280.05
280.05
281.17
286.77
293.49
304.41
313.38
317.86
324.58
331.30
335.50
339.98
342.22
344.46
346.70
348.94
353.42
357.90
364.63
371.07
380.03
391.23
404.39
420.08
437.72
457.88
477.77
500.17
522.29
546.66
571.30
597.91
624.51
653.36
682.48
713.57
728.97
760.06
786.94
804.58
826.71
840.15
840.15
$ 177.06
278.83
278.83
278.83
278.83
279.95
285.52
292.21
303.09
312.01
316.47
323.16
329.86
334.04
338.50
340.73
342.96
345.19
347.42
351.88
356.34
363.04
369.45
378.37
389.53
402.63
418.25
435.81
455.89
475.68
497.99
520.02
544.28
568.81
595.30
621.79
650.51
679.51
710.46
725.79
756.74
783.51
801.08
823.11
836.49
836.49
$ 182.78
287.85
287.85
287.85
287.85
289.00
294.76
301.67
312.89
322.10
326.71
333.62
340.53
344.84
349.45
351.75
354.06
356.36
358.66
363.27
367.87
374.78
381.40
390.61
402.13
415.66
431.78
449.91
470.63
491.07
514.10
536.84
561.88
587.21
614.56
641.91
671.55
701.49
733.44
749.27
781.22
808.86
826.99
849.73
863.55
863.55
$ 176.84
278.49
278.49
278.49
278.49
279.60
285.17
291.86
302.72
311.63
316.09
322.77
329.45
333.63
338.09
340.31
342.54
344.77
347.00
351.45
355.91
362.59
369.00
377.91
389.05
402.14
417.74
435.28
455.33
475.10
497.38
519.38
543.61
568.12
594.58
621.03
649.72
678.68
709.59
724.91
755.82
782.56
800.10
822.10
835.47
835.47
$ 184.00
289.77
289.77
289.77
289.77
290.93
296.72
303.68
314.98
324.25
328.89
335.84
342.80
347.14
351.78
354.10
356.42
358.74
361.05
365.69
370.33
377.28
383.95
393.22
404.81
418.43
434.66
452.91
473.77
494.35
517.53
540.42
565.63
591.13
618.66
646.19
676.03
706.17
738.33
754.27
786.44
814.25
832.51
855.40
869.31
869.31
$ 172.92
272.32
272.32
272.32
272.32
273.41
278.86
285.39
296.01
304.73
309.08
315.62
322.15
326.24
330.60
332.78
334.95
337.13
339.31
343.67
348.02
354.56
360.82
369.54
380.43
393.23
408.48
425.64
445.24
464.58
486.36
507.88
531.57
555.53
581.40
607.27
635.32
663.64
693.87
708.85
739.08
765.22
782.38
803.89
816.96
816.96
$ 175.79
276.84
276.84
276.84
276.84
277.95
283.48
290.13
300.93
309.78
314.21
320.86
327.50
331.65
336.08
338.30
340.51
342.73
344.94
349.37
353.80
360.45
366.81
375.67
386.75
399.76
415.26
432.70
452.63
472.29
494.44
516.31
540.39
564.75
591.05
617.35
645.87
674.66
705.39
720.61
751.34
777.92
795.36
817.23
830.52
830.52
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
19
0W2U
88380VA0740001
Anthem HealthKeepers Preferred Guided Access Plus gtoa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 177.00
278.74
278.74
278.74
278.74
279.85
285.43
292.12
302.99
311.91
316.37
323.06
329.75
333.93
338.39
340.62
342.85
345.08
347.31
351.77
356.23
362.92
369.33
378.25
389.40
402.50
418.11
435.67
455.74
475.53
497.83
519.85
544.10
568.63
595.11
621.59
650.30
679.29
710.23
725.56
756.50
783.26
800.82
822.84
836.22
836.22
$ 148.60
234.02
234.02
234.02
234.02
234.96
239.64
245.25
254.38
261.87
265.61
271.23
276.85
280.36
284.10
285.97
287.84
289.72
291.59
295.33
299.08
304.69
310.08
317.57
326.93
337.92
351.03
365.77
382.62
399.24
417.96
436.45
456.81
477.40
499.63
521.86
545.97
570.31
596.28
609.15
635.13
657.60
672.34
690.83
702.06
702.06
$ 165.11
260.01
260.01
260.01
260.01
261.05
266.25
272.49
282.63
290.95
295.11
301.35
307.59
311.49
315.65
317.73
319.81
321.89
323.97
328.13
332.29
338.53
344.51
352.83
363.23
375.45
390.02
406.40
425.12
443.58
464.38
484.92
507.54
530.42
555.12
579.82
606.60
633.64
662.51
676.81
705.67
730.63
747.01
767.55
780.03
780.03
$ 160.50
252.75
252.75
252.75
252.75
253.76
258.82
264.88
274.74
282.83
286.87
292.94
299.00
302.79
306.84
308.86
310.88
312.90
314.93
318.97
323.01
329.08
334.89
342.98
353.09
364.97
379.13
395.05
413.25
431.19
451.41
471.38
493.37
515.61
539.62
563.63
589.67
615.95
644.01
657.91
685.96
710.23
726.15
746.12
758.25
758.25
$ 164.20
258.58
258.58
258.58
258.58
259.61
264.79
270.99
281.08
289.35
293.49
299.69
305.90
309.78
313.92
315.98
318.05
320.12
322.19
326.33
330.47
336.67
342.62
350.89
361.24
373.39
387.87
404.16
422.78
441.14
461.82
482.25
504.75
527.50
552.07
576.63
603.27
630.16
658.86
673.08
701.79
726.61
742.90
763.33
775.74
775.74
$ 165.67
260.89
260.89
260.89
260.89
261.93
267.15
273.41
283.59
291.94
296.11
302.37
308.63
312.55
316.72
318.81
320.89
322.98
325.07
329.24
333.42
339.68
345.68
354.03
364.46
376.73
391.34
407.77
426.56
445.08
465.95
486.56
509.26
532.22
557.00
581.78
608.66
635.79
664.75
679.10
708.06
733.10
749.54
770.15
782.67
782.67
$ 164.94
259.75
259.75
259.75
259.75
260.79
265.98
272.22
282.35
290.66
294.82
301.05
307.28
311.18
315.34
317.41
319.49
321.57
323.65
327.80
331.96
338.19
344.17
352.48
362.87
375.08
389.63
405.99
424.69
443.13
463.91
484.43
507.03
529.89
554.57
579.24
606.00
633.01
661.84
676.13
704.96
729.90
746.26
766.78
779.25
779.25
$ 170.28
268.15
268.15
268.15
268.15
269.22
274.59
281.02
291.48
300.06
304.35
310.79
317.22
321.24
325.53
327.68
329.82
331.97
334.11
338.41
342.70
349.13
355.30
363.88
374.61
387.21
402.23
419.12
438.43
457.46
478.92
500.10
523.43
547.03
572.50
597.97
625.59
653.48
683.25
697.99
727.76
753.50
770.39
791.58
804.45
804.45
$ 164.74
259.44
259.44
259.44
259.44
260.48
265.67
271.89
282.01
290.31
294.46
300.69
306.92
310.81
314.96
317.04
319.11
321.19
323.26
327.41
331.56
337.79
343.76
352.06
362.44
374.63
389.16
405.50
424.18
442.60
463.36
483.86
506.43
529.26
553.90
578.55
605.27
632.26
661.05
675.32
704.12
729.03
745.37
765.87
778.32
778.32
$ 171.42
269.95
269.95
269.95
269.95
271.03
276.43
282.91
293.44
302.07
306.39
312.87
319.35
323.40
327.72
329.88
332.04
334.20
336.36
340.68
345.00
351.47
357.68
366.32
377.12
389.81
404.93
421.93
441.37
460.53
482.13
503.46
526.94
550.70
576.34
601.99
629.79
657.87
687.83
702.68
732.64
758.56
775.57
796.89
809.85
809.85
$ 161.09
253.69
253.69
253.69
253.69
254.70
259.78
265.87
275.76
283.88
287.94
294.03
300.12
303.92
307.98
310.01
312.04
314.07
316.10
320.16
324.22
330.30
336.14
344.26
354.40
366.33
380.54
396.52
414.78
432.80
453.09
473.13
495.20
517.53
541.63
565.73
591.86
618.24
646.40
660.36
688.51
712.87
728.85
748.89
761.07
761.07
$ 163.77
257.90
257.90
257.90
257.90
258.93
264.09
270.28
280.34
288.59
292.72
298.91
305.10
308.96
313.09
315.15
317.22
319.28
321.34
325.47
329.60
335.79
341.72
349.97
360.29
372.41
386.85
403.10
421.67
439.98
460.61
480.98
503.42
526.12
550.62
575.12
601.68
628.50
657.13
671.31
699.94
724.70
740.95
761.32
773.70
773.70
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
20
0SN4
88380VA0740103
Anthem HealthKeepers Preferred Guided Access Plus gnbf
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 192.73
303.51
303.51
303.51
303.51
304.72
310.79
318.08
329.92
339.63
344.48
351.77
359.05
363.60
368.46
370.89
373.32
375.75
378.17
383.03
387.89
395.17
402.15
411.86
424.00
438.27
455.27
474.39
496.24
517.79
542.07
566.05
592.45
619.16
647.99
676.83
708.09
739.65
773.34
790.04
823.73
852.86
871.98
895.96
910.53
910.53
$ 175.77
276.81
276.81
276.81
276.81
277.92
283.45
290.10
300.89
309.75
314.18
320.82
327.47
331.62
336.05
338.26
340.48
342.69
344.91
349.33
353.76
360.41
366.77
375.63
386.70
399.71
415.22
432.65
452.58
472.24
494.38
516.25
540.33
564.69
590.99
617.29
645.80
674.59
705.31
720.54
751.26
777.84
795.28
817.14
830.43
830.43
$ 182.02
286.65
286.65
286.65
286.65
287.80
293.53
300.41
311.59
320.76
325.35
332.23
339.11
343.41
347.99
350.29
352.58
354.87
357.17
361.75
366.34
373.22
379.81
388.98
400.45
413.92
429.98
448.03
468.67
489.02
511.96
534.60
559.54
584.77
612.00
639.23
668.75
698.57
730.38
746.15
777.97
805.49
823.55
846.19
859.95
859.95
$ 175.35
276.14
276.14
276.14
276.14
277.24
282.77
289.39
300.16
309.00
313.42
320.05
326.67
330.82
335.23
337.44
339.65
341.86
344.07
348.49
352.91
359.53
365.89
374.72
385.77
398.75
414.21
431.61
451.49
471.09
493.19
515.00
539.03
563.33
589.56
615.79
644.23
672.95
703.60
718.79
749.44
775.95
793.35
815.17
828.42
828.42
$ 178.49
281.09
281.09
281.09
281.09
282.21
287.84
294.58
305.54
314.54
319.04
325.78
332.53
336.75
341.24
343.49
345.74
347.99
350.24
354.74
359.23
365.98
372.44
381.44
392.68
405.89
421.64
439.34
459.58
479.54
502.03
524.23
548.69
573.42
600.13
626.83
655.78
685.02
716.22
731.68
762.88
789.86
807.57
829.78
843.27
843.27
$ 178.47
281.06
281.06
281.06
281.06
282.18
287.81
294.55
305.51
314.51
319.00
325.75
332.49
336.71
341.21
343.46
345.70
347.95
350.20
354.70
359.19
365.94
372.40
381.40
392.64
405.85
421.59
439.30
459.53
479.49
501.97
524.18
548.63
573.36
600.06
626.76
655.71
684.94
716.14
731.60
762.80
789.78
807.49
829.69
843.18
843.18
$ 185.93
292.80
292.80
292.80
292.80
293.97
299.83
306.85
318.27
327.64
332.33
339.36
346.38
350.77
355.46
357.80
360.14
362.49
364.83
369.51
374.20
381.23
387.96
397.33
409.04
422.80
439.20
457.65
478.73
499.52
522.94
546.07
571.55
597.31
625.13
652.94
683.10
713.55
746.05
762.16
794.66
822.77
841.21
864.35
878.40
878.40
$ 185.41
291.98
291.98
291.98
291.98
293.15
298.99
306.00
317.38
326.73
331.40
338.40
345.41
349.79
354.46
356.80
359.14
361.47
363.81
368.48
373.15
380.16
386.87
396.22
407.90
421.62
437.97
456.36
477.39
498.12
521.48
544.54
569.94
595.64
623.38
651.12
681.19
711.56
743.97
760.02
792.43
820.46
838.86
861.92
875.94
875.94
$ 180.75
284.64
284.64
284.64
284.64
285.78
291.47
298.30
309.40
318.51
323.07
329.90
336.73
341.00
345.55
347.83
350.11
352.38
354.66
359.22
363.77
370.60
377.15
386.26
397.64
411.02
426.96
444.89
465.39
485.60
508.37
530.85
555.62
580.67
607.71
634.75
664.07
693.67
725.26
740.92
772.51
799.84
817.77
840.26
853.92
853.92
$ 195.64
308.09
308.09
308.09
308.09
309.32
315.48
322.88
334.89
344.75
349.68
357.08
364.47
369.09
374.02
376.49
378.95
381.42
383.88
388.81
393.74
401.13
408.22
418.08
430.40
444.88
462.14
481.54
503.73
525.60
550.25
574.59
601.39
628.50
657.77
687.04
718.77
750.82
785.01
801.96
836.16
865.73
885.14
909.48
924.27
924.27
$ 179.20
282.20
282.20
282.20
282.20
283.33
288.97
295.75
306.75
315.78
320.30
327.07
333.84
338.08
342.59
344.85
347.11
349.36
351.62
356.14
360.65
367.42
373.92
382.95
394.23
407.50
423.30
441.08
461.40
481.43
504.01
526.30
550.85
575.69
602.50
629.31
658.37
687.72
719.05
734.57
765.89
792.98
810.76
833.05
846.60
846.60
$ 181.49
285.81
285.81
285.81
285.81
286.95
292.67
299.53
310.68
319.82
324.39
331.25
338.11
342.40
346.97
349.26
351.55
353.83
356.12
360.69
365.27
372.12
378.70
387.84
399.28
412.71
428.72
446.72
467.30
487.59
510.46
533.04
557.90
583.05
610.20
637.36
666.79
696.52
728.24
743.96
775.69
803.13
821.13
843.71
857.43
857.43
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
21
0SN8
88380VA0740025
Anthem HealthKeepers Preferred DirectAccess gjba
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 205.58
323.75
323.75
323.75
323.75
325.05
331.52
339.29
351.92
362.28
367.46
375.23
383.00
387.85
393.03
395.62
398.21
400.80
403.39
408.57
413.75
421.52
428.97
439.33
452.28
467.50
485.63
506.02
529.33
552.32
578.22
603.79
631.96
660.45
691.21
721.96
755.31
788.98
824.92
842.72
878.66
909.74
930.13
955.71
971.25
971.25
$ 187.49
295.26
295.26
295.26
295.26
296.44
302.35
309.43
320.95
330.40
335.12
342.21
349.29
353.72
358.45
360.81
363.17
365.53
367.89
372.62
377.34
384.43
391.22
400.67
412.48
426.36
442.89
461.49
482.75
503.71
527.33
550.66
576.35
602.33
630.38
658.43
688.84
719.55
752.32
768.56
801.34
829.68
848.28
871.61
885.78
885.78
$ 194.16
305.76
305.76
305.76
305.76
306.98
313.10
320.44
332.36
342.15
347.04
354.38
361.71
366.30
371.19
373.64
376.08
378.53
380.98
385.87
390.76
398.10
405.13
414.92
427.15
441.52
458.64
477.90
499.92
521.63
546.09
570.24
596.84
623.75
652.80
681.84
713.34
745.14
779.08
795.89
829.83
859.19
878.45
902.60
917.28
917.28
$ 187.04
294.55
294.55
294.55
294.55
295.73
301.62
308.69
320.18
329.60
334.31
341.38
348.45
352.87
357.58
359.94
362.30
364.65
367.01
371.72
376.43
383.50
390.28
399.70
411.49
425.33
441.83
460.38
481.59
502.50
526.07
549.34
574.96
600.88
628.86
656.85
687.19
717.82
750.51
766.71
799.41
827.69
846.24
869.51
883.65
883.65
$ 190.39
299.83
299.83
299.83
299.83
301.03
307.03
314.22
325.92
335.51
340.31
347.50
354.70
359.20
363.99
366.39
368.79
371.19
373.59
378.39
383.18
390.38
397.27
406.87
418.86
432.95
449.75
468.63
490.22
511.51
535.50
559.18
585.27
611.65
640.14
668.62
699.50
730.69
763.97
780.46
813.74
842.52
861.41
885.10
899.49
899.49
$ 190.37
299.80
299.80
299.80
299.80
301.00
307.00
314.19
325.88
335.48
340.27
347.47
354.66
359.16
363.96
366.36
368.75
371.15
373.55
378.35
383.14
390.34
397.24
406.83
418.82
432.91
449.70
468.59
490.17
511.46
535.44
559.13
585.21
611.59
640.07
668.55
699.43
730.61
763.89
780.38
813.66
842.44
861.33
885.01
899.40
899.40
$ 198.32
312.32
312.32
312.32
312.32
313.57
319.82
327.31
339.49
349.49
354.48
361.98
369.47
374.16
379.16
381.66
384.15
386.65
389.15
394.15
399.14
406.64
413.82
423.82
436.31
450.99
468.48
488.16
510.64
532.82
557.80
582.48
609.65
637.13
666.80
696.47
728.64
761.12
795.79
812.97
847.64
877.62
897.30
921.97
936.96
936.96
$ 197.77
311.45
311.45
311.45
311.45
312.70
318.92
326.40
338.55
348.51
353.50
360.97
368.45
373.12
378.10
380.59
383.08
385.58
388.07
393.05
398.03
405.51
412.67
422.64
435.10
449.73
467.18
486.80
509.22
531.33
556.25
580.85
607.95
635.36
664.95
694.53
726.61
759.00
793.57
810.70
845.28
875.17
894.80
919.40
934.35
934.35
$ 192.80
303.62
303.62
303.62
303.62
304.83
310.91
318.19
330.03
339.75
344.61
351.90
359.18
363.74
368.59
371.02
373.45
375.88
378.31
383.17
388.03
395.31
402.30
412.01
424.16
438.43
455.43
474.56
496.42
517.98
542.27
566.25
592.67
619.38
648.23
677.07
708.35
739.92
773.62
790.32
824.02
853.17
872.30
896.29
910.86
910.86
$ 208.68
328.63
328.63
328.63
328.63
329.94
336.52
344.40
357.22
367.74
373.00
380.88
388.77
393.70
398.96
401.59
404.21
406.84
409.47
414.73
419.99
427.88
435.43
445.95
459.10
474.54
492.95
513.65
537.31
560.64
586.93
612.89
641.49
670.41
701.63
732.84
766.69
800.87
837.35
855.42
891.90
923.45
944.15
970.12
985.89
985.89
$ 191.14
301.01
301.01
301.01
301.01
302.21
308.23
315.46
327.20
336.83
341.65
348.87
356.09
360.61
365.43
367.83
370.24
372.65
375.06
379.87
384.69
391.92
398.84
408.47
420.51
434.66
451.52
470.48
492.15
513.52
537.60
561.38
587.57
614.06
642.66
671.25
702.26
733.56
766.97
783.53
816.94
845.84
864.80
888.58
903.03
903.03
$ 193.59
304.86
304.86
304.86
304.86
306.08
312.18
319.49
331.38
341.14
346.02
353.33
360.65
365.22
370.10
372.54
374.98
377.42
379.86
384.73
389.61
396.93
403.94
413.70
425.89
440.22
457.29
476.50
498.45
520.09
544.48
568.56
595.09
621.91
650.88
679.84
711.24
742.94
776.78
793.55
827.39
856.66
875.86
899.95
914.58
914.58
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
22
0SNC
88380VA0740032
Anthem HealthKeepers Preferred DirectAccess ghfa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 181.17
285.31
285.31
285.31
285.31
286.45
292.16
299.00
310.13
319.26
323.83
330.67
337.52
341.80
346.37
348.65
350.93
353.21
355.50
360.06
364.63
371.47
378.04
387.17
398.58
411.99
427.97
445.94
466.48
486.74
509.56
532.10
556.93
582.03
609.14
636.24
665.63
695.30
726.97
742.66
774.33
801.72
819.70
842.24
855.93
855.93
$ 165.23
260.21
260.21
260.21
260.21
261.25
266.46
272.70
282.85
291.17
295.34
301.58
307.83
311.73
315.89
317.98
320.06
322.14
324.22
328.39
332.55
338.79
344.78
353.10
363.51
375.74
390.32
406.71
425.44
443.92
464.74
485.29
507.93
530.83
555.55
580.27
607.07
634.13
663.02
677.33
706.21
731.19
747.58
768.14
780.63
780.63
$ 171.11
269.46
269.46
269.46
269.46
270.54
275.93
282.39
292.90
301.53
305.84
312.30
318.77
322.81
327.12
329.28
331.44
333.59
335.75
340.06
344.37
350.84
357.03
365.66
376.44
389.10
404.19
421.17
440.57
459.70
481.26
502.54
525.99
549.70
575.30
600.90
628.65
656.67
686.58
701.40
731.31
757.18
774.16
795.45
808.38
808.38
$ 164.83
259.58
259.58
259.58
259.58
260.62
265.81
272.04
282.16
290.47
294.62
300.85
307.08
310.98
315.13
317.21
319.28
321.36
323.44
327.59
331.74
337.97
343.94
352.25
362.63
374.83
389.37
405.72
424.41
442.84
463.61
484.12
506.70
529.54
554.20
578.86
605.60
632.60
661.41
675.69
704.50
729.42
745.77
766.28
778.74
778.74
$ 167.79
264.23
264.23
264.23
264.23
265.29
270.57
276.91
287.22
295.67
299.90
306.24
312.58
316.55
320.78
322.89
325.00
327.12
329.23
333.46
337.69
344.03
350.10
358.56
369.13
381.55
396.35
412.99
432.02
450.78
471.91
492.79
515.78
539.03
564.13
589.23
616.45
643.93
673.26
687.79
717.12
742.49
759.13
780.01
792.69
792.69
$ 167.77
264.20
264.20
264.20
264.20
265.26
270.54
276.88
287.19
295.64
299.87
306.21
312.55
316.51
320.74
322.85
324.97
327.08
329.19
333.42
337.65
343.99
350.07
358.52
369.09
381.50
396.30
412.94
431.97
450.73
471.86
492.73
515.72
538.97
564.07
589.17
616.38
643.86
673.18
687.71
717.04
742.40
759.05
779.92
792.60
792.60
$ 174.78
275.24
275.24
275.24
275.24
276.34
281.85
288.45
299.19
307.99
312.40
319.00
325.61
329.74
334.14
336.34
338.55
340.75
342.95
347.35
351.76
358.36
364.69
373.50
384.51
397.45
412.86
430.20
450.02
469.56
491.58
513.32
537.27
561.49
587.64
613.79
642.13
670.76
701.31
716.45
747.00
773.42
790.76
812.51
825.72
825.72
$ 174.29
274.47
274.47
274.47
274.47
275.57
281.06
287.64
298.35
307.13
311.52
318.11
324.70
328.82
333.21
335.40
337.60
339.79
341.99
346.38
350.77
357.36
363.67
372.46
383.43
396.33
411.71
429.00
448.76
468.25
490.20
511.89
535.77
559.92
585.99
612.07
640.34
668.88
699.35
714.45
744.91
771.26
788.55
810.24
823.41
823.41
$ 169.91
267.57
267.57
267.57
267.57
268.64
273.99
280.41
290.85
299.41
303.69
310.11
316.54
320.55
324.83
326.97
329.11
331.25
333.39
337.67
341.95
348.38
354.53
363.09
373.80
386.37
401.36
418.21
437.48
456.47
477.88
499.02
522.30
545.84
571.26
596.68
624.24
652.07
681.77
696.48
726.18
751.87
768.73
789.87
802.71
802.71
$ 183.90
289.61
289.61
289.61
289.61
290.77
296.56
303.51
314.81
324.07
328.71
335.66
342.61
346.95
351.59
353.90
356.22
358.54
360.85
365.49
370.12
377.07
383.73
393.00
404.59
418.20
434.42
452.66
473.51
494.07
517.24
540.12
565.32
590.80
618.32
645.83
675.66
705.78
737.93
753.85
786.00
813.80
832.05
854.93
868.83
868.83
$ 168.45
265.27
265.27
265.27
265.27
266.33
271.64
278.00
288.35
296.84
301.08
307.45
313.81
317.79
322.04
324.16
326.28
328.40
330.53
334.77
339.02
345.38
351.48
359.97
370.58
383.05
397.91
414.62
433.72
452.55
473.77
494.73
517.81
541.15
566.35
591.55
618.87
646.46
675.91
690.50
719.94
745.41
762.12
783.08
795.81
795.81
$ 170.61
268.67
268.67
268.67
268.67
269.74
275.12
281.57
292.04
300.64
304.94
311.39
317.84
321.87
326.17
328.31
330.46
332.61
334.76
339.06
343.36
349.81
355.99
364.59
375.33
387.96
403.01
419.93
439.28
458.35
479.84
501.07
524.44
548.09
573.61
599.13
626.81
654.75
684.57
699.35
729.17
754.96
771.89
793.11
806.01
806.01
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
23
0SND
88380VA0740027
Anthem HealthKeepers Preferred DirectAccess gkfa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 183.79
289.43
289.43
289.43
289.43
290.59
296.38
303.32
314.61
323.87
328.50
335.45
342.40
346.74
351.37
353.68
356.00
358.31
360.63
365.26
369.89
376.84
383.49
392.76
404.33
417.94
434.15
452.38
473.22
493.77
516.92
539.79
564.97
590.44
617.93
645.43
675.24
705.34
737.47
753.39
785.51
813.30
831.53
854.40
868.29
868.29
$ 167.62
263.97
263.97
263.97
263.97
265.03
270.31
276.64
286.94
295.38
299.61
305.94
312.28
316.24
320.46
322.57
324.68
326.79
328.91
333.13
337.35
343.69
349.76
358.21
368.77
381.17
395.96
412.59
431.59
450.33
471.45
492.30
515.27
538.50
563.58
588.65
615.84
643.29
672.60
687.11
716.41
741.76
758.39
779.24
791.91
791.91
$ 173.58
273.35
273.35
273.35
273.35
274.44
279.91
286.47
297.13
305.88
310.25
316.81
323.37
327.47
331.85
334.03
336.22
338.41
340.59
344.97
349.34
355.90
362.19
370.94
381.87
394.72
410.03
427.25
446.93
466.34
488.20
509.80
533.58
557.63
583.60
609.57
637.73
666.15
696.50
711.53
741.87
768.11
785.33
806.93
820.05
820.05
$ 167.21
263.33
263.33
263.33
263.33
264.38
269.65
275.97
286.24
294.67
298.88
305.20
311.52
315.47
319.68
321.79
323.90
326.00
328.11
332.32
336.54
342.86
348.91
357.34
367.87
380.25
395.00
411.58
430.54
449.24
470.31
491.11
514.02
537.19
562.21
587.23
614.35
641.74
670.96
685.45
714.68
739.96
756.55
777.35
789.99
789.99
$ 170.21
268.05
268.05
268.05
268.05
269.12
274.48
280.92
291.37
299.95
304.24
310.67
317.10
321.12
325.41
327.56
329.70
331.85
333.99
338.28
342.57
349.00
355.17
363.74
374.47
387.06
402.08
418.96
438.26
457.29
478.74
499.91
523.23
546.82
572.29
597.75
625.36
653.24
682.99
697.73
727.49
753.22
770.11
791.28
804.15
804.15
$ 170.19
268.02
268.02
268.02
268.02
269.09
274.45
280.88
291.34
299.91
304.20
310.64
317.07
321.09
325.38
327.52
329.66
331.81
333.95
338.24
342.53
348.96
355.13
363.70
374.42
387.02
402.03
418.92
438.21
457.24
478.68
499.86
523.18
546.76
572.22
597.68
625.29
653.16
682.91
697.66
727.41
753.14
770.02
791.20
804.06
804.06
$ 177.30
279.21
279.21
279.21
279.21
280.33
285.91
292.61
303.50
312.44
316.90
323.60
330.31
334.49
338.96
341.19
343.43
345.66
347.90
352.36
356.83
363.53
369.95
378.89
390.06
403.18
418.82
436.41
456.51
476.33
498.67
520.73
545.02
569.59
596.11
622.64
651.40
680.43
711.43
726.78
757.78
784.58
802.17
824.23
837.63
837.63
$ 176.80
278.43
278.43
278.43
278.43
279.54
285.11
291.79
302.65
311.56
316.02
322.70
329.38
333.56
338.01
340.24
342.47
344.70
346.92
351.38
355.83
362.52
368.92
377.83
388.97
402.05
417.65
435.19
455.23
475.00
497.28
519.27
543.50
568.00
594.45
620.90
649.58
678.53
709.44
724.75
755.66
782.39
799.93
821.93
835.29
835.29
$ 172.36
271.44
271.44
271.44
271.44
272.53
277.95
284.47
295.06
303.74
308.08
314.60
321.11
325.19
329.53
331.70
333.87
336.04
338.21
342.56
346.90
353.41
359.66
368.34
379.20
391.96
407.16
424.26
443.80
463.08
484.79
506.24
529.85
553.74
579.52
605.31
633.27
661.50
691.63
706.56
736.69
762.75
779.85
801.29
814.32
814.32
$ 186.56
293.79
293.79
293.79
293.79
294.97
300.84
307.89
319.35
328.75
333.45
340.50
347.55
351.96
356.66
359.01
361.36
363.71
366.06
370.76
375.46
382.51
389.27
398.67
410.42
424.23
440.69
459.19
480.35
501.21
524.71
547.92
573.48
599.33
627.24
655.15
685.41
715.97
748.58
764.74
797.35
825.55
844.06
867.27
881.37
881.37
$ 170.88
269.10
269.10
269.10
269.10
270.18
275.56
282.02
292.51
301.12
305.43
311.89
318.35
322.38
326.69
328.84
330.99
333.15
335.30
339.60
343.91
350.37
356.56
365.17
375.93
388.58
403.65
420.60
439.98
459.08
480.61
501.87
525.28
548.96
574.53
600.09
627.81
655.80
685.67
700.47
730.34
756.17
773.12
794.38
807.30
807.30
$ 173.07
272.55
272.55
272.55
272.55
273.64
279.09
285.63
296.26
304.98
309.34
315.89
322.43
326.51
330.88
333.06
335.24
337.42
339.60
343.96
348.32
354.86
361.13
369.85
380.75
393.56
408.83
426.00
445.62
464.97
486.77
508.31
532.02
556.00
581.89
607.79
635.86
664.20
694.46
709.45
739.70
765.87
783.04
804.57
817.65
817.65
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
24
0SNF
88380VA0740028
Anthem HealthKeepers Preferred DirectAccess gcga
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 194.85
306.85
306.85
306.85
306.85
308.08
314.21
321.58
333.55
343.37
348.27
355.64
363.00
367.61
372.52
374.97
377.43
379.88
382.34
387.24
392.15
399.52
406.58
416.40
428.67
443.09
460.28
479.61
501.70
523.49
548.03
572.28
598.97
625.97
655.12
684.28
715.88
747.79
781.85
798.73
832.79
862.25
881.58
905.82
920.55
920.55
$ 177.70
279.85
279.85
279.85
279.85
280.97
286.57
293.28
304.20
313.15
317.63
324.35
331.06
335.26
339.74
341.98
344.22
346.45
348.69
353.17
357.65
364.36
370.80
379.76
390.95
404.10
419.78
437.41
457.55
477.42
499.81
521.92
546.27
570.89
597.48
624.07
652.89
681.99
713.06
728.45
759.51
786.38
804.01
826.12
839.55
839.55
$ 184.02
289.80
289.80
289.80
289.80
290.96
296.76
303.71
315.01
324.29
328.92
335.88
342.83
347.18
351.82
354.14
356.45
358.77
361.09
365.73
370.36
377.32
383.99
393.26
404.85
418.47
434.70
452.96
473.82
494.40
517.58
540.48
565.69
591.19
618.72
646.25
676.10
706.24
738.41
754.35
786.52
814.34
832.60
855.49
869.40
869.40
$ 177.28
279.18
279.18
279.18
279.18
280.30
285.88
292.58
303.47
312.40
316.87
323.57
330.27
334.46
338.92
341.16
343.39
345.62
347.86
352.33
356.79
363.49
369.91
378.85
390.01
403.14
418.77
436.36
456.46
476.28
498.62
520.67
544.96
569.53
596.05
622.57
651.33
680.36
711.35
726.71
757.69
784.50
802.08
824.14
837.54
837.54
$ 180.45
284.18
284.18
284.18
284.18
285.32
291.00
297.82
308.90
318.00
322.54
329.36
336.18
340.45
344.99
347.27
349.54
351.81
354.09
358.64
363.18
370.00
376.54
385.63
397.00
410.36
426.27
444.17
464.63
484.81
507.55
530.00
554.72
579.73
606.72
633.72
662.99
692.55
724.09
739.72
771.26
798.55
816.45
838.90
852.54
852.54
$ 180.44
284.15
284.15
284.15
284.15
285.29
290.97
297.79
308.87
317.96
322.51
329.33
336.15
340.41
344.96
347.23
349.50
351.78
354.05
358.60
363.14
369.96
376.50
385.59
396.96
410.31
426.23
444.13
464.59
484.76
507.49
529.94
554.66
579.67
606.66
633.65
662.92
692.47
724.01
739.64
771.18
798.46
816.36
838.81
852.45
852.45
$ 187.97
296.02
296.02
296.02
296.02
297.20
303.12
310.23
321.77
331.25
335.98
343.09
350.19
354.63
359.37
361.74
364.10
366.47
368.84
373.58
378.31
385.42
392.23
401.70
413.54
427.45
444.03
462.68
483.99
505.01
528.69
552.08
577.83
603.88
632.00
660.12
690.61
721.40
754.26
770.54
803.40
831.82
850.47
873.85
888.06
888.06
$ 187.45
295.19
295.19
295.19
295.19
296.37
302.27
309.36
320.87
330.32
335.04
342.13
349.21
353.64
358.36
360.72
363.08
365.45
367.81
372.53
377.25
384.34
391.13
400.57
412.38
426.25
442.79
461.38
482.64
503.59
527.21
550.53
576.21
602.19
630.23
658.27
688.68
719.38
752.14
768.38
801.15
829.48
848.08
871.40
885.57
885.57
$ 182.73
287.77
287.77
287.77
287.77
288.92
294.68
301.58
312.81
322.01
326.62
333.53
340.43
344.75
349.35
351.65
353.96
356.26
358.56
363.17
367.77
374.68
381.30
390.50
402.01
415.54
431.66
449.78
470.50
490.94
513.96
536.69
561.73
587.05
614.39
641.73
671.37
701.30
733.24
749.07
781.01
808.63
826.76
849.50
863.31
863.31
$ 197.78
311.47
311.47
311.47
311.47
312.72
318.95
326.42
338.57
348.53
353.52
360.99
368.47
373.14
378.12
380.62
383.11
385.60
388.09
393.08
398.06
405.53
412.70
422.66
435.12
449.76
467.21
486.83
509.25
531.37
556.29
580.89
607.99
635.40
664.99
694.58
726.66
759.05
793.63
810.76
845.33
875.23
894.85
919.46
934.41
934.41
$ 181.17
285.30
285.30
285.30
285.30
286.44
292.15
298.99
310.12
319.25
323.82
330.66
337.51
341.79
346.35
348.64
350.92
353.20
355.48
360.05
364.61
371.46
378.02
387.15
398.56
411.97
427.95
445.92
466.47
486.72
509.55
532.08
556.91
582.01
609.12
636.22
665.60
695.28
726.94
742.64
774.30
801.69
819.67
842.21
855.90
855.90
$ 183.48
288.95
288.95
288.95
288.95
290.11
295.88
302.82
314.09
323.34
327.96
334.89
341.83
346.16
350.79
353.10
355.41
357.72
360.03
364.65
369.28
376.21
382.86
392.11
403.66
417.24
433.43
451.63
472.43
492.95
516.06
538.89
564.03
589.46
616.91
644.36
674.12
704.17
736.24
752.14
784.21
811.95
830.15
852.98
866.85
866.85
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
25
0SNH
88380VA0740030
Anthem HealthKeepers Preferred DirectAccess gtga
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 188.88
297.45
297.45
297.45
297.45
298.64
304.59
311.73
323.33
332.85
337.61
344.74
351.88
356.35
361.10
363.48
365.86
368.24
370.62
375.38
380.14
387.28
394.12
403.64
415.54
429.52
446.18
464.91
486.33
507.45
531.25
554.74
580.62
606.80
635.06
663.31
693.95
724.89
757.90
774.26
807.28
835.83
854.57
878.07
892.35
892.35
$ 172.26
271.27
271.27
271.27
271.27
272.36
277.78
284.29
294.87
303.55
307.89
314.40
320.91
324.98
329.32
331.49
333.66
335.83
338.00
342.34
346.68
353.19
359.43
368.11
378.96
391.71
406.91
424.00
443.53
462.79
484.49
505.92
529.52
553.39
579.16
604.93
632.87
661.08
691.20
706.12
736.23
762.27
779.36
800.79
813.81
813.81
$ 178.38
280.92
280.92
280.92
280.92
282.04
287.66
294.40
305.36
314.35
318.84
325.59
332.33
336.54
341.04
343.28
345.53
347.78
350.03
354.52
359.02
365.76
372.22
381.21
392.45
405.65
421.38
439.08
459.30
479.25
501.72
523.92
548.36
573.08
599.76
626.45
655.39
684.60
715.78
731.23
762.42
789.39
807.08
829.28
842.76
842.76
$ 171.84
270.62
270.62
270.62
270.62
271.70
277.11
283.61
294.16
302.82
307.15
313.65
320.14
324.20
328.53
330.70
332.86
335.03
337.19
341.52
345.85
352.35
358.57
367.23
378.06
390.78
405.93
422.98
442.46
461.68
483.33
504.71
528.25
552.06
577.77
603.48
631.36
659.50
689.54
704.42
734.46
760.44
777.49
798.87
811.86
811.86
$ 174.92
275.47
275.47
275.47
275.47
276.57
282.08
288.69
299.44
308.25
312.66
319.27
325.88
330.01
334.42
336.62
338.83
341.03
343.24
347.64
352.05
358.66
365.00
373.81
384.83
397.78
413.21
430.56
450.39
469.95
491.99
513.75
537.72
561.96
588.13
614.30
642.67
671.32
701.90
717.05
747.63
774.07
791.43
813.19
826.41
826.41
$ 174.90
275.44
275.44
275.44
275.44
276.54
282.05
288.66
299.40
308.22
312.62
319.23
325.85
329.98
334.38
336.59
338.79
340.99
343.20
347.61
352.01
358.62
364.96
373.77
384.79
397.74
413.16
430.51
450.34
469.90
491.94
513.70
537.66
561.90
588.06
614.23
642.60
671.25
701.82
716.97
747.54
773.99
791.34
813.10
826.32
826.32
$ 182.21
286.94
286.94
286.94
286.94
288.09
293.83
300.71
311.90
321.09
325.68
332.56
339.45
343.75
348.35
350.64
352.94
355.23
357.53
362.12
366.71
373.60
380.20
389.38
400.86
414.34
430.41
448.49
469.15
489.52
512.47
535.14
560.11
585.36
612.62
639.88
669.43
699.27
731.12
746.90
778.76
806.30
824.38
847.05
860.82
860.82
$ 181.70
286.14
286.14
286.14
286.14
287.28
293.01
299.87
311.03
320.19
324.77
331.64
338.50
342.80
347.37
349.66
351.95
354.24
356.53
361.11
365.69
372.55
379.14
388.29
399.74
413.19
429.21
447.24
467.84
488.15
511.05
533.65
558.55
583.73
610.91
638.09
667.56
697.32
729.08
744.82
776.58
804.05
822.08
844.69
858.42
858.42
$ 177.13
278.95
278.95
278.95
278.95
280.07
285.64
292.34
303.22
312.15
316.61
323.30
330.00
334.18
338.65
340.88
343.11
345.34
347.57
352.03
356.50
363.19
369.61
378.54
389.69
402.80
418.43
436.00
456.08
475.89
498.20
520.24
544.51
569.06
595.56
622.06
650.79
679.80
710.76
726.11
757.07
783.85
801.42
823.46
836.85
836.85
$ 191.73
301.93
301.93
301.93
301.93
303.14
309.18
316.42
328.20
337.86
342.69
349.94
357.18
361.71
366.54
368.96
371.37
373.79
376.20
381.04
385.87
393.11
400.06
409.72
421.80
435.99
452.90
471.92
493.66
515.09
539.25
563.10
589.37
615.94
644.62
673.30
704.40
735.80
769.32
785.92
819.44
848.42
867.44
891.30
905.79
905.79
$ 175.61
276.55
276.55
276.55
276.55
277.66
283.19
289.82
300.61
309.46
313.88
320.52
327.16
331.31
335.73
337.94
340.16
342.37
344.58
349.01
353.43
360.07
366.43
375.28
386.34
399.34
414.83
432.25
452.16
471.79
493.92
515.77
539.83
564.16
590.43
616.71
645.19
673.95
704.65
719.86
750.56
777.11
794.53
816.38
829.65
829.65
$ 177.86
280.09
280.09
280.09
280.09
281.21
286.81
293.53
304.46
313.42
317.90
324.62
331.35
335.55
340.03
342.27
344.51
346.75
348.99
353.47
357.96
364.68
371.12
380.08
391.29
404.45
420.14
437.78
457.95
477.83
500.24
522.37
546.74
571.38
597.99
624.60
653.45
682.58
713.67
729.07
760.16
787.05
804.70
826.83
840.27
840.27
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
26
0SMZ
88380VA0740029
Anthem HealthKeepers Preferred DirectAccess gyha
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 202.23
318.47
318.47
318.47
318.47
319.74
326.11
333.76
346.18
356.37
361.46
369.11
376.75
381.53
386.62
389.17
391.72
394.27
396.81
401.91
407.00
414.65
421.97
432.16
444.90
459.87
477.71
497.77
520.70
543.31
568.79
593.95
621.65
649.68
679.93
710.19
742.99
776.11
811.46
828.98
864.33
894.90
914.96
940.12
955.41
955.41
$ 184.43
290.44
290.44
290.44
290.44
291.60
297.41
304.38
315.71
325.00
329.65
336.62
343.59
347.95
352.59
354.92
357.24
359.56
361.89
366.54
371.18
378.15
384.83
394.13
405.74
419.40
435.66
453.96
474.87
495.49
518.73
541.67
566.94
592.50
620.09
647.68
677.60
707.80
740.04
756.02
788.25
816.14
834.43
857.38
871.32
871.32
$ 190.99
300.77
300.77
300.77
300.77
301.97
307.99
315.21
326.94
336.56
341.37
348.59
355.81
360.32
365.13
367.54
369.95
372.35
374.76
379.57
384.38
391.60
398.52
408.14
420.18
434.31
451.16
470.10
491.76
513.11
537.18
560.94
587.10
613.57
642.14
670.72
701.70
732.98
766.36
782.90
816.29
845.16
864.11
887.87
902.31
902.31
$ 183.98
289.74
289.74
289.74
289.74
290.90
296.69
303.65
314.95
324.22
328.85
335.81
342.76
347.11
351.74
354.06
356.38
358.70
361.02
365.65
370.29
377.24
383.91
393.18
404.77
418.38
434.61
452.86
473.72
494.30
517.48
540.37
565.57
591.07
618.59
646.12
675.96
706.10
738.26
754.19
786.35
814.17
832.42
855.31
869.22
869.22
$ 187.29
294.94
294.94
294.94
294.94
296.12
302.02
309.10
320.60
330.04
334.76
341.84
348.91
353.34
358.06
360.42
362.78
365.14
367.50
372.21
376.93
384.01
390.80
400.23
412.03
425.89
442.41
460.99
482.23
503.17
526.76
550.06
575.72
601.68
629.70
657.72
688.10
718.77
751.51
767.73
800.47
828.78
847.36
870.66
884.82
884.82
$ 187.27
294.91
294.91
294.91
294.91
296.09
301.99
309.07
320.57
330.00
334.72
341.80
348.88
353.30
358.02
360.38
362.74
365.10
367.46
372.18
376.89
383.97
390.76
400.19
411.99
425.85
442.37
460.94
482.18
503.12
526.71
550.01
575.66
601.62
629.63
657.65
688.03
718.70
751.43
767.65
800.39
828.70
847.28
870.57
884.73
884.73
$ 195.08
307.22
307.22
307.22
307.22
308.45
314.59
321.97
333.95
343.78
348.69
356.07
363.44
368.05
372.97
375.42
377.88
380.34
382.80
387.71
392.63
400.00
407.07
416.90
429.19
443.63
460.83
480.18
502.30
524.12
548.69
572.97
599.69
626.73
655.91
685.10
716.74
748.70
782.80
799.69
833.80
863.29
882.64
906.91
921.66
921.66
$ 194.54
306.36
306.36
306.36
306.36
307.59
313.71
321.07
333.01
342.82
347.72
355.07
362.42
367.02
371.92
374.37
376.82
379.27
381.72
386.63
391.53
398.88
405.93
415.73
427.98
442.38
459.54
478.84
500.90
522.65
547.16
571.36
598.01
624.97
654.08
683.18
714.74
746.60
780.61
797.46
831.46
860.87
880.17
904.37
919.08
919.08
$ 189.65
298.66
298.66
298.66
298.66
299.85
305.83
313.00
324.64
334.20
338.98
346.15
353.31
357.79
362.57
364.96
367.35
369.74
372.13
376.91
381.69
388.86
395.72
405.28
417.23
431.27
447.99
466.81
488.31
509.51
533.41
557.00
582.98
609.27
637.64
666.01
696.77
727.83
760.99
777.41
810.56
839.23
858.05
881.64
895.98
895.98
$ 205.27
323.26
323.26
323.26
323.26
324.55
331.02
338.78
351.38
361.73
366.90
374.66
382.42
387.27
392.44
395.02
397.61
400.20
402.78
407.95
413.13
420.88
428.32
438.66
451.59
466.79
484.89
505.26
528.53
551.48
577.34
602.88
631.00
659.45
690.16
720.87
754.17
787.78
823.67
841.45
877.33
908.36
928.73
954.26
969.78
969.78
$ 188.02
296.10
296.10
296.10
296.10
297.28
303.21
310.31
321.86
331.34
336.07
343.18
350.29
354.73
359.47
361.83
364.20
366.57
368.94
373.68
378.42
385.52
392.33
401.81
413.65
427.57
444.15
462.80
484.12
505.15
528.83
552.23
577.99
604.04
632.17
660.30
690.80
721.60
754.46
770.75
803.62
832.04
850.70
874.09
888.30
888.30
$ 190.43
299.89
299.89
299.89
299.89
301.09
307.09
314.28
325.98
335.58
340.38
347.57
354.77
359.27
364.07
366.47
368.86
371.26
373.66
378.46
383.26
390.46
397.35
406.95
418.95
433.04
449.84
468.73
490.32
511.61
535.60
559.29
585.39
611.78
640.27
668.75
699.64
730.83
764.12
780.61
813.90
842.69
861.58
885.28
899.67
899.67
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
27
0SN3
88380VA0740026
Anthem HealthKeepers Preferred DirectAccess gzha
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 184.42
290.42
290.42
290.42
290.42
291.58
297.39
304.36
315.69
324.98
329.63
336.60
343.57
347.92
352.57
354.89
357.22
359.54
361.86
366.51
371.16
378.13
384.81
394.10
405.72
419.37
435.63
453.93
474.84
495.46
518.69
541.63
566.90
592.46
620.05
647.64
677.55
707.75
739.99
755.96
788.20
816.08
834.38
857.32
871.26
871.26
$ 168.19
264.87
264.87
264.87
264.87
265.93
271.23
277.58
287.91
296.39
300.63
306.98
313.34
317.31
321.55
323.67
325.79
327.91
330.03
334.27
338.50
344.86
350.95
359.43
370.02
382.47
397.31
413.99
433.06
451.87
473.06
493.98
517.03
540.33
565.50
590.66
617.94
645.49
674.89
689.46
718.86
744.28
760.97
781.90
794.61
794.61
$ 174.17
274.29
274.29
274.29
274.29
275.39
280.87
287.46
298.15
306.93
311.32
317.90
324.49
328.60
332.99
335.18
337.38
339.57
341.77
346.15
350.54
357.13
363.43
372.21
383.18
396.07
411.44
428.72
448.46
467.94
489.88
511.55
535.41
559.55
585.61
611.67
639.92
668.44
698.89
713.98
744.42
770.75
788.04
809.70
822.87
822.87
$ 167.79
264.23
264.23
264.23
264.23
265.29
270.57
276.91
287.22
295.67
299.90
306.24
312.58
316.55
320.78
322.89
325.00
327.12
329.23
333.46
337.69
344.03
350.10
358.56
369.13
381.55
396.35
412.99
432.02
450.78
471.91
492.79
515.78
539.03
564.13
589.23
616.45
643.93
673.26
687.79
717.12
742.49
759.13
780.01
792.69
792.69
$ 170.79
268.96
268.96
268.96
268.96
270.04
275.42
281.87
292.36
300.97
305.27
311.72
318.18
322.21
326.52
328.67
330.82
332.97
335.12
339.43
343.73
350.19
356.37
364.98
375.74
388.38
403.44
420.38
439.75
458.85
480.36
501.61
525.01
548.68
574.23
599.78
627.48
655.46
685.31
700.10
729.96
755.78
772.72
793.97
806.88
806.88
$ 170.77
268.93
268.93
268.93
268.93
270.01
275.38
281.84
292.33
300.93
305.24
311.69
318.14
322.18
326.48
328.63
330.78
332.94
335.09
339.39
343.69
350.15
356.33
364.94
375.70
388.33
403.40
420.34
439.70
458.79
480.31
501.55
524.95
548.62
574.17
599.71
627.41
655.38
685.23
700.02
729.88
755.69
772.64
793.88
806.79
806.79
$ 177.90
280.16
280.16
280.16
280.16
281.28
286.88
293.61
304.53
313.50
317.98
324.71
331.43
335.63
340.11
342.36
344.60
346.84
349.08
353.56
358.04
364.77
371.21
380.18
391.38
404.55
420.24
437.89
458.06
477.95
500.37
522.50
546.87
571.53
598.14
624.76
653.61
682.75
713.85
729.26
760.35
787.25
804.90
827.03
840.48
840.48
$ 177.41
279.38
279.38
279.38
279.38
280.50
286.09
292.79
303.69
312.63
317.10
323.80
330.51
334.70
339.17
341.40
343.64
345.87
348.11
352.58
357.05
363.75
370.18
379.12
390.29
403.42
419.07
436.67
456.79
476.62
498.97
521.04
545.35
569.94
596.48
623.02
651.79
680.85
711.86
727.23
758.24
785.06
802.66
824.73
838.14
838.14
$ 172.95
272.36
272.36
272.36
272.36
273.45
278.90
285.43
296.06
304.77
309.13
315.67
322.20
326.29
330.65
332.82
335.00
337.18
339.36
343.72
348.08
354.61
360.88
369.59
380.49
393.29
408.54
425.70
445.31
464.65
486.43
507.95
531.65
555.61
581.49
607.36
635.42
663.74
693.97
708.95
739.19
765.33
782.49
804.01
817.08
817.08
$ 187.19
294.79
294.79
294.79
294.79
295.97
301.86
308.94
320.44
329.87
334.59
341.66
348.74
353.16
357.88
360.23
362.59
364.95
367.31
372.02
376.74
383.82
390.60
400.03
411.82
425.68
442.19
460.76
481.98
502.91
526.49
549.78
575.43
601.37
629.38
657.38
687.75
718.40
751.12
767.34
800.06
828.36
846.93
870.22
884.37
884.37
$ 171.46
270.02
270.02
270.02
270.02
271.10
276.50
282.98
293.51
302.15
306.47
312.95
319.43
323.48
327.80
329.96
332.12
334.28
336.44
340.77
345.09
351.57
357.78
366.42
377.22
389.91
405.03
422.04
441.48
460.65
482.26
503.59
527.08
550.84
576.49
602.14
629.96
658.04
688.01
702.86
732.83
758.76
775.77
797.10
810.06
810.06
$ 173.66
273.48
273.48
273.48
273.48
274.57
280.04
286.61
297.27
306.02
310.40
316.96
323.53
327.63
332.00
334.19
336.38
338.57
340.76
345.13
349.51
356.07
362.36
371.11
382.05
394.91
410.22
427.45
447.14
466.56
488.44
510.04
533.83
557.90
583.88
609.86
638.03
666.47
696.83
711.87
742.22
768.48
785.71
807.31
820.44
820.44
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
28
0SNK
88380VA0740031
Anthem HealthKeepers Preferred DirectAccess gbia
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 197.25
310.63
310.63
310.63
310.63
311.87
318.09
325.54
337.65
347.59
352.57
360.02
367.48
372.13
377.10
379.59
382.07
384.56
387.04
392.02
396.99
404.44
411.58
421.52
433.95
448.55
465.95
485.51
507.88
529.93
554.79
579.32
606.35
633.69
663.20
692.70
724.70
757.01
791.49
808.57
843.05
872.87
892.44
916.98
931.89
931.89
$ 179.90
283.30
283.30
283.30
283.30
284.43
290.10
296.90
307.95
317.01
321.55
328.34
335.14
339.39
343.93
346.19
348.46
350.73
352.99
357.52
362.06
368.86
375.37
384.44
395.77
409.09
424.95
442.80
463.20
483.31
505.97
528.35
553.00
577.93
604.85
631.76
660.94
690.40
721.85
737.43
768.88
796.07
813.92
836.30
849.90
849.90
$ 186.29
293.37
293.37
293.37
293.37
294.54
300.41
307.45
318.89
328.28
332.97
340.02
347.06
351.46
356.15
358.50
360.85
363.19
365.54
370.23
374.93
381.97
388.72
398.10
409.84
423.63
440.06
458.54
479.66
500.49
523.96
547.14
572.66
598.47
626.34
654.22
684.43
714.94
747.51
763.64
796.21
824.37
842.85
866.03
880.11
880.11
$ 179.46
282.61
282.61
282.61
282.61
283.74
289.39
296.18
307.20
316.24
320.76
327.54
334.33
338.57
343.09
345.35
347.61
349.87
352.13
356.65
361.18
367.96
374.46
383.50
394.81
408.09
423.92
441.72
462.07
482.13
504.74
527.07
551.65
576.52
603.37
630.22
659.33
688.72
720.09
735.63
767.00
794.13
811.94
834.26
847.83
847.83
$ 182.68
287.68
287.68
287.68
287.68
288.83
294.58
301.49
312.71
321.91
326.52
333.42
340.33
344.64
349.24
351.54
353.85
356.15
358.45
363.05
367.66
374.56
381.18
390.38
401.89
415.41
431.52
449.64
470.36
490.78
513.80
536.52
561.55
586.87
614.20
641.53
671.16
701.08
733.01
748.83
780.76
808.38
826.50
849.23
863.04
863.04
$ 182.66
287.65
287.65
287.65
287.65
288.80
294.55
301.46
312.68
321.88
326.48
333.39
340.29
344.60
349.21
351.51
353.81
356.11
358.41
363.01
367.62
374.52
381.14
390.34
401.85
415.37
431.48
449.60
470.31
490.73
513.74
536.47
561.49
586.81
614.13
641.46
671.09
701.00
732.93
748.75
780.68
808.30
826.42
849.14
862.95
862.95
$ 190.28
299.66
299.66
299.66
299.66
300.86
306.85
314.04
325.73
335.32
340.11
347.31
354.50
358.99
363.79
366.18
368.58
370.98
373.38
378.17
382.97
390.16
397.05
406.64
418.63
432.71
449.49
468.37
489.94
511.22
535.19
558.87
584.94
611.31
639.77
668.24
699.11
730.27
763.53
780.01
813.28
842.04
860.92
884.60
898.98
898.98
$ 189.75
298.82
298.82
298.82
298.82
300.02
305.99
313.16
324.82
334.38
339.16
346.33
353.50
357.99
362.77
365.16
367.55
369.94
372.33
377.11
381.89
389.06
395.94
405.50
417.45
431.50
448.23
467.06
488.57
509.79
533.69
557.30
583.30
609.59
637.98
666.37
697.15
728.22
761.39
777.83
811.00
839.68
858.51
882.12
896.46
896.46
$ 184.98
291.31
291.31
291.31
291.31
292.48
298.30
305.29
316.65
325.98
330.64
337.63
344.62
348.99
353.65
355.98
358.31
360.64
362.97
367.63
372.29
379.29
385.99
395.31
406.96
420.65
436.97
455.32
476.29
496.97
520.28
543.29
568.64
594.27
621.95
649.62
679.63
709.92
742.26
758.28
790.62
818.58
836.93
859.95
873.93
873.93
$ 200.22
315.31
315.31
315.31
315.31
316.57
322.88
330.44
342.74
352.83
357.88
365.44
373.01
377.74
382.79
385.31
387.83
390.35
392.88
397.92
402.97
410.53
417.79
427.88
440.49
455.31
472.97
492.83
515.53
537.92
563.14
588.05
615.49
643.23
673.19
703.14
735.62
768.41
803.41
820.75
855.75
886.02
905.89
930.80
945.93
945.93
$ 183.39
288.81
288.81
288.81
288.81
289.97
295.74
302.67
313.94
323.18
327.80
334.73
341.66
345.99
350.62
352.93
355.24
357.55
359.86
364.48
369.10
376.03
382.67
391.92
403.47
417.04
433.22
451.41
472.20
492.71
515.81
538.63
563.76
589.17
616.61
644.05
673.79
703.83
735.89
751.77
783.83
811.56
829.75
852.57
866.43
866.43
$ 185.74
292.51
292.51
292.51
292.51
293.68
299.53
306.55
317.96
327.32
332.00
339.02
346.04
350.43
355.11
357.45
359.79
362.13
364.47
369.15
373.83
380.85
387.58
396.94
408.64
422.38
438.77
457.19
478.25
499.02
522.42
545.53
570.98
596.72
624.51
652.30
682.43
712.85
745.32
761.40
793.87
821.95
840.38
863.49
877.53
877.53
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
29
0SNV
88380VA0740038
Anthem HealthKeepers Preferred DirectAccess gaaf
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 201.89
317.94
317.94
317.94
317.94
319.21
325.57
333.20
345.60
355.77
360.86
368.49
376.12
380.89
385.98
388.52
391.07
393.61
396.15
401.24
406.33
413.96
421.27
431.44
444.16
459.11
476.91
496.94
519.83
542.41
567.84
592.96
620.62
648.60
678.80
709.01
741.75
774.82
810.11
827.60
862.89
893.41
913.44
938.56
953.82
953.82
$ 184.13
289.97
289.97
289.97
289.97
291.13
296.93
303.89
315.20
324.48
329.12
336.08
343.03
347.38
352.02
354.34
356.66
358.98
361.30
365.94
370.58
377.54
384.21
393.49
405.09
418.72
434.96
453.22
474.10
494.69
517.89
540.79
566.02
591.54
619.09
646.63
676.50
706.66
738.84
754.79
786.98
814.82
833.08
855.99
869.91
869.91
$ 190.68
300.28
300.28
300.28
300.28
301.48
307.49
314.69
326.40
336.01
340.82
348.02
355.23
359.74
364.54
366.94
369.34
371.75
374.15
378.95
383.76
390.96
397.87
407.48
419.49
433.60
450.42
469.34
490.96
512.28
536.30
560.02
586.15
612.57
641.10
669.62
700.55
731.78
765.11
781.63
814.96
843.79
862.70
886.43
900.84
900.84
$ 183.69
289.27
289.27
289.27
289.27
290.43
296.21
303.15
314.44
323.69
328.32
335.26
342.21
346.55
351.17
353.49
355.80
358.12
360.43
365.06
369.69
376.63
383.28
392.54
404.11
417.71
433.91
452.13
472.96
493.49
516.64
539.49
564.66
590.11
617.59
645.07
674.87
704.95
737.06
752.97
785.08
812.85
831.07
853.93
867.81
867.81
$ 186.98
294.45
294.45
294.45
294.45
295.63
301.52
308.58
320.07
329.49
334.20
341.27
348.33
352.75
357.46
359.82
362.17
364.53
366.88
371.60
376.31
383.37
390.15
399.57
411.35
425.19
441.68
460.23
481.43
502.33
525.89
549.15
574.77
600.68
628.65
656.62
686.95
717.57
750.26
766.45
799.14
827.40
845.95
869.22
883.35
883.35
$ 186.96
294.42
294.42
294.42
294.42
295.60
301.49
308.55
320.03
329.46
334.17
341.23
348.30
352.72
357.43
359.78
362.14
364.49
366.85
371.56
376.27
383.33
390.11
399.53
411.30
425.14
441.63
460.18
481.38
502.28
525.83
549.09
574.71
600.62
628.59
656.56
686.88
717.50
750.18
766.38
799.06
827.32
845.87
869.13
883.26
883.26
$ 194.77
306.72
306.72
306.72
306.72
307.95
314.08
321.44
333.40
343.22
348.13
355.49
362.85
367.45
372.36
374.81
377.27
379.72
382.17
387.08
391.99
399.35
406.40
416.22
428.49
442.90
460.08
479.40
501.49
523.26
547.80
572.03
598.72
625.71
654.85
683.99
715.58
747.48
781.52
798.39
832.44
861.88
881.21
905.44
920.16
920.16
$ 194.22
305.86
305.86
305.86
305.86
307.08
313.20
320.54
332.47
342.26
347.15
354.49
361.83
366.42
371.31
373.76
376.21
378.65
381.10
386.00
390.89
398.23
405.26
415.05
427.29
441.66
458.79
478.06
500.08
521.80
546.27
570.43
597.04
623.95
653.01
682.07
713.57
745.38
779.33
796.15
830.10
859.47
878.74
902.90
917.58
917.58
$ 189.34
298.17
298.17
298.17
298.17
299.36
305.33
312.48
324.11
333.65
338.42
345.58
352.74
357.21
361.98
364.36
366.75
369.13
371.52
376.29
381.06
388.22
395.08
404.62
416.54
430.56
447.26
466.04
487.51
508.68
532.53
556.09
582.03
608.27
636.59
664.92
695.63
726.64
759.74
776.14
809.23
837.86
856.64
880.20
894.51
894.51
$ 204.93
322.73
322.73
322.73
322.73
324.02
330.48
338.22
350.81
361.13
366.30
374.04
381.79
386.63
391.79
394.38
396.96
399.54
402.12
407.29
412.45
420.19
427.62
437.94
450.85
466.02
484.10
504.43
527.66
550.58
576.40
601.89
629.97
658.37
689.03
719.69
752.93
786.49
822.32
840.07
875.89
906.87
927.20
952.70
968.19
968.19
$ 187.71
295.61
295.61
295.61
295.61
296.79
302.70
309.80
321.33
330.79
335.52
342.61
349.71
354.14
358.87
361.24
363.60
365.97
368.33
373.06
377.79
384.88
391.68
401.14
412.97
426.86
443.42
462.04
483.32
504.31
527.96
551.31
577.03
603.04
631.13
659.21
689.66
720.40
753.21
769.47
802.29
830.66
849.29
872.64
886.83
886.83
$ 190.11
299.39
299.39
299.39
299.39
300.59
306.58
313.76
325.44
335.02
339.81
346.99
354.18
358.67
363.46
365.85
368.25
370.64
373.04
377.83
382.62
389.81
396.69
406.27
418.25
432.32
449.09
467.95
489.50
510.76
534.71
558.36
584.41
610.76
639.20
667.64
698.48
729.61
762.85
779.31
812.54
841.29
860.15
883.80
898.17
898.17
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
30
0SNZ
88380VA0740033
Anthem HealthKeepers Preferred DirectAccess gpqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 202.87
319.48
319.48
319.48
319.48
320.76
327.15
334.82
347.27
357.50
362.61
370.28
377.94
382.74
387.85
390.40
392.96
395.52
398.07
403.18
408.30
415.96
423.31
433.53
446.31
461.33
479.22
499.35
522.35
545.03
570.59
595.83
623.62
651.74
682.09
712.44
745.35
778.57
814.04
831.61
867.07
897.74
917.87
943.10
958.44
958.44
$ 185.02
291.37
291.37
291.37
291.37
292.54
298.36
305.36
316.72
326.04
330.70
337.70
344.69
349.06
353.72
356.05
358.39
360.72
363.05
367.71
372.37
379.36
386.07
395.39
407.04
420.74
437.06
455.41
476.39
497.08
520.39
543.41
568.75
594.39
622.07
649.76
679.77
710.07
742.41
758.44
790.78
818.75
837.11
860.12
874.11
874.11
$ 191.60
301.73
301.73
301.73
301.73
302.94
308.97
316.21
327.98
337.64
342.46
349.71
356.95
361.47
366.30
368.71
371.13
373.54
375.96
380.78
385.61
392.85
399.79
409.45
421.52
435.70
452.60
471.60
493.33
514.75
538.89
562.73
588.98
615.53
644.19
672.86
703.94
735.32
768.81
785.40
818.90
847.86
866.87
890.71
905.19
905.19
$ 184.58
290.67
290.67
290.67
290.67
291.83
297.65
304.62
315.96
325.26
329.91
336.89
343.86
348.22
352.87
355.20
357.52
359.85
362.17
366.83
371.48
378.45
385.14
394.44
406.07
419.73
436.01
454.32
475.25
495.88
519.14
542.10
567.39
592.97
620.58
648.19
678.13
708.36
740.63
756.61
788.88
816.78
835.09
858.06
872.01
872.01
$ 187.88
295.88
295.88
295.88
295.88
297.06
302.98
310.08
321.62
331.09
335.82
342.92
350.03
354.46
359.20
361.57
363.93
366.30
368.67
373.40
378.13
385.24
392.04
401.51
413.34
427.25
443.82
462.46
483.76
504.77
528.44
551.82
577.56
603.60
631.70
659.81
690.29
721.06
753.90
770.18
803.02
831.42
850.06
873.44
887.64
887.64
$ 187.86
295.85
295.85
295.85
295.85
297.03
302.95
310.05
321.59
331.06
335.79
342.89
349.99
354.43
359.16
361.53
363.90
366.26
368.63
373.36
378.10
385.20
392.00
401.47
413.30
427.21
443.78
462.41
483.71
504.72
528.39
551.76
577.50
603.53
631.64
659.75
690.22
720.99
753.83
770.10
802.94
831.34
849.98
873.35
887.55
887.55
$ 195.71
308.20
308.20
308.20
308.20
309.43
315.60
322.99
335.01
344.88
349.81
357.20
364.60
369.22
374.15
376.62
379.09
381.55
384.02
388.95
393.88
401.28
408.37
418.23
430.56
445.04
462.30
481.72
503.91
525.79
550.45
574.79
601.61
628.73
658.01
687.29
719.03
751.08
785.29
802.24
836.45
866.04
885.46
909.81
924.60
924.60
$ 195.16
307.34
307.34
307.34
307.34
308.57
314.72
322.09
334.08
343.91
348.83
356.21
363.58
368.19
373.11
375.57
378.03
380.49
382.95
387.86
392.78
400.16
407.23
417.06
429.35
443.80
461.01
480.37
502.50
524.32
548.91
573.19
599.93
626.97
656.17
685.37
717.02
748.99
783.10
800.01
834.12
863.63
882.99
907.27
922.02
922.02
$ 190.26
299.62
299.62
299.62
299.62
300.82
306.81
314.00
325.69
335.27
340.07
347.26
354.45
358.94
363.74
366.14
368.53
370.93
373.33
378.12
382.91
390.11
397.00
406.58
418.57
432.65
449.43
468.31
489.88
511.15
535.12
558.79
584.86
611.22
639.69
668.15
699.01
730.17
763.43
779.91
813.17
841.93
860.81
884.48
898.86
898.86
$ 205.92
324.29
324.29
324.29
324.29
325.59
332.07
339.86
352.50
362.88
368.07
375.85
383.64
388.50
393.69
396.28
398.88
401.47
404.07
409.25
414.44
422.23
429.68
440.06
453.03
468.27
486.44
506.87
530.21
553.24
579.18
604.80
633.01
661.55
692.36
723.17
756.57
790.29
826.29
844.13
880.12
911.25
931.69
957.30
972.87
972.87
$ 188.62
297.04
297.04
297.04
297.04
298.23
304.17
311.30
322.88
332.39
337.14
344.27
351.40
355.85
360.61
362.98
365.36
367.74
370.11
374.86
379.62
386.75
393.58
403.08
414.96
428.93
445.56
464.27
485.66
506.75
530.51
553.98
579.82
605.96
634.18
662.40
692.99
723.89
756.86
773.20
806.17
834.68
853.40
876.86
891.12
891.12
$ 191.03
300.84
300.84
300.84
300.84
302.04
308.06
315.28
327.01
336.64
341.45
348.67
355.89
360.41
365.22
367.63
370.03
372.44
374.85
379.66
384.47
391.69
398.61
408.24
420.27
434.41
451.26
470.21
491.87
513.23
537.30
561.07
587.24
613.71
642.29
670.87
701.86
733.15
766.54
783.09
816.48
845.36
864.31
888.08
902.52
902.52
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
31
0SP6
88380VA0740034
Anthem HealthKeepers Preferred DirectAccess gqqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 187.36
295.06
295.06
295.06
295.06
296.24
302.14
309.22
320.73
330.17
334.89
341.97
349.06
353.48
358.20
360.56
362.92
365.28
367.64
372.37
377.09
384.17
390.95
400.40
412.20
426.07
442.59
461.18
482.42
503.37
526.98
550.29
575.96
601.92
629.95
657.98
688.37
719.06
751.81
768.04
800.79
829.12
847.71
871.02
885.18
885.18
$ 170.88
269.10
269.10
269.10
269.10
270.18
275.56
282.02
292.51
301.12
305.43
311.89
318.35
322.38
326.69
328.84
330.99
333.15
335.30
339.60
343.91
350.37
356.56
365.17
375.93
388.58
403.65
420.60
439.98
459.08
480.61
501.87
525.28
548.96
574.53
600.09
627.81
655.80
685.67
700.47
730.34
756.17
773.12
794.38
807.30
807.30
$ 176.96
278.67
278.67
278.67
278.67
279.78
285.36
292.05
302.91
311.83
316.29
322.98
329.67
333.85
338.31
340.53
342.76
344.99
347.22
351.68
356.14
362.83
369.24
378.16
389.30
402.40
418.01
435.56
455.63
475.41
497.70
519.72
543.96
568.49
594.96
621.43
650.14
679.12
710.05
725.38
756.31
783.06
800.62
822.63
836.01
836.01
$ 170.47
268.45
268.45
268.45
268.45
269.52
274.89
281.34
291.81
300.40
304.69
311.13
317.58
321.60
325.90
328.05
330.19
332.34
334.49
338.78
343.08
349.52
355.70
364.29
375.02
387.64
402.68
419.59
438.92
457.98
479.45
500.66
524.01
547.64
573.14
598.64
626.29
654.21
684.01
698.78
728.57
754.34
771.26
792.46
805.35
805.35
$ 173.52
273.26
273.26
273.26
273.26
274.35
279.82
286.38
297.03
305.78
310.15
316.71
323.27
327.37
331.74
333.92
336.11
338.30
340.48
344.85
349.23
355.78
362.07
370.81
381.74
394.59
409.89
427.11
446.78
466.18
488.04
509.63
533.40
557.45
583.41
609.37
637.52
665.93
696.27
711.30
741.63
767.86
785.08
806.66
819.78
819.78
$ 173.51
273.24
273.24
273.24
273.24
274.33
279.80
286.36
297.01
305.76
310.13
316.69
323.24
327.34
331.71
333.90
336.09
338.27
340.46
344.83
349.20
355.76
362.04
370.79
381.72
394.56
409.86
427.07
446.75
466.15
488.01
509.59
533.36
557.41
583.37
609.33
637.47
665.89
696.22
711.24
741.57
767.80
785.02
806.60
819.72
819.72
$ 180.75
284.65
284.65
284.65
284.65
285.79
291.48
298.31
309.41
318.52
323.08
329.91
336.74
341.01
345.57
347.84
350.12
352.40
354.67
359.23
363.78
370.61
377.16
386.27
397.66
411.03
426.98
444.91
465.40
485.61
508.38
530.87
555.64
580.69
607.73
634.77
664.09
693.69
725.29
740.94
772.54
799.87
817.80
840.29
853.95
853.95
$ 180.24
283.85
283.85
283.85
283.85
284.99
290.66
297.47
308.54
317.63
322.17
328.98
335.79
340.05
344.59
346.86
349.14
351.41
353.68
358.22
362.76
369.57
376.10
385.18
396.54
409.88
425.78
443.66
464.09
484.25
506.96
529.38
554.08
579.05
606.02
632.99
662.22
691.74
723.25
738.86
770.37
797.62
815.50
837.93
851.55
851.55
$ 175.72
276.72
276.72
276.72
276.72
277.83
283.36
290.00
300.79
309.65
314.08
320.72
327.36
331.51
335.94
338.15
340.37
342.58
344.79
349.22
353.65
360.29
366.65
375.51
386.58
399.58
415.08
432.51
452.44
472.08
494.22
516.08
540.16
564.51
590.80
617.09
645.59
674.37
705.08
720.30
751.02
777.58
795.02
816.88
830.16
830.16
$ 190.19
299.51
299.51
299.51
299.51
300.71
306.70
313.89
325.57
335.15
339.94
347.13
354.32
358.81
363.61
366.00
368.40
370.79
373.19
377.98
382.77
389.96
396.85
406.44
418.42
432.49
449.27
468.13
489.70
510.96
534.92
558.59
584.64
611.00
639.45
667.91
698.76
729.91
763.15
779.62
812.87
841.62
860.49
884.15
898.53
898.53
$ 174.21
274.34
274.34
274.34
274.34
275.44
280.92
287.51
298.21
306.99
311.38
317.96
324.54
328.66
333.05
335.24
337.44
339.63
341.83
346.22
350.61
357.19
363.50
372.28
383.25
396.15
411.51
428.79
448.55
468.02
489.97
511.64
535.51
559.65
585.72
611.78
640.04
668.57
699.02
714.11
744.56
770.90
788.18
809.85
823.02
823.02
$ 176.43
277.85
277.85
277.85
277.85
278.96
284.52
291.19
302.02
310.91
315.36
322.03
328.70
332.86
337.31
339.53
341.76
343.98
346.20
350.65
355.09
361.76
368.15
377.04
388.16
401.22
416.78
434.28
454.28
474.01
496.24
518.19
542.36
566.81
593.21
619.61
648.22
677.12
707.96
723.24
754.08
780.76
798.26
820.21
833.55
833.55
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
32
0SP8
88380VA0740035
Anthem HealthKeepers Preferred DirectAccess grqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 186.94
294.40
294.40
294.40
294.40
295.58
301.47
308.53
320.01
329.43
334.14
341.21
348.28
352.69
357.40
359.76
362.11
364.47
366.82
371.53
376.24
383.31
390.08
399.50
411.28
425.11
441.60
460.15
481.34
502.25
525.80
549.06
574.67
600.58
628.54
656.51
686.84
717.45
750.13
766.32
799.00
827.26
845.81
869.07
883.20
883.20
$ 170.49
268.49
268.49
268.49
268.49
269.56
274.93
281.38
291.85
300.44
304.74
311.18
317.62
321.65
325.95
328.09
330.24
332.39
334.54
338.83
343.13
349.57
355.75
364.34
375.08
387.70
402.74
419.65
438.98
458.04
479.52
500.73
524.09
547.72
573.23
598.73
626.39
654.31
684.11
698.88
728.68
754.46
771.37
792.58
805.47
805.47
$ 176.56
278.04
278.04
278.04
278.04
279.15
284.71
291.39
302.23
311.13
315.58
322.25
328.92
333.09
337.54
339.76
341.99
344.21
346.44
350.89
355.34
362.01
368.40
377.30
388.42
401.49
417.06
434.58
454.60
474.34
496.58
518.54
542.73
567.20
593.62
620.03
648.67
677.58
708.45
723.74
754.60
781.29
798.81
820.77
834.12
834.12
$ 170.08
267.84
267.84
267.84
267.84
268.91
274.27
280.70
291.14
299.71
304.00
310.43
316.85
320.87
325.16
327.30
329.44
331.59
333.73
338.01
342.30
348.73
354.89
363.46
374.17
386.76
401.76
418.63
437.92
456.94
478.36
499.52
522.82
546.39
571.84
597.28
624.87
652.73
682.46
697.19
726.92
752.63
769.50
790.66
803.52
803.52
$ 173.13
272.65
272.65
272.65
272.65
273.74
279.19
285.74
296.37
305.10
309.46
316.00
322.54
326.63
331.00
333.18
335.36
337.54
339.72
344.08
348.45
354.99
361.26
369.99
380.89
393.71
408.98
426.15
445.78
465.14
486.95
508.49
532.21
556.21
582.11
608.01
636.09
664.45
694.71
709.71
739.97
766.15
783.32
804.86
817.95
817.95
$ 173.11
272.62
272.62
272.62
272.62
273.71
279.16
285.71
296.34
305.06
309.42
315.97
322.51
326.60
330.96
333.14
335.32
337.50
339.68
344.05
348.41
354.95
361.22
369.95
380.85
393.66
408.93
426.11
445.73
465.09
486.90
508.44
532.15
556.14
582.04
607.94
636.02
664.37
694.64
709.63
739.89
766.06
783.24
804.77
817.86
817.86
$ 180.34
284.00
284.00
284.00
284.00
285.14
290.82
297.63
308.71
317.80
322.34
329.16
335.97
340.23
344.78
347.05
349.32
351.59
353.86
358.41
362.95
369.77
376.30
385.39
396.75
410.10
426.00
443.89
464.34
484.50
507.22
529.66
554.37
579.36
606.34
633.32
662.57
692.11
723.63
739.25
770.78
798.04
815.93
838.37
852.00
852.00
$ 179.84
283.21
283.21
283.21
283.21
284.34
290.01
296.80
307.85
316.91
321.44
328.24
335.04
339.29
343.82
346.08
348.35
350.61
352.88
357.41
361.94
368.74
375.25
384.32
395.64
408.96
424.82
442.66
463.05
483.16
505.81
528.19
552.83
577.75
604.65
631.56
660.73
690.18
721.62
737.20
768.63
795.82
813.66
836.04
849.63
849.63
$ 175.32
276.09
276.09
276.09
276.09
277.19
282.72
289.34
300.11
308.94
313.36
319.99
326.61
330.76
335.17
337.38
339.59
341.80
344.01
348.43
352.84
359.47
365.82
374.65
385.70
398.67
414.14
431.53
451.41
471.01
493.10
514.91
538.93
563.22
589.45
615.68
644.12
672.83
703.48
718.66
749.31
775.81
793.21
815.02
828.27
828.27
$ 189.76
298.83
298.83
298.83
298.83
300.03
306.00
313.17
324.83
334.39
339.17
346.34
353.52
358.00
362.78
365.17
367.56
369.95
372.34
377.12
381.90
389.08
395.95
405.51
417.47
431.51
448.25
467.07
488.59
509.80
533.71
557.32
583.32
609.61
638.00
666.39
697.17
728.25
761.42
777.85
811.02
839.71
858.54
882.15
896.49
896.49
$ 173.81
273.72
273.72
273.72
273.72
274.81
280.29
286.86
297.53
306.29
310.67
317.24
323.81
327.92
332.30
334.49
336.68
338.87
341.06
345.43
349.81
356.38
362.68
371.44
382.39
395.25
410.58
427.82
447.53
466.97
488.86
510.49
534.30
558.39
584.39
610.40
638.59
667.06
697.44
712.49
742.88
769.15
786.40
808.02
821.16
821.16
$ 176.03
277.22
277.22
277.22
277.22
278.33
283.87
290.53
301.34
310.21
314.64
321.30
327.95
332.11
336.55
338.76
340.98
343.20
345.42
349.85
354.29
360.94
367.32
376.19
387.28
400.31
415.83
433.29
453.25
472.94
495.11
517.02
541.13
565.53
591.86
618.20
646.75
675.59
706.36
721.60
752.38
778.99
796.45
818.35
831.66
831.66
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
33
0SNW
16064VA1210015
Anthem Preferred DirectAccess w/HSA gxqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 173.87
273.81
273.81
273.81
273.81
274.91
280.38
286.95
297.63
306.39
310.77
317.35
323.92
328.02
332.41
334.60
336.79
338.98
341.17
345.55
349.93
356.50
362.80
371.56
382.51
395.38
410.72
427.97
447.68
467.12
489.02
510.66
534.48
558.57
584.58
610.60
638.80
667.27
697.67
712.73
743.12
769.41
786.66
808.29
821.43
821.43
$ 158.58
249.73
249.73
249.73
249.73
250.73
255.72
261.72
271.46
279.45
283.44
289.44
295.43
299.18
303.17
305.17
307.17
309.17
311.16
315.16
319.15
325.15
330.89
338.88
348.87
360.61
374.60
390.33
408.31
426.04
446.02
465.75
487.47
509.45
533.17
556.90
582.62
608.59
636.31
650.05
677.77
701.74
717.47
737.20
749.19
749.19
$ 169.15
266.38
266.38
266.38
266.38
267.45
272.77
279.17
289.56
298.08
302.34
308.73
315.13
319.12
323.39
325.52
327.65
329.78
331.91
336.17
340.43
346.83
352.95
361.48
372.13
384.65
399.57
416.35
435.53
454.44
475.75
496.80
519.97
543.42
568.72
594.03
621.46
649.17
678.74
693.39
722.96
748.53
765.31
786.35
799.14
799.14
$ 158.19
249.12
249.12
249.12
249.12
250.12
255.10
261.08
270.79
278.77
282.75
288.73
294.71
298.45
302.43
304.42
306.42
308.41
310.40
314.39
318.38
324.35
330.08
338.06
348.02
359.73
373.68
389.37
407.31
425.00
444.93
464.61
486.28
508.20
531.87
555.54
581.20
607.11
634.76
648.46
676.11
700.03
715.72
735.40
747.36
747.36
$ 164.24
258.65
258.65
258.65
258.65
259.68
264.86
271.07
281.15
289.43
293.57
299.78
305.98
309.86
314.00
316.07
318.14
320.21
322.28
326.42
330.55
336.76
342.71
350.99
361.33
373.49
387.98
404.27
422.89
441.26
461.95
482.38
504.88
527.65
552.22
576.79
603.43
630.33
659.04
673.27
701.98
726.81
743.10
763.53
775.95
775.95
$ 156.17
245.94
245.94
245.94
245.94
246.92
251.84
257.75
267.34
275.21
279.14
285.04
290.95
294.64
298.57
300.54
302.51
304.47
306.44
310.38
314.31
320.21
325.87
333.74
343.58
355.14
368.91
384.40
402.11
419.57
439.25
458.68
480.07
501.72
525.08
548.45
573.78
599.36
626.66
640.18
667.48
691.09
706.59
726.01
737.82
737.82
$ 173.09
272.59
272.59
272.59
272.59
273.68
279.13
285.67
296.31
305.03
309.39
315.93
322.47
326.56
330.92
333.10
335.29
337.47
339.65
344.01
348.37
354.91
361.18
369.90
380.81
393.62
408.89
426.06
445.68
465.04
486.85
508.38
532.10
556.08
581.98
607.88
635.95
664.30
694.56
709.55
739.81
765.98
783.15
804.69
817.77
817.77
$ 167.26
263.40
263.40
263.40
263.40
264.45
269.72
276.04
286.32
294.74
298.96
305.28
311.60
315.55
319.77
321.87
323.98
326.09
328.20
332.41
336.63
342.95
349.01
357.43
367.97
380.35
395.10
411.69
430.66
449.36
470.43
491.24
514.16
537.34
562.36
587.38
614.51
641.91
671.14
685.63
714.87
740.15
756.75
777.56
790.20
790.20
$ 174.97
275.54
275.54
275.54
275.54
276.64
282.15
288.77
299.51
308.33
312.74
319.35
325.96
330.10
334.51
336.71
338.91
341.12
343.32
347.73
352.14
358.75
365.09
373.91
384.93
397.88
413.31
430.67
450.51
470.07
492.11
513.88
537.85
562.10
588.28
614.45
642.83
671.49
702.08
717.23
747.82
774.27
791.63
813.39
826.62
826.62
$ 167.67
264.04
264.04
264.04
264.04
265.10
270.38
276.71
287.01
295.46
299.69
306.02
312.36
316.32
320.54
322.66
324.77
326.88
328.99
333.22
337.44
343.78
349.85
358.30
368.86
381.27
396.06
412.69
431.71
450.45
471.58
492.43
515.41
538.64
563.73
588.81
616.01
643.47
672.77
687.30
716.60
741.95
758.59
779.45
792.12
792.12
$ 158.41
249.47
249.47
249.47
249.47
250.47
255.46
261.44
271.17
279.16
283.15
289.14
295.12
298.87
302.86
304.85
306.85
308.84
310.84
314.83
318.82
324.81
330.55
338.53
348.51
360.23
374.21
389.92
407.88
425.60
445.55
465.26
486.97
508.92
532.62
556.32
582.01
607.96
635.65
649.37
677.06
701.01
716.73
736.44
748.41
748.41
$ 168.58
265.48
265.48
265.48
265.48
266.54
271.85
278.22
288.58
297.07
301.32
307.69
314.06
318.05
322.29
324.42
326.54
328.66
330.79
335.04
339.28
345.65
351.76
360.26
370.88
383.35
398.22
414.95
434.06
452.91
474.15
495.12
518.22
541.58
566.80
592.02
619.36
646.97
676.44
691.04
720.51
746.00
762.72
783.70
796.44
796.44
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
34
0SP0
16064VA1210017
Anthem Preferred DirectAccess w/HRA ggra
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 176.56
278.05
278.05
278.05
278.05
279.16
284.72
291.40
302.24
311.14
315.59
322.26
328.93
333.10
337.55
339.78
342.00
344.23
346.45
350.90
355.35
362.02
368.42
377.31
388.44
401.50
417.08
434.59
454.61
474.35
496.60
518.56
542.75
567.22
593.64
620.05
648.69
677.61
708.47
723.76
754.63
781.32
798.84
820.80
834.15
834.15
$ 161.04
253.60
253.60
253.60
253.60
254.61
259.69
265.77
275.66
283.78
287.84
293.92
300.01
303.81
307.87
309.90
311.93
313.96
315.99
320.04
324.10
330.19
336.02
344.14
354.28
366.20
380.40
396.38
414.64
432.64
452.93
472.96
495.03
517.34
541.44
565.53
591.65
618.02
646.17
660.12
688.27
712.62
728.59
748.63
760.80
760.80
$ 171.77
270.50
270.50
270.50
270.50
271.58
276.99
283.48
294.03
302.69
307.02
313.51
320.00
324.06
328.39
330.55
332.72
334.88
337.04
341.37
345.70
352.19
358.41
367.07
377.89
390.60
405.75
422.79
442.27
461.47
483.11
504.48
528.02
551.82
577.52
603.22
631.08
659.21
689.23
704.11
734.14
760.11
777.15
798.52
811.50
811.50
$ 160.64
252.98
252.98
252.98
252.98
253.99
259.05
265.12
274.99
283.08
287.13
293.20
299.28
303.07
307.12
309.14
311.17
313.19
315.21
319.26
323.31
329.38
335.20
343.29
353.41
365.30
379.47
395.41
413.62
431.58
451.82
471.81
493.82
516.08
540.11
564.15
590.20
616.51
644.59
658.51
686.59
710.87
726.81
746.80
758.94
758.94
$ 166.79
262.66
262.66
262.66
262.66
263.71
268.96
275.27
285.51
293.92
298.12
304.42
310.73
314.67
318.87
320.97
323.07
325.17
327.27
331.48
335.68
341.98
348.02
356.43
366.94
379.28
393.99
410.54
429.45
448.10
469.11
489.86
512.71
535.83
560.78
585.73
612.79
640.10
669.26
683.70
712.86
738.07
754.62
775.37
787.98
787.98
$ 158.59
249.75
249.75
249.75
249.75
250.75
255.74
261.74
271.48
279.47
283.47
289.46
295.45
299.20
303.20
305.19
307.19
309.19
311.19
315.18
319.18
325.17
330.92
338.91
348.90
360.64
374.63
390.36
408.34
426.07
446.05
465.78
487.51
509.49
533.22
556.94
582.67
608.64
636.36
650.10
677.82
701.80
717.53
737.26
749.25
749.25
$ 175.77
276.81
276.81
276.81
276.81
277.92
283.45
290.10
300.89
309.75
314.18
320.82
327.47
331.62
336.05
338.26
340.48
342.69
344.91
349.33
353.76
360.41
366.77
375.63
386.70
399.71
415.22
432.65
452.58
472.24
494.38
516.25
540.33
564.69
590.99
617.29
645.80
674.59
705.31
720.54
751.26
777.84
795.28
817.14
830.43
830.43
$ 169.85
267.48
267.48
267.48
267.48
268.55
273.90
280.32
290.75
299.31
303.59
310.01
316.43
320.44
324.72
326.86
329.00
331.14
333.28
337.56
341.84
348.26
354.41
362.97
373.67
386.24
401.22
418.07
437.33
456.32
477.72
498.85
522.12
545.66
571.07
596.48
624.03
651.85
681.54
696.25
725.94
751.62
768.47
789.60
802.44
802.44
$ 177.67
279.80
279.80
279.80
279.80
280.92
286.52
293.23
304.14
313.10
317.57
324.29
331.00
335.20
339.68
341.92
344.15
346.39
348.63
353.11
357.58
364.30
370.74
379.69
390.88
404.03
419.70
437.33
457.47
477.34
499.72
521.83
546.17
570.79
597.37
623.95
652.77
681.87
712.93
728.32
759.38
786.24
803.87
825.97
839.40
839.40
$ 170.26
268.13
268.13
268.13
268.13
269.20
274.57
281.00
291.46
300.04
304.33
310.76
317.20
321.22
325.51
327.65
329.80
331.94
334.09
338.38
342.67
349.11
355.27
363.85
374.58
387.18
402.20
419.09
438.39
457.43
478.88
500.06
523.39
546.99
572.46
597.93
625.55
653.43
683.20
697.94
727.70
753.45
770.34
791.52
804.39
804.39
$ 160.86
253.33
253.33
253.33
253.33
254.34
259.41
265.49
275.37
283.48
287.53
293.61
299.69
303.49
307.54
309.57
311.60
313.62
315.65
319.70
323.76
329.84
335.66
343.77
353.90
365.81
380.00
395.95
414.19
432.18
452.45
472.46
494.50
516.79
540.86
564.93
591.02
617.37
645.48
659.42
687.54
711.86
727.82
747.83
759.99
759.99
$ 171.19
269.59
269.59
269.59
269.59
270.67
276.06
282.53
293.04
301.67
305.98
312.45
318.92
322.97
327.28
329.44
331.60
333.75
335.91
340.22
344.54
351.01
357.21
365.83
376.62
389.29
404.39
421.37
440.78
459.92
481.49
502.79
526.24
549.96
575.57
601.19
628.95
656.99
686.92
701.74
731.67
757.55
774.53
795.83
808.77
808.77
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
35
0SP2
16064VA1210018
Anthem Preferred DirectAccess w/HRA ghra
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 182.23
286.97
286.97
286.97
286.97
288.12
293.86
300.74
311.94
321.12
325.71
332.60
339.49
343.79
348.38
350.68
352.97
355.27
357.56
362.16
366.75
373.63
380.24
389.42
400.90
414.38
430.46
448.53
469.20
489.57
512.53
535.20
560.17
585.42
612.68
639.94
669.50
699.35
731.20
746.98
778.84
806.39
824.46
847.14
860.91
860.91
$ 166.20
261.74
261.74
261.74
261.74
262.79
268.02
274.30
284.51
292.89
297.07
303.36
309.64
313.56
317.75
319.85
321.94
324.03
326.13
330.32
334.50
340.79
346.81
355.18
365.65
377.95
392.61
409.10
427.94
446.53
467.47
488.15
510.92
533.95
558.81
583.68
610.64
637.86
666.91
681.31
710.36
735.49
751.98
772.66
785.22
785.22
$ 177.28
279.18
279.18
279.18
279.18
280.30
285.88
292.58
303.47
312.40
316.87
323.57
330.27
334.46
338.92
341.16
343.39
345.62
347.86
352.33
356.79
363.49
369.91
378.85
390.01
403.14
418.77
436.36
456.46
476.28
498.62
520.67
544.96
569.53
596.05
622.57
651.33
680.36
711.35
726.71
757.69
784.50
802.08
824.14
837.54
837.54
$ 165.80
261.10
261.10
261.10
261.10
262.14
267.37
273.63
283.82
292.17
296.35
302.61
308.88
312.80
316.98
319.06
321.15
323.24
325.33
329.51
333.69
339.95
345.96
354.31
364.76
377.03
391.65
408.10
426.90
445.44
466.32
486.95
509.67
532.64
557.45
582.25
609.15
636.30
665.28
679.64
708.63
733.69
750.14
770.77
783.30
783.30
$ 172.14
271.09
271.09
271.09
271.09
272.17
277.60
284.10
294.67
303.35
307.69
314.19
320.70
324.77
329.10
331.27
333.44
335.61
337.78
342.12
346.45
352.96
359.19
367.87
378.71
391.45
406.64
423.71
443.23
462.48
484.17
505.58
529.17
553.02
578.78
604.53
632.45
660.65
690.74
705.65
735.74
761.76
778.84
800.26
813.27
813.27
$ 163.68
257.76
257.76
257.76
257.76
258.79
263.95
270.13
280.19
288.43
292.56
298.74
304.93
308.80
312.92
314.98
317.04
319.11
321.17
325.29
329.42
335.60
341.53
349.78
360.09
372.21
386.64
402.88
421.44
439.74
460.36
480.72
503.15
525.83
550.32
574.80
601.35
628.16
656.77
670.95
699.56
724.31
740.54
760.91
773.28
773.28
$ 181.41
285.69
285.69
285.69
285.69
286.83
292.55
299.40
310.55
319.69
324.26
331.11
337.97
342.26
346.83
349.11
351.40
353.68
355.97
360.54
365.11
371.97
378.54
387.68
399.11
412.54
428.54
446.53
467.10
487.39
510.24
532.81
557.67
582.81
609.95
637.09
666.51
696.23
727.94
743.65
775.36
802.79
820.79
843.36
857.07
857.07
$ 175.30
276.07
276.07
276.07
276.07
277.17
282.70
289.32
300.09
308.92
313.34
319.97
326.59
330.73
335.15
337.36
339.57
341.77
343.98
348.40
352.82
359.44
365.79
374.63
385.67
398.65
414.11
431.50
451.37
470.98
493.06
514.87
538.89
563.18
589.41
615.64
644.07
672.78
703.43
718.61
749.25
775.76
793.15
814.96
828.21
828.21
$ 183.38
288.78
288.78
288.78
288.78
289.94
295.71
302.64
313.90
323.14
327.77
334.70
341.63
345.96
350.58
352.89
355.20
357.51
359.82
364.44
369.06
375.99
382.63
391.87
403.43
417.00
433.17
451.36
472.16
492.66
515.76
538.57
563.70
589.11
616.55
643.98
673.72
703.76
735.81
751.69
783.75
811.47
829.66
852.48
866.34
866.34
$ 175.73
276.74
276.74
276.74
276.74
277.85
283.38
290.02
300.82
309.67
314.10
320.74
327.38
331.53
335.96
338.18
340.39
342.60
344.82
349.25
353.67
360.32
366.68
375.54
386.61
399.61
415.11
432.54
452.47
472.12
494.26
516.12
540.20
564.55
590.84
617.13
645.63
674.42
705.13
720.35
751.07
777.64
795.07
816.94
830.22
830.22
$ 166.03
261.46
261.46
261.46
261.46
262.51
267.74
274.01
284.21
292.57
296.76
303.03
309.31
313.23
317.41
319.50
321.60
323.69
325.78
329.96
334.15
340.42
346.43
354.80
365.26
377.55
392.19
408.66
427.49
446.05
466.97
487.62
510.37
533.38
558.22
583.06
609.99
637.18
666.20
680.58
709.60
734.70
751.17
771.83
784.38
784.38
$ 176.68
278.24
278.24
278.24
278.24
279.35
284.92
291.60
302.45
311.35
315.80
322.48
329.16
333.33
337.78
340.01
342.24
344.46
346.69
351.14
355.59
362.27
368.67
377.57
388.70
401.78
417.36
434.89
454.92
474.68
496.94
518.92
543.12
567.61
594.04
620.48
649.13
678.07
708.96
724.26
755.14
781.85
799.38
821.36
834.72
834.72
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
36
0SP4
16064VA1210019
Anthem Preferred DirectAccess w/HRA gmra
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 185.32
291.84
291.84
291.84
291.84
293.01
298.84
305.85
317.23
326.57
331.24
338.24
345.25
349.62
354.29
356.63
358.96
361.30
363.63
368.30
372.97
379.98
386.69
396.03
407.70
421.42
437.76
456.15
477.16
497.88
521.23
544.28
569.67
595.35
623.08
650.80
680.86
711.21
743.61
759.66
792.05
820.07
838.46
861.51
875.52
875.52
$ 169.02
266.18
266.18
266.18
266.18
267.24
272.57
278.96
289.34
297.86
302.11
308.50
314.89
318.88
323.14
325.27
327.40
329.53
331.66
335.92
340.18
346.57
352.69
361.21
371.85
384.36
399.27
416.04
435.20
454.10
475.40
496.43
519.58
543.01
568.29
593.58
621.00
648.68
678.23
692.87
722.41
747.97
764.74
785.76
798.54
798.54
$ 180.29
283.92
283.92
283.92
283.92
285.06
290.73
297.55
308.62
317.71
322.25
329.06
335.88
340.14
344.68
346.95
349.22
351.49
353.76
358.31
362.85
369.66
376.19
385.28
396.64
409.98
425.88
443.77
464.21
484.37
507.08
529.51
554.21
579.20
606.17
633.14
662.39
691.91
723.43
739.04
770.56
797.82
815.70
838.13
851.76
851.76
$ 168.61
265.53
265.53
265.53
265.53
266.59
271.90
278.28
288.63
297.13
301.38
307.75
314.12
318.10
322.35
324.48
326.60
328.73
330.85
335.10
339.35
345.72
351.83
360.32
370.95
383.43
398.30
415.02
434.14
452.99
474.24
495.21
518.31
541.68
566.91
592.13
619.48
647.10
676.57
691.17
720.65
746.14
762.87
783.84
796.59
796.59
$ 175.06
275.69
275.69
275.69
275.69
276.79
282.31
288.92
299.68
308.50
312.91
319.52
326.14
330.28
334.69
336.89
339.10
341.30
343.51
347.92
352.33
358.95
365.29
374.11
385.14
398.10
413.54
430.90
450.75
470.33
492.38
514.16
538.15
562.41
588.60
614.79
643.18
671.86
702.46
717.62
748.22
774.69
792.06
813.84
827.07
827.07
$ 166.45
262.13
262.13
262.13
262.13
263.18
268.42
274.71
284.94
293.32
297.52
303.81
310.10
314.03
318.23
320.32
322.42
324.52
326.61
330.81
335.00
341.29
347.32
355.71
366.20
378.52
393.20
409.71
428.58
447.19
468.16
488.87
511.68
534.75
559.65
584.55
611.55
638.81
667.91
682.32
711.42
736.59
753.10
773.81
786.39
786.39
$ 184.49
290.54
290.54
290.54
290.54
291.70
297.51
304.49
315.82
325.11
329.76
336.74
343.71
348.07
352.72
355.04
357.36
359.69
362.01
366.66
371.31
378.28
384.97
394.26
405.88
419.54
435.81
454.11
475.03
495.66
518.90
541.86
567.13
592.70
620.30
647.90
677.83
708.05
740.30
756.28
788.53
816.42
834.72
857.67
871.62
871.62
$ 178.28
280.75
280.75
280.75
280.75
281.87
287.49
294.23
305.18
314.16
318.65
325.39
332.13
336.34
340.83
343.08
345.32
347.57
349.81
354.31
358.80
365.54
371.99
380.98
392.21
405.40
421.13
438.81
459.03
478.96
501.42
523.60
548.02
572.73
599.40
626.07
654.99
684.19
715.35
730.79
761.96
788.91
806.59
828.77
842.25
842.25
$ 186.49
293.68
293.68
293.68
293.68
294.85
300.73
307.78
319.23
328.63
333.33
340.38
347.42
351.83
356.53
358.88
361.23
363.58
365.93
370.62
375.32
382.37
389.13
398.52
410.27
424.07
440.52
459.02
480.17
501.02
524.51
547.71
573.26
599.11
627.01
654.91
685.16
715.70
748.30
764.45
797.05
825.24
843.74
866.94
881.04
881.04
$ 178.71
281.43
281.43
281.43
281.43
282.56
288.18
294.94
305.91
314.92
319.42
326.18
332.93
337.15
341.66
343.91
346.16
348.41
350.66
355.16
359.67
366.42
372.89
381.90
393.16
406.38
422.15
439.88
460.14
480.12
502.63
524.87
549.35
574.12
600.85
627.59
656.58
685.84
717.08
732.56
763.80
790.82
808.55
830.78
844.29
844.29
$ 168.85
265.90
265.90
265.90
265.90
266.96
272.28
278.66
289.03
297.54
301.80
308.18
314.56
318.55
322.80
324.93
327.06
329.18
331.31
335.57
339.82
346.20
352.32
360.83
371.46
383.96
398.85
415.60
434.75
453.63
474.90
495.90
519.04
542.44
567.70
592.96
620.34
648.00
677.51
692.14
721.65
747.18
763.93
784.94
797.70
797.70
$ 179.68
282.96
282.96
282.96
282.96
284.09
289.75
296.54
307.58
316.63
321.16
327.95
334.74
338.99
343.51
345.78
348.04
350.30
352.57
357.10
361.62
368.41
374.92
383.98
395.30
408.59
424.44
442.27
462.64
482.73
505.37
527.72
552.34
577.24
604.12
631.00
660.15
689.57
720.98
736.54
767.95
795.12
812.94
835.30
848.88
848.88
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
37
0SP9
16064VA1210014
Anthem Preferred DirectAccess w/HSA gtqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 199.35
313.93
313.93
313.93
313.93
315.19
321.46
329.00
341.24
351.29
356.31
363.84
371.38
376.09
381.11
383.62
386.13
388.65
391.16
396.18
401.20
408.74
415.96
426.00
438.56
453.31
470.90
490.67
513.28
535.56
560.68
585.48
612.79
640.42
670.24
700.06
732.40
765.05
799.89
817.16
852.01
882.14
901.92
926.72
941.79
941.79
$ 181.81
286.32
286.32
286.32
286.32
287.47
293.19
300.06
311.23
320.39
324.97
331.84
338.72
343.01
347.59
349.88
352.17
354.46
356.75
361.34
365.92
372.79
379.37
388.54
399.99
413.45
429.48
447.52
468.13
488.46
511.37
533.99
558.90
584.09
611.29
638.49
667.98
697.76
729.54
745.29
777.07
804.56
822.60
845.22
858.96
858.96
$ 193.94
305.41
305.41
305.41
305.41
306.63
312.74
320.07
331.98
341.75
346.64
353.97
361.30
365.88
370.77
373.21
375.65
378.10
380.54
385.43
390.31
397.64
404.67
414.44
426.66
441.01
458.12
477.36
499.35
521.03
545.46
569.59
596.16
623.04
652.05
681.06
712.52
744.28
778.18
794.98
828.88
858.20
877.44
901.57
916.23
916.23
$ 181.37
285.62
285.62
285.62
285.62
286.76
292.47
299.33
310.47
319.61
324.18
331.03
337.89
342.17
346.74
349.03
351.31
353.60
355.88
360.45
365.02
371.88
378.45
387.59
399.01
412.44
428.43
446.42
466.99
487.27
510.12
532.68
557.53
582.66
609.80
636.93
666.35
696.06
727.76
743.47
775.17
802.59
820.59
843.15
856.86
856.86
$ 188.31
296.55
296.55
296.55
296.55
297.74
303.67
310.78
322.35
331.84
336.58
343.70
350.82
355.27
360.01
362.38
364.76
367.13
369.50
374.25
378.99
386.11
392.93
402.42
414.28
428.22
444.83
463.51
484.86
505.91
529.64
553.07
578.87
604.96
633.13
661.31
691.85
722.69
755.61
771.92
804.84
833.31
851.99
875.42
889.65
889.65
$ 179.05
281.97
281.97
281.97
281.97
283.10
288.74
295.50
306.50
315.52
320.04
326.80
333.57
337.80
342.31
344.57
346.82
349.08
351.33
355.85
360.36
367.12
373.61
382.63
393.91
407.16
422.96
440.72
461.02
481.04
503.60
525.87
550.41
575.22
602.01
628.79
657.84
687.16
718.46
733.97
765.27
792.34
810.10
832.38
845.91
845.91
$ 198.46
312.53
312.53
312.53
312.53
313.78
320.03
327.53
339.72
349.72
354.72
362.22
369.72
374.41
379.41
381.91
384.41
386.91
389.41
394.41
399.41
406.91
414.10
424.10
436.60
451.29
468.80
488.48
510.99
533.18
558.18
582.87
610.06
637.56
667.25
696.94
729.13
761.64
796.33
813.52
848.21
878.21
897.90
922.59
937.59
937.59
$ 191.77
302.00
302.00
302.00
302.00
303.21
309.25
316.50
328.27
337.94
342.77
350.02
357.27
361.80
366.63
369.04
371.46
373.88
376.29
381.12
385.96
393.20
400.15
409.81
421.89
436.09
453.00
472.03
493.77
515.21
539.37
563.23
589.50
616.08
644.77
673.46
704.57
735.97
769.50
786.11
819.63
848.62
867.65
891.50
906.00
906.00
$ 200.60
315.91
315.91
315.91
315.91
317.17
323.49
331.07
343.39
353.50
358.56
366.14
373.72
378.46
383.51
386.04
388.57
391.10
393.62
398.68
403.73
411.31
418.58
428.69
441.33
456.17
473.87
493.77
516.51
538.94
564.22
589.17
616.66
644.46
674.47
704.48
737.02
769.87
804.94
822.31
857.38
887.71
907.61
932.57
947.73
947.73
$ 192.23
302.73
302.73
302.73
302.73
303.94
310.00
317.26
329.07
338.75
343.60
350.86
358.13
362.67
367.51
369.94
372.36
374.78
377.20
382.05
386.89
394.15
401.12
410.80
422.91
437.14
454.10
473.17
494.96
516.46
540.68
564.59
590.93
617.57
646.33
675.09
706.27
737.75
771.36
788.01
821.61
850.67
869.74
893.66
908.19
908.19
$ 181.62
286.02
286.02
286.02
286.02
287.16
292.88
299.75
310.90
320.06
324.63
331.50
338.36
342.65
347.23
349.52
351.80
354.09
356.38
360.96
365.53
372.40
378.98
388.13
399.57
413.01
429.03
447.05
467.64
487.95
510.83
533.43
558.31
583.48
610.65
637.82
667.28
697.03
728.78
744.51
776.26
803.72
821.74
844.33
858.06
858.06
$ 193.27
304.37
304.37
304.37
304.37
305.59
311.67
318.98
330.85
340.59
345.46
352.76
360.07
364.64
369.51
371.94
374.38
376.81
379.25
384.11
388.98
396.29
403.29
413.03
425.20
439.51
456.56
475.73
497.64
519.26
543.60
567.65
594.13
620.91
649.83
678.75
710.10
741.75
775.53
792.28
826.06
855.28
874.46
898.50
913.11
913.11
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
38
0W35
88380VA0740004
Anthem HealthKeepers Preferred Guided Access Plus w/HSA gsab
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 168.03
264.61
264.61
264.61
264.61
265.67
270.96
277.31
287.63
296.10
300.33
306.68
313.03
317.00
321.24
323.35
325.47
327.59
329.70
333.94
338.17
344.52
350.61
359.08
369.66
382.10
396.92
413.59
432.64
451.42
472.59
493.50
516.52
539.80
564.94
590.08
617.34
644.85
674.23
688.78
718.15
743.55
760.22
781.13
793.83
793.83
$ 153.24
241.33
241.33
241.33
241.33
242.30
247.12
252.91
262.33
270.05
273.91
279.70
285.49
289.11
292.97
294.91
296.84
298.77
300.70
304.56
308.42
314.21
319.76
327.48
337.14
348.48
362.00
377.20
394.57
411.71
431.02
450.08
471.08
492.31
515.24
538.17
563.02
588.12
614.91
628.18
654.97
678.14
693.34
712.41
723.99
723.99
$ 158.69
249.91
249.91
249.91
249.91
250.91
255.91
261.91
271.65
279.65
283.65
289.65
295.64
299.39
303.39
305.39
307.39
309.39
311.39
315.39
319.38
325.38
331.13
339.13
349.12
360.87
374.87
390.61
408.60
426.35
446.34
466.08
487.82
509.82
533.56
557.30
583.04
609.03
636.77
650.52
678.26
702.25
717.99
737.73
749.73
749.73
$ 152.87
240.74
240.74
240.74
240.74
241.70
246.52
252.30
261.68
269.39
273.24
279.02
284.80
288.41
292.26
294.18
296.11
298.04
299.96
303.81
307.67
313.44
318.98
326.68
336.31
347.63
361.11
376.28
393.61
410.70
429.96
448.98
469.92
491.11
513.98
536.85
561.65
586.68
613.41
626.65
653.37
676.48
691.65
710.66
722.22
722.22
$ 155.61
245.06
245.06
245.06
245.06
246.04
250.94
256.82
266.38
274.22
278.14
284.02
289.91
293.58
297.50
299.46
301.42
303.38
305.34
309.27
313.19
319.07
324.70
332.55
342.35
353.87
367.59
383.03
400.67
418.07
437.68
457.04
478.36
499.92
523.20
546.48
571.72
597.21
624.41
637.89
665.09
688.62
704.06
723.42
735.18
735.18
$ 155.59
245.03
245.03
245.03
245.03
246.01
250.91
256.79
266.35
274.19
278.11
283.99
289.87
293.55
297.47
299.43
301.39
303.35
305.31
309.23
313.15
319.03
324.66
332.51
342.31
353.82
367.55
382.98
400.62
418.02
437.62
456.98
478.30
499.86
523.14
546.42
571.65
597.14
624.34
637.81
665.01
688.53
703.97
723.33
735.09
735.09
$ 162.10
255.27
255.27
255.27
255.27
256.29
261.40
267.52
277.48
285.65
289.73
295.86
301.98
305.81
309.90
311.94
313.98
316.02
318.07
322.15
326.24
332.36
338.23
346.40
356.61
368.61
382.91
398.99
417.37
435.49
455.91
476.08
498.29
520.75
545.00
569.25
595.54
622.09
650.43
664.47
692.80
717.31
733.39
753.56
765.81
765.81
$ 161.64
254.55
254.55
254.55
254.55
255.57
260.66
266.77
276.70
284.84
288.91
295.02
301.13
304.95
309.02
311.06
313.10
315.13
317.17
321.24
325.31
331.42
337.28
345.42
355.61
367.57
381.83
397.86
416.19
434.26
454.63
474.74
496.88
519.28
543.46
567.65
593.87
620.34
648.59
662.59
690.85
715.29
731.32
751.43
763.65
763.65
$ 157.58
248.16
248.16
248.16
248.16
249.15
254.12
260.07
269.75
277.69
281.66
287.62
293.57
297.30
301.27
303.25
305.24
307.22
309.21
313.18
317.15
323.10
328.81
336.75
346.68
358.34
372.24
387.87
405.74
423.36
443.21
462.82
484.41
506.25
529.82
553.40
578.96
604.77
632.31
645.96
673.51
697.33
712.96
732.57
744.48
744.48
$ 170.56
268.60
268.60
268.60
268.60
269.67
275.05
281.49
291.97
300.56
304.86
311.31
317.75
321.78
326.08
328.23
330.38
332.53
334.68
338.97
343.27
349.72
355.90
364.49
375.23
387.86
402.90
419.82
439.16
458.23
479.72
500.94
524.31
547.94
573.46
598.98
626.64
654.58
684.39
699.17
728.98
754.77
771.69
792.91
805.80
805.80
$ 156.22
246.02
246.02
246.02
246.02
247.00
251.92
257.83
267.42
275.30
279.23
285.14
291.04
294.73
298.67
300.64
302.60
304.57
306.54
310.48
314.41
320.32
325.98
333.85
343.69
355.25
369.03
384.53
402.24
419.71
439.39
458.83
480.23
501.88
525.25
548.62
573.96
599.55
626.86
640.39
667.70
691.32
706.82
726.25
738.06
738.06
$ 158.22
249.17
249.17
249.17
249.17
250.17
255.15
261.13
270.85
278.82
282.81
288.79
294.77
298.51
302.49
304.49
306.48
308.47
310.47
314.45
318.44
324.42
330.15
338.12
348.09
359.80
373.76
389.45
407.39
425.08
445.02
464.70
486.38
508.31
531.98
555.65
581.31
607.23
634.89
648.59
676.25
700.17
715.87
735.55
747.51
747.51
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
39
0W36
88380VA0740005
Anthem HealthKeepers Preferred Guided Access Plus w/HSA gvab
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 162.74
256.28
256.28
256.28
256.28
257.31
262.43
268.58
278.58
286.78
290.88
297.03
303.18
307.02
311.12
313.17
315.22
317.27
319.32
323.43
327.53
333.68
339.57
347.77
358.02
370.07
384.42
400.57
419.02
437.21
457.72
477.96
500.26
522.81
547.16
571.50
597.90
624.55
653.00
667.10
695.54
720.15
736.29
756.54
768.84
768.84
$ 148.42
233.73
233.73
233.73
233.73
234.66
239.34
244.95
254.06
261.54
265.28
270.89
276.50
280.01
283.75
285.62
287.49
289.36
291.23
294.97
298.71
304.32
309.69
317.17
326.52
337.51
350.60
365.32
382.15
398.74
417.44
435.91
456.24
476.81
499.01
521.22
545.29
569.60
595.54
608.40
634.34
656.78
671.51
689.97
701.19
701.19
$ 153.70
242.04
242.04
242.04
242.04
243.01
247.85
253.66
263.10
270.84
274.72
280.52
286.33
289.96
293.84
295.77
297.71
299.65
301.58
305.45
309.33
315.14
320.70
328.45
338.13
349.51
363.06
378.31
395.74
412.92
432.28
451.40
472.46
493.76
516.76
539.75
564.68
589.85
616.72
630.03
656.90
680.13
695.38
714.50
726.12
726.12
$ 148.06
233.16
233.16
233.16
233.16
234.09
238.76
244.35
253.44
260.91
264.64
270.23
275.83
279.33
283.06
284.92
286.79
288.65
290.52
294.25
297.98
303.57
308.94
316.40
325.72
336.68
349.74
364.43
381.22
397.77
416.42
434.84
455.13
475.65
497.80
519.95
543.96
568.21
594.09
606.92
632.80
655.18
669.87
688.29
699.48
699.48
$ 150.71
237.34
237.34
237.34
237.34
238.29
243.04
248.73
257.99
265.58
269.38
275.08
280.77
284.33
288.13
290.03
291.93
293.83
295.73
299.52
303.32
309.02
314.48
322.07
331.56
342.72
356.01
370.96
388.05
404.90
423.89
442.64
463.29
484.17
506.72
529.27
553.71
578.40
604.74
617.80
644.14
666.93
681.88
700.63
712.02
712.02
$ 150.70
237.32
237.32
237.32
237.32
238.27
243.02
248.71
257.97
265.56
269.36
275.05
280.75
284.31
288.11
290.01
291.90
293.80
295.70
299.50
303.29
308.99
314.45
322.04
331.54
342.69
355.98
370.93
388.02
404.87
423.85
442.60
463.25
484.13
506.68
529.22
553.67
578.35
604.69
617.74
644.09
666.87
681.82
700.57
711.96
711.96
$ 156.99
247.23
247.23
247.23
247.23
248.22
253.16
259.10
268.74
276.65
280.61
286.54
292.47
296.18
300.14
302.12
304.09
306.07
308.05
312.00
315.96
321.89
327.58
335.49
345.38
357.00
370.85
386.42
404.22
421.77
441.55
461.08
482.59
504.35
527.84
551.32
576.79
602.50
629.94
643.54
670.98
694.72
710.29
729.82
741.69
741.69
$ 156.55
246.54
246.54
246.54
246.54
247.53
252.46
258.37
267.99
275.88
279.82
285.74
291.66
295.35
299.30
301.27
303.24
305.22
307.19
311.13
315.08
321.00
326.67
334.55
344.42
356.00
369.81
385.34
403.09
420.60
440.32
459.80
481.25
502.94
526.36
549.78
575.18
600.82
628.18
641.74
669.11
692.78
708.31
727.79
739.62
739.62
$ 152.62
240.34
240.34
240.34
240.34
241.30
246.11
251.88
261.25
268.94
272.79
278.55
284.32
287.93
291.77
293.70
295.62
297.54
299.46
303.31
307.15
312.92
318.45
326.14
335.75
347.05
360.51
375.65
392.96
410.02
429.25
448.23
469.14
490.29
513.13
535.96
560.71
585.71
612.39
625.61
652.28
675.36
690.50
709.48
721.02
721.02
$ 165.19
260.14
260.14
260.14
260.14
261.18
266.38
272.63
282.77
291.10
295.26
301.50
307.75
311.65
315.81
317.89
319.97
322.05
324.13
328.30
332.46
338.70
344.69
353.01
363.42
375.64
390.21
406.60
425.33
443.80
464.61
485.16
507.79
530.69
555.40
580.11
606.91
633.96
662.84
677.14
706.02
730.99
747.38
767.93
780.42
780.42
$ 151.31
238.28
238.28
238.28
238.28
239.23
244.00
249.72
259.01
266.64
270.45
276.17
281.89
285.46
289.27
291.18
293.08
294.99
296.90
300.71
304.52
310.24
315.72
323.35
332.88
344.08
357.42
372.43
389.59
406.51
425.57
444.39
465.12
486.09
508.73
531.36
555.91
580.69
607.14
620.24
646.69
669.57
684.58
703.40
714.84
714.84
$ 153.24
241.33
241.33
241.33
241.33
242.30
247.12
252.91
262.33
270.05
273.91
279.70
285.49
289.11
292.97
294.91
296.84
298.77
300.70
304.56
308.42
314.21
319.76
327.48
337.14
348.48
362.00
377.20
394.57
411.71
431.02
450.08
471.08
492.31
515.24
538.17
563.02
588.12
614.91
628.18
654.97
678.14
693.34
712.41
723.99
723.99
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
40
0W37
88380VA0740006
Anthem HealthKeepers Preferred Guided Access Plus w/HRA gbbb
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 165.87
261.21
261.21
261.21
261.21
262.25
267.48
273.75
283.94
292.29
296.47
302.74
309.01
312.93
317.11
319.20
321.29
323.38
325.47
329.65
333.83
340.10
346.10
354.46
364.91
377.19
391.82
408.27
427.08
445.62
466.52
487.16
509.88
532.87
557.68
582.50
609.40
636.57
665.56
679.93
708.92
734.00
750.46
771.09
783.63
783.63
$ 151.28
238.23
238.23
238.23
238.23
239.18
243.95
249.67
258.96
266.58
270.39
276.11
281.83
285.40
289.21
291.12
293.02
294.93
296.83
300.65
304.46
310.18
315.65
323.28
332.81
344.00
357.35
372.35
389.51
406.42
425.48
444.30
465.02
485.99
508.62
531.25
555.79
580.57
607.01
620.11
646.56
669.43
684.43
703.25
714.69
714.69
$ 156.65
246.70
246.70
246.70
246.70
247.69
252.62
258.54
268.16
276.06
280.00
285.93
291.85
295.55
299.49
301.47
303.44
305.41
307.39
311.34
315.28
321.20
326.88
334.77
344.64
356.23
370.05
385.59
403.35
420.87
440.61
460.10
481.56
503.27
526.70
550.14
575.55
601.21
628.59
642.16
669.54
693.23
708.77
728.26
740.10
740.10
$ 150.91
237.65
237.65
237.65
237.65
238.60
243.35
249.06
258.33
265.93
269.73
275.44
281.14
284.70
288.51
290.41
292.31
294.21
296.11
299.91
303.72
309.42
314.89
322.49
332.00
343.17
356.48
371.45
388.56
405.43
424.44
443.22
463.89
484.81
507.38
529.96
554.44
579.15
605.53
618.60
644.98
667.80
682.77
701.54
712.95
712.95
$ 153.61
241.91
241.91
241.91
241.91
242.88
247.72
253.52
262.96
270.70
274.57
280.37
286.18
289.81
293.68
295.61
297.55
299.48
301.42
305.29
309.16
314.97
320.53
328.27
337.95
349.32
362.87
378.11
395.52
412.70
432.05
451.16
472.21
493.50
516.48
539.46
564.38
589.53
616.39
629.69
656.54
679.77
695.01
714.12
725.73
725.73
$ 153.60
241.89
241.89
241.89
241.89
242.86
247.70
253.50
262.93
270.67
274.55
280.35
286.16
289.78
293.65
295.59
297.52
299.46
301.39
305.27
309.14
314.94
320.50
328.24
337.92
349.29
362.84
378.07
395.49
412.66
432.02
451.12
472.17
493.46
516.44
539.41
564.33
589.49
616.34
629.64
656.49
679.71
694.95
714.06
725.67
725.67
$ 160.01
251.99
251.99
251.99
251.99
253.00
258.04
264.09
273.91
281.98
286.01
292.06
298.10
301.88
305.92
307.93
309.95
311.96
313.98
318.01
322.04
328.09
333.89
341.95
352.03
363.87
377.99
393.86
412.00
429.89
450.05
469.96
491.88
514.06
538.00
561.94
587.89
614.10
642.07
655.93
683.90
708.09
723.97
743.87
755.97
755.97
$ 159.57
251.29
251.29
251.29
251.29
252.30
257.32
263.35
273.15
281.19
285.21
291.25
297.28
301.05
305.07
307.08
309.09
311.10
313.11
317.13
321.15
327.18
332.96
341.00
351.05
362.86
376.94
392.77
410.86
428.70
448.80
468.66
490.52
512.63
536.50
560.38
586.26
612.39
640.29
654.11
682.00
706.12
721.96
741.81
753.87
753.87
$ 155.56
244.97
244.97
244.97
244.97
245.95
250.85
256.73
266.28
274.12
278.04
283.92
289.80
293.47
297.39
299.35
301.31
303.27
305.23
309.15
313.07
318.95
324.59
332.42
342.22
353.74
367.46
382.89
400.53
417.92
437.52
456.87
478.18
499.74
523.01
546.28
571.52
596.99
624.18
637.66
664.85
688.37
703.80
723.15
734.91
734.91
$ 168.37
265.15
265.15
265.15
265.15
266.21
271.51
277.88
288.22
296.70
300.95
307.31
313.67
317.65
321.89
324.01
326.13
328.26
330.38
334.62
338.86
345.23
351.32
359.81
370.41
382.88
397.73
414.43
433.52
452.35
473.56
494.50
517.57
540.91
566.10
591.28
618.59
646.17
675.60
690.19
719.62
745.07
761.78
782.72
795.45
795.45
$ 154.22
242.87
242.87
242.87
242.87
243.84
248.70
254.53
264.00
271.77
275.66
281.49
287.32
290.96
294.84
296.79
298.73
300.67
302.62
306.50
310.39
316.22
321.80
329.57
339.29
350.70
364.31
379.61
397.09
414.34
433.77
452.95
474.08
495.45
518.53
541.60
566.62
591.87
618.83
632.19
659.15
682.46
697.77
716.95
728.61
728.61
$ 156.19
245.97
245.97
245.97
245.97
246.95
251.87
257.78
267.37
275.24
279.18
285.08
290.98
294.67
298.61
300.58
302.54
304.51
306.48
310.41
314.35
320.25
325.91
333.78
343.62
355.18
368.96
384.45
402.16
419.62
439.30
458.73
480.13
501.78
525.15
548.51
573.85
599.43
626.73
640.26
667.56
691.18
706.67
726.10
737.91
737.91
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
41
0SNX
88380VA0740037
Anthem HealthKeepers Preferred DirectAccess w/HSA gxqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 164.08
258.40
258.40
258.40
258.40
259.43
264.60
270.80
280.88
289.15
293.28
299.49
305.69
309.56
313.70
315.76
317.83
319.90
321.97
326.10
330.24
336.44
342.38
350.65
360.98
373.13
387.60
403.88
422.48
440.83
461.50
481.92
504.40
527.14
551.68
576.23
602.85
629.72
658.40
672.62
701.30
726.10
742.38
762.80
775.20
775.20
$ 149.64
235.66
235.66
235.66
235.66
236.60
241.32
246.97
256.16
263.70
267.47
273.13
278.79
282.32
286.09
287.98
289.86
291.75
293.63
297.40
301.17
306.83
312.25
319.79
329.22
340.29
353.49
368.34
385.30
402.04
420.89
439.51
460.01
480.75
503.13
525.52
549.79
574.30
600.46
613.42
639.58
662.20
677.05
695.67
706.98
706.98
$ 154.97
244.04
244.04
244.04
244.04
245.02
249.90
255.75
265.27
273.08
276.99
282.84
288.70
292.36
296.26
298.22
300.17
302.12
304.07
307.98
311.88
317.74
323.35
331.16
340.92
352.39
366.06
381.43
399.01
416.33
435.86
455.13
476.37
497.84
521.03
544.21
569.35
594.73
621.81
635.24
662.32
685.75
701.13
720.41
732.12
732.12
$ 149.28
235.09
235.09
235.09
235.09
236.03
240.73
246.37
255.54
263.07
266.83
272.47
278.11
281.64
285.40
287.28
289.16
291.04
292.92
296.68
300.45
306.09
311.49
319.02
328.42
339.47
352.64
367.45
384.37
401.06
419.87
438.44
458.90
479.58
501.92
524.25
548.46
572.91
599.01
611.94
638.03
660.60
675.41
693.99
705.27
705.27
$ 151.96
239.30
239.30
239.30
239.30
240.26
245.04
250.79
260.12
267.78
271.61
277.35
283.09
286.68
290.51
292.42
294.34
296.25
298.17
302.00
305.83
311.57
317.07
324.73
334.30
345.55
358.95
374.03
391.26
408.25
427.39
446.29
467.11
488.17
510.91
533.64
558.29
583.17
609.74
622.90
649.46
672.43
687.51
706.41
717.90
717.90
$ 151.94
239.28
239.28
239.28
239.28
240.24
245.02
250.77
260.10
267.75
271.58
277.33
283.07
286.66
290.49
292.40
294.31
296.23
298.14
301.97
305.80
311.54
317.05
324.70
334.27
345.52
358.92
373.99
391.22
408.21
427.35
446.26
467.07
488.13
510.86
533.59
558.24
583.13
609.69
622.85
649.41
672.38
687.45
706.35
717.84
717.84
$ 158.29
249.27
249.27
249.27
249.27
250.27
255.25
261.23
270.96
278.93
282.92
288.90
294.89
298.63
302.61
304.61
306.60
308.60
310.59
314.58
318.57
324.55
330.28
338.26
348.23
359.95
373.91
389.61
407.56
425.25
445.20
464.89
486.58
508.51
532.19
555.87
581.55
607.47
635.14
648.85
676.52
700.45
716.15
735.85
747.81
747.81
$ 157.85
248.58
248.58
248.58
248.58
249.57
254.55
260.51
270.21
278.16
282.14
288.10
294.07
297.80
301.78
303.76
305.75
307.74
309.73
313.71
317.69
323.65
329.37
337.32
347.27
358.95
372.87
388.53
406.43
424.08
443.96
463.60
485.23
507.10
530.72
554.33
579.94
605.79
633.38
647.05
674.65
698.51
714.17
733.81
745.74
745.74
$ 153.88
242.33
242.33
242.33
242.33
243.30
248.15
253.96
263.41
271.17
275.04
280.86
286.68
290.31
294.19
296.13
298.07
300.00
301.94
305.82
309.70
315.51
321.09
328.84
338.54
349.92
363.50
378.76
396.21
413.41
432.80
451.95
473.03
494.35
517.37
540.40
565.36
590.56
617.46
630.78
657.68
680.95
696.21
715.36
726.99
726.99
$ 166.55
262.29
262.29
262.29
262.29
263.34
268.58
274.88
285.11
293.50
297.70
303.99
310.29
314.22
318.42
320.52
322.62
324.72
326.81
331.01
335.21
341.50
347.53
355.93
366.42
378.75
393.44
409.96
428.84
447.47
468.45
489.17
511.99
535.07
559.99
584.91
611.92
639.20
668.31
682.74
711.86
737.03
753.56
774.28
786.87
786.87
$ 152.56
240.25
240.25
240.25
240.25
241.21
246.02
251.78
261.15
268.84
272.68
278.45
284.22
287.82
291.66
293.59
295.51
297.43
299.35
303.20
307.04
312.81
318.33
326.02
335.63
346.92
360.38
375.51
392.81
409.87
429.09
448.07
468.97
490.11
512.93
535.76
560.50
585.49
612.16
625.37
652.04
675.10
690.24
709.22
720.75
720.75
$ 154.51
243.32
243.32
243.32
243.32
244.29
249.16
255.00
264.49
272.28
276.17
282.01
287.85
291.50
295.39
297.34
299.28
301.23
303.18
307.07
310.96
316.80
322.40
330.19
339.92
351.35
364.98
380.31
397.83
415.10
434.57
453.79
474.96
496.37
519.49
542.60
567.67
592.97
619.98
633.36
660.37
683.73
699.06
718.28
729.96
729.96
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
42
0SP1
88380VA0740039
Anthem HealthKeepers Preferred DirectAccess w/HRA ggra
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 166.62
262.40
262.40
262.40
262.40
263.45
268.70
275.00
285.23
293.63
297.82
304.12
310.42
314.36
318.55
320.65
322.75
324.85
326.95
331.15
335.35
341.64
347.68
356.08
366.57
378.91
393.60
410.13
429.02
447.65
468.65
489.38
512.20
535.30
560.22
585.15
612.18
639.47
668.60
683.03
712.15
737.34
753.88
774.60
787.20
787.20
$ 151.96
239.31
239.31
239.31
239.31
240.27
245.05
250.80
260.13
267.79
271.62
277.36
283.10
286.69
290.52
292.44
294.35
296.27
298.18
302.01
305.84
311.58
317.09
324.74
334.32
345.56
358.97
374.04
391.27
408.26
427.41
446.31
467.13
488.19
510.93
533.66
558.31
583.20
609.76
622.92
649.49
672.46
687.54
706.44
717.93
717.93
$ 157.37
247.82
247.82
247.82
247.82
248.81
253.77
259.72
269.38
277.31
281.28
287.22
293.17
296.89
300.85
302.84
304.82
306.80
308.78
312.75
316.71
322.66
328.36
336.29
346.20
357.85
371.73
387.34
405.19
422.78
442.61
462.18
483.74
505.55
529.10
552.64
578.16
603.94
631.45
645.08
672.58
696.37
711.99
731.56
743.46
743.46
$ 151.60
238.74
238.74
238.74
238.74
239.69
244.47
250.20
259.51
267.15
270.97
276.70
282.43
286.01
289.83
291.74
293.65
295.56
297.47
301.29
305.11
310.84
316.33
323.97
333.52
344.74
358.11
373.15
390.34
407.29
426.39
445.25
466.02
487.03
509.71
532.39
556.98
581.81
608.31
621.44
647.94
670.86
685.90
704.76
716.22
716.22
$ 154.32
243.02
243.02
243.02
243.02
243.99
248.85
254.68
264.16
271.94
275.83
281.66
287.49
291.14
295.03
296.97
298.91
300.86
302.80
306.69
310.58
316.41
322.00
329.78
339.50
350.92
364.53
379.84
397.34
414.59
434.03
453.23
474.38
495.76
518.85
541.93
566.97
592.24
619.21
632.58
659.56
682.89
698.20
717.40
729.06
729.06
$ 154.30
242.99
242.99
242.99
242.99
243.96
248.82
254.65
264.13
271.91
275.79
281.63
287.46
291.10
294.99
296.93
298.88
300.82
302.77
306.65
310.54
316.37
321.96
329.74
339.46
350.88
364.49
379.79
397.29
414.54
433.98
453.18
474.32
495.70
518.78
541.87
566.90
592.17
619.14
632.50
659.47
682.80
698.11
717.31
728.97
728.97
$ 160.74
253.14
253.14
253.14
253.14
254.15
259.22
265.29
275.16
283.26
287.31
293.39
299.46
303.26
307.31
309.34
311.36
313.39
315.41
319.46
323.51
329.59
335.41
343.51
353.64
365.53
379.71
395.66
413.88
431.86
452.11
472.11
494.13
516.41
540.45
564.50
590.58
616.90
645.00
658.92
687.02
711.32
727.27
747.27
759.42
759.42
$ 160.29
252.43
252.43
252.43
252.43
253.44
258.49
264.55
274.39
282.47
286.51
292.57
298.62
302.41
306.45
308.47
310.49
312.51
314.53
318.57
322.61
328.66
334.47
342.55
352.64
364.51
378.65
394.55
412.72
430.65
450.84
470.78
492.74
514.96
538.94
562.92
588.92
615.17
643.19
657.08
685.10
709.33
725.23
745.17
757.29
757.29
$ 156.27
246.09
246.09
246.09
246.09
247.07
252.00
257.90
267.50
275.37
279.31
285.22
291.12
294.82
298.75
300.72
302.69
304.66
306.63
310.57
314.50
320.41
326.07
333.94
343.79
355.35
369.14
384.64
402.36
419.83
439.52
458.96
480.37
502.02
525.40
548.78
574.13
599.72
627.04
640.57
667.89
691.51
707.02
726.46
738.27
738.27
$ 169.14
266.36
266.36
266.36
266.36
267.43
272.75
279.15
289.53
298.06
302.32
308.71
315.10
319.10
323.36
325.49
327.62
329.75
331.88
336.15
340.41
346.80
352.93
361.45
372.10
384.62
399.54
416.32
435.50
454.41
475.72
496.76
519.93
543.37
568.68
593.98
621.42
649.12
678.69
693.34
722.90
748.47
765.25
786.29
799.08
799.08
$ 154.92
243.97
243.97
243.97
243.97
244.95
249.83
255.68
265.20
273.00
276.91
282.76
288.62
292.28
296.18
298.13
300.08
302.03
303.99
307.89
311.79
317.65
323.26
331.07
340.83
352.29
365.96
381.33
398.89
416.21
435.73
455.00
476.23
497.70
520.88
544.05
569.18
594.55
621.64
635.05
662.13
685.56
700.93
720.20
731.91
731.91
$ 156.90
247.09
247.09
247.09
247.09
248.08
253.02
258.95
268.59
276.49
280.45
286.38
292.31
296.01
299.97
301.94
303.92
305.90
307.87
311.83
315.78
321.71
327.39
335.30
345.18
356.80
370.64
386.20
403.99
421.54
441.30
460.82
482.32
504.06
527.54
551.01
576.46
602.16
629.59
643.18
670.60
694.32
709.89
729.41
741.27
741.27
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
43
0SP3
88380VA0740040
Anthem HealthKeepers Preferred DirectAccess w/HRA ghra
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 171.95
270.79
270.79
270.79
270.79
271.87
277.29
283.79
294.35
303.01
307.35
313.85
320.34
324.41
328.74
330.91
333.07
335.24
337.40
341.74
346.07
352.57
358.80
367.46
378.29
391.02
406.19
423.24
442.74
461.97
483.63
505.02
528.58
552.41
578.14
603.86
631.75
659.92
689.97
704.87
734.92
760.92
777.98
799.37
812.37
812.37
$ 156.83
246.97
246.97
246.97
246.97
247.96
252.90
258.82
268.46
276.36
280.31
286.24
292.17
295.87
299.82
301.80
303.77
305.75
307.72
311.68
315.63
321.55
327.24
335.14
345.02
356.62
370.46
386.01
403.80
421.33
441.09
460.60
482.09
503.82
527.28
550.74
576.18
601.87
629.28
642.86
670.28
693.99
709.54
729.06
740.91
740.91
$ 162.40
255.75
255.75
255.75
255.75
256.77
261.89
268.03
278.00
286.18
290.28
296.41
302.55
306.39
310.48
312.53
314.57
316.62
318.66
322.76
326.85
332.99
338.87
347.05
357.28
369.30
383.63
399.74
418.15
436.31
456.77
476.97
499.22
521.73
546.03
570.32
596.66
623.26
651.65
665.72
694.11
718.66
734.77
754.97
767.25
767.25
$ 156.44
246.37
246.37
246.37
246.37
247.36
252.28
258.20
267.80
275.69
279.63
285.54
291.46
295.15
299.09
301.06
303.04
305.01
306.98
310.92
314.86
320.77
326.44
334.32
344.18
355.76
369.56
385.08
402.81
420.31
440.02
459.48
480.91
502.59
526.00
549.41
574.78
600.40
627.75
641.30
668.65
692.30
707.82
727.28
739.11
739.11
$ 159.25
250.79
250.79
250.79
250.79
251.79
256.81
262.83
272.61
280.63
284.65
290.67
296.68
300.45
304.46
306.47
308.47
310.48
312.48
316.50
320.51
326.53
332.30
340.32
350.35
362.14
376.19
391.98
410.04
427.85
447.91
467.72
489.54
511.61
535.44
559.26
585.09
611.18
639.01
652.81
680.64
704.72
720.52
740.33
752.37
752.37
$ 159.23
250.76
250.76
250.76
250.76
251.76
256.78
262.80
272.58
280.60
284.61
290.63
296.65
300.41
304.42
306.43
308.43
310.44
312.45
316.46
320.47
326.49
332.26
340.28
350.31
362.10
376.14
391.94
409.99
427.80
447.86
467.67
489.48
511.55
535.37
559.19
585.02
611.10
638.94
652.73
680.56
704.64
720.43
740.24
752.28
752.28
$ 165.88
261.23
261.23
261.23
261.23
262.27
267.50
273.77
283.96
292.32
296.50
302.77
309.04
312.95
317.13
319.22
321.31
323.40
325.49
329.67
333.85
340.12
346.13
354.49
364.94
377.22
391.85
408.30
427.11
445.66
466.56
487.19
509.92
532.91
557.73
582.54
609.45
636.62
665.61
679.98
708.98
734.06
750.51
771.15
783.69
783.69
$ 165.42
260.50
260.50
260.50
260.50
261.54
266.75
273.00
283.16
291.50
295.67
301.92
308.17
312.08
316.25
318.33
320.42
322.50
324.58
328.75
332.92
339.17
345.16
353.50
363.92
376.16
390.75
407.16
425.92
444.41
465.25
485.83
508.50
531.42
556.17
580.92
607.75
634.84
663.75
678.08
707.00
732.01
748.42
769.00
781.50
781.50
$ 161.26
253.96
253.96
253.96
253.96
254.98
260.06
266.15
276.05
284.18
288.24
294.34
300.43
304.24
308.31
310.34
312.37
314.40
316.43
320.50
324.56
330.66
336.50
344.62
354.78
366.72
380.94
396.94
415.22
433.26
453.57
473.64
495.73
518.08
542.20
566.33
592.49
618.90
647.09
661.06
689.25
713.63
729.63
749.69
761.88
761.88
$ 174.54
274.87
274.87
274.87
274.87
275.97
281.47
288.06
298.78
307.58
311.98
318.57
325.17
329.29
333.69
335.89
338.09
340.29
342.49
346.89
351.28
357.88
364.20
373.00
383.99
396.91
412.31
429.62
449.41
468.93
490.92
512.63
536.55
560.73
586.85
612.96
641.27
669.86
700.37
715.49
746.00
772.38
789.70
811.42
824.61
824.61
$ 159.87
251.77
251.77
251.77
251.77
252.78
257.81
263.85
273.67
281.73
285.76
291.80
297.84
301.62
305.65
307.66
309.68
311.69
313.71
317.73
321.76
327.80
333.60
341.65
351.72
363.56
377.66
393.52
411.64
429.52
449.66
469.55
491.46
513.61
537.53
561.45
587.38
613.56
641.51
655.36
683.30
707.47
723.34
743.23
755.31
755.31
$ 161.93
255.00
255.00
255.00
255.00
256.02
261.12
267.24
277.19
285.35
289.43
295.55
301.67
305.49
309.57
311.61
313.65
315.69
317.73
321.81
325.89
332.01
337.88
346.04
356.24
368.22
382.50
398.57
416.93
435.03
455.43
475.58
497.76
520.20
544.43
568.65
594.92
621.44
649.74
663.77
692.07
716.55
732.62
752.76
765.00
765.00
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
44
0SP5
88380VA0740041
Anthem HealthKeepers Preferred DirectAccess w/HRA gmra
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 174.89
275.41
275.41
275.41
275.41
276.51
282.02
288.63
299.37
308.18
312.59
319.20
325.81
329.94
334.35
336.55
338.75
340.96
343.16
347.57
351.97
358.58
364.92
373.73
384.75
397.69
413.12
430.47
450.30
469.85
491.88
513.64
537.60
561.84
588.00
614.16
642.53
671.17
701.74
716.89
747.46
773.90
791.25
813.01
826.23
826.23
$ 159.50
251.18
251.18
251.18
251.18
252.18
257.21
263.24
273.03
281.07
285.09
291.12
297.15
300.91
304.93
306.94
308.95
310.96
312.97
316.99
321.01
327.04
332.81
340.85
350.90
362.70
376.77
392.59
410.68
428.51
448.61
468.45
490.30
512.41
536.27
560.13
586.00
612.13
640.01
653.82
681.70
705.82
721.64
741.48
753.54
753.54
$ 165.17
260.11
260.11
260.11
260.11
261.15
266.35
272.60
282.74
291.06
295.22
301.47
307.71
311.61
315.77
317.85
319.94
322.02
324.10
328.26
332.42
338.66
344.65
352.97
363.37
375.60
390.17
406.55
425.28
443.75
464.56
485.11
507.73
530.62
555.33
580.05
606.84
633.89
662.76
677.07
705.94
730.91
747.30
767.84
780.33
780.33
$ 159.11
250.57
250.57
250.57
250.57
251.57
256.58
262.60
272.37
280.39
284.40
290.41
296.42
300.18
304.19
306.20
308.20
310.21
312.21
316.22
320.23
326.24
332.01
340.02
350.05
361.82
375.86
391.64
409.68
427.47
447.52
467.31
489.11
511.16
534.97
558.77
584.58
610.64
638.45
652.23
680.05
704.10
719.89
739.68
751.71
751.71
$ 161.96
255.06
255.06
255.06
255.06
256.08
261.18
267.30
277.25
285.41
289.49
295.61
301.74
305.56
309.64
311.68
313.72
315.76
317.80
321.89
325.97
332.09
337.95
346.12
356.32
368.31
382.59
398.66
417.02
435.13
455.54
475.69
497.88
520.32
544.55
568.78
595.05
621.58
649.89
663.92
692.23
716.72
732.79
752.94
765.18
765.18
$ 161.95
255.04
255.04
255.04
255.04
256.06
261.16
267.28
277.23
285.39
289.47
295.59
301.71
305.54
309.62
311.66
313.70
315.74
317.78
321.86
325.94
332.06
337.93
346.09
356.29
368.28
382.56
398.63
416.99
435.10
455.50
475.65
497.84
520.28
544.51
568.74
595.01
621.53
649.84
663.87
692.18
716.66
732.73
752.88
765.12
765.12
$ 168.71
265.68
265.68
265.68
265.68
266.74
272.06
278.43
288.79
297.30
301.55
307.92
314.30
318.28
322.54
324.66
326.79
328.91
331.04
335.29
339.54
345.92
352.03
360.53
371.15
383.64
398.52
415.26
434.39
453.25
474.50
495.49
518.61
541.99
567.23
592.47
619.83
647.46
676.95
691.57
721.06
746.56
763.30
784.29
797.04
797.04
$ 168.24
264.94
264.94
264.94
264.94
266.00
271.30
277.66
287.99
296.47
300.71
307.07
313.42
317.40
321.64
323.76
325.88
328.00
330.12
334.35
338.59
344.95
351.05
359.52
370.12
382.57
397.41
414.10
433.18
451.99
473.18
494.11
517.16
540.48
565.65
590.82
618.11
645.66
675.07
689.64
719.05
744.48
761.17
782.10
794.82
794.82
$ 164.01
258.29
258.29
258.29
258.29
259.32
264.49
270.69
280.76
289.03
293.16
299.36
305.56
309.43
313.56
315.63
317.70
319.76
321.83
325.96
330.09
336.29
342.23
350.50
360.83
372.97
387.44
403.71
422.30
440.64
461.31
481.71
504.18
526.91
551.45
575.99
602.59
629.45
658.12
672.33
701.00
725.79
742.07
762.47
774.87
774.87
$ 177.52
279.56
279.56
279.56
279.56
280.68
286.27
292.98
303.88
312.83
317.30
324.01
330.72
334.91
339.39
341.62
343.86
346.10
348.33
352.80
357.28
363.99
370.42
379.36
390.55
403.68
419.34
436.95
457.08
476.93
499.29
521.38
545.70
570.30
596.86
623.42
652.21
681.29
712.32
727.69
758.73
785.56
803.18
825.26
838.68
838.68
$ 162.60
256.07
256.07
256.07
256.07
257.09
262.22
268.36
278.35
286.54
290.64
296.79
302.93
306.77
310.87
312.92
314.97
317.01
319.06
323.16
327.26
333.40
339.29
347.49
357.73
369.77
384.11
400.24
418.67
436.86
457.34
477.57
499.85
522.38
546.71
571.04
597.41
624.04
652.47
666.55
694.97
719.56
735.69
755.92
768.21
768.21
$ 164.68
259.34
259.34
259.34
259.34
260.38
265.56
271.79
281.90
290.20
294.35
300.58
306.80
310.69
314.84
316.91
318.99
321.06
323.14
327.29
331.44
337.66
343.63
351.92
362.30
374.49
389.01
405.35
424.02
442.43
463.18
483.67
506.23
529.05
553.69
578.33
605.04
632.01
660.80
675.06
703.85
728.75
745.08
765.57
778.02
778.02
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
45
0SPA
88380VA0740036
Anthem HealthKeepers Preferred DirectAccess w/HSA gtqa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 188.11
296.23
296.23
296.23
296.23
297.41
303.34
310.45
322.00
331.48
336.22
343.33
350.44
354.88
359.62
361.99
364.36
366.73
369.10
373.84
378.58
385.69
392.50
401.98
413.83
427.76
444.35
463.01
484.34
505.37
529.07
552.47
578.24
604.31
632.45
660.59
691.10
721.91
754.79
771.09
803.97
832.41
851.07
874.47
888.69
888.69
$ 171.55
270.16
270.16
270.16
270.16
271.24
276.64
283.13
293.66
302.31
306.63
313.12
319.60
323.65
327.97
330.14
332.30
334.46
336.62
340.94
345.26
351.75
357.96
366.61
377.41
390.11
405.24
422.26
441.71
460.89
482.51
503.85
527.35
551.13
576.79
602.46
630.28
658.38
688.37
703.23
733.21
759.15
776.17
797.51
810.48
810.48
$ 177.65
279.77
279.77
279.77
279.77
280.89
286.48
293.20
304.11
313.06
317.54
324.25
330.97
335.16
339.64
341.88
344.12
346.36
348.59
353.07
357.55
364.26
370.70
379.65
390.84
403.99
419.66
437.28
457.42
477.29
499.67
521.77
546.11
570.73
597.31
623.89
652.70
681.80
712.85
728.24
759.30
786.15
803.78
825.88
839.31
839.31
$ 171.14
269.51
269.51
269.51
269.51
270.59
275.98
282.45
292.96
301.58
305.89
312.36
318.83
322.87
327.19
329.34
331.50
333.65
335.81
340.12
344.43
350.90
357.10
365.73
376.51
389.17
404.27
421.24
440.65
459.78
481.34
502.64
526.08
549.80
575.40
601.01
628.77
656.80
686.71
701.53
731.45
757.32
774.30
795.59
808.53
808.53
$ 174.21
274.34
274.34
274.34
274.34
275.44
280.92
287.51
298.21
306.99
311.38
317.96
324.54
328.66
333.05
335.24
337.44
339.63
341.83
346.22
350.61
357.19
363.50
372.28
383.25
396.15
411.51
428.79
448.55
468.02
489.97
511.64
535.51
559.65
585.72
611.78
640.04
668.57
699.02
714.11
744.56
770.90
788.18
809.85
823.02
823.02
$ 174.19
274.31
274.31
274.31
274.31
275.41
280.89
287.48
298.17
306.95
311.34
317.93
324.51
328.62
333.01
335.21
337.40
339.60
341.79
346.18
350.57
357.15
363.46
372.24
383.21
396.10
411.47
428.75
448.50
467.97
489.92
511.59
535.45
559.59
585.65
611.71
639.97
668.49
698.94
714.03
744.48
770.81
788.09
809.76
822.93
822.93
$ 181.46
285.77
285.77
285.77
285.77
286.91
292.63
299.49
310.63
319.78
324.35
331.21
338.07
342.35
346.92
349.21
351.50
353.78
356.07
360.64
365.21
372.07
378.65
387.79
399.22
412.65
428.66
446.66
467.23
487.52
510.39
532.96
557.82
582.97
610.12
637.27
666.70
696.42
728.14
743.86
775.58
803.01
821.02
843.59
857.31
857.31
$ 180.96
284.97
284.97
284.97
284.97
286.11
291.81
298.65
309.76
318.88
323.44
330.28
337.12
341.39
345.95
348.23
350.51
352.79
355.07
359.63
364.19
371.03
377.59
386.70
398.10
411.50
427.46
445.41
465.93
486.16
508.96
531.47
556.26
581.34
608.41
635.48
664.84
694.47
726.10
741.78
773.41
800.77
818.72
841.23
854.91
854.91
$ 176.41
277.81
277.81
277.81
277.81
278.92
284.48
291.14
301.98
310.87
315.31
321.98
328.65
332.82
337.26
339.48
341.71
343.93
346.15
350.60
355.04
361.71
368.10
376.99
388.10
401.16
416.72
434.22
454.22
473.94
496.17
518.12
542.29
566.73
593.12
619.52
648.13
677.02
707.86
723.14
753.98
780.65
798.15
820.10
833.43
833.43
$ 190.94
300.69
300.69
300.69
300.69
301.89
307.91
315.12
326.85
336.47
341.28
348.50
355.72
360.23
365.04
367.44
369.85
372.25
374.66
379.47
384.28
391.50
398.41
408.04
420.06
434.20
451.04
469.98
491.63
512.98
537.03
560.79
586.95
613.41
641.97
670.54
701.51
732.78
766.16
782.70
816.07
844.94
863.88
887.64
902.07
902.07
$ 174.89
275.42
275.42
275.42
275.42
276.52
282.03
288.64
299.38
308.19
312.60
319.21
325.82
329.95
334.36
336.56
338.77
340.97
343.17
347.58
351.99
358.60
364.93
373.74
384.76
397.71
413.13
430.48
450.31
469.87
491.90
513.66
537.62
561.86
588.02
614.19
642.55
671.20
701.77
716.92
747.49
773.93
791.28
813.04
826.26
826.26
$ 177.13
278.94
278.94
278.94
278.94
280.06
285.63
292.33
303.21
312.13
316.60
323.29
329.99
334.17
338.63
340.86
343.10
345.33
347.56
352.02
356.49
363.18
369.60
378.52
389.68
402.79
418.41
435.98
456.07
475.87
498.19
520.22
544.49
569.04
595.54
622.04
650.77
679.78
710.74
726.08
757.04
783.82
801.39
823.43
836.82
836.82
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
46
0SNL
16064VA1210021
Anthem Essential DirectAccess gvia
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 157.79
248.49
248.49
248.49
248.49
249.48
254.45
260.42
270.11
278.06
282.04
288.00
293.96
297.69
301.67
303.65
305.64
307.63
309.62
313.59
317.57
323.53
329.25
337.20
347.14
358.82
372.74
388.39
406.28
423.92
443.80
463.43
485.05
506.92
530.53
554.13
579.73
605.57
633.15
646.82
674.40
698.26
713.91
733.54
745.47
745.47
$ 143.92
226.64
226.64
226.64
226.64
227.55
232.08
237.52
246.36
253.61
257.24
262.68
268.12
271.51
275.14
276.95
278.77
280.58
282.39
286.02
289.65
295.09
300.30
307.55
316.62
327.27
339.96
354.24
370.56
386.65
404.78
422.68
442.40
462.35
483.88
505.41
528.75
552.32
577.48
589.94
615.10
636.86
651.14
669.04
679.92
679.92
$ 153.51
241.75
241.75
241.75
241.75
242.72
247.55
253.35
262.78
270.52
274.39
280.19
285.99
289.62
293.48
295.42
297.35
299.29
301.22
305.09
308.96
314.76
320.32
328.05
337.72
349.09
362.63
377.86
395.26
412.43
431.77
450.86
471.90
493.17
516.14
539.10
564.00
589.14
615.98
629.28
656.11
679.32
694.55
713.65
725.25
725.25
$ 143.57
226.09
226.09
226.09
226.09
226.99
231.52
236.94
245.76
252.99
256.61
262.04
267.46
270.86
274.47
276.28
278.09
279.90
281.71
285.33
288.94
294.37
299.57
306.80
315.85
326.47
339.14
353.38
369.66
385.71
403.80
421.66
441.33
461.22
482.70
504.18
527.47
550.98
576.08
588.51
613.61
635.31
649.56
667.42
678.27
678.27
$ 149.05
234.73
234.73
234.73
234.73
235.67
240.36
246.00
255.15
262.66
266.42
272.05
277.69
281.21
284.96
286.84
288.72
290.60
292.47
296.23
299.98
305.62
311.02
318.53
327.92
338.95
352.10
366.88
383.78
400.45
419.23
437.77
458.19
478.85
501.15
523.45
547.63
572.04
598.09
611.00
637.06
659.59
674.38
692.92
704.19
704.19
$ 141.73
223.19
223.19
223.19
223.19
224.08
228.55
233.90
242.61
249.75
253.32
258.68
264.03
267.38
270.95
272.74
274.52
276.31
278.09
281.67
285.24
290.59
295.73
302.87
311.80
322.29
334.79
348.85
364.92
380.76
398.62
416.25
435.67
455.31
476.51
497.71
520.70
543.91
568.69
580.96
605.74
627.16
641.22
658.86
669.57
669.57
$ 157.09
247.38
247.38
247.38
247.38
248.37
253.32
259.25
268.90
276.82
280.78
286.71
292.65
296.36
300.32
302.30
304.28
306.26
308.24
312.19
316.15
322.09
327.78
335.69
345.59
357.22
371.07
386.65
404.47
422.03
441.82
461.36
482.89
504.66
528.16
551.66
577.14
602.87
630.32
643.93
671.39
695.14
710.72
730.27
742.14
742.14
$ 151.80
239.05
239.05
239.05
239.05
240.01
244.79
250.52
259.85
267.50
271.32
277.06
282.80
286.38
290.21
292.12
294.03
295.94
297.86
301.68
305.51
311.24
316.74
324.39
333.95
345.19
358.58
373.64
390.85
407.82
426.94
445.83
466.63
487.66
510.37
533.08
557.70
582.56
609.10
622.25
648.78
671.73
686.79
705.68
717.15
717.15
$ 158.79
250.06
250.06
250.06
250.06
251.06
256.06
262.06
271.82
279.82
283.82
289.82
295.82
299.57
303.57
305.57
307.57
309.57
311.57
315.58
319.58
325.58
331.33
339.33
349.33
361.09
375.09
390.84
408.85
426.60
446.61
466.36
488.12
510.12
533.88
557.63
583.39
609.40
637.15
650.91
678.66
702.67
718.42
738.18
750.18
750.18
$ 152.17
239.63
239.63
239.63
239.63
240.59
245.38
251.13
260.48
268.15
271.98
277.73
283.48
287.08
290.91
292.83
294.74
296.66
298.58
302.41
306.25
312.00
317.51
325.18
334.76
346.03
359.45
374.54
391.80
408.81
427.98
446.91
467.76
488.85
511.61
534.37
559.06
583.98
610.58
623.76
650.36
673.36
688.46
707.39
718.89
718.89
$ 143.76
226.40
226.40
226.40
226.40
227.31
231.83
237.27
246.10
253.34
256.96
262.40
267.83
271.23
274.85
276.66
278.47
280.28
282.09
285.72
289.34
294.77
299.98
307.22
316.28
326.92
339.60
353.86
370.16
386.24
404.35
422.24
441.93
461.86
483.36
504.87
528.19
551.74
576.87
589.32
614.45
636.18
650.45
668.33
679.20
679.20
$ 152.99
240.93
240.93
240.93
240.93
241.89
246.71
252.49
261.89
269.60
273.46
279.24
285.02
288.63
292.49
294.42
296.34
298.27
300.20
304.05
307.91
313.69
319.23
326.94
336.58
347.90
361.40
376.57
393.92
411.03
430.30
449.33
470.30
491.50
514.39
537.27
562.09
587.15
613.89
627.14
653.88
677.01
692.19
711.23
722.79
722.79
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
47
0SNN
16064VA1210020
Anthem Essential DirectAccess ghia
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 162.36
255.69
255.69
255.69
255.69
256.71
261.83
267.96
277.94
286.12
290.21
296.34
302.48
306.32
310.41
312.45
314.50
316.54
318.59
322.68
326.77
332.91
338.79
346.97
357.20
369.22
383.54
399.64
418.05
436.21
456.66
476.86
499.11
521.61
545.90
570.19
596.52
623.12
651.50
665.56
693.94
718.49
734.60
754.80
767.07
767.07
$ 148.08
233.20
233.20
233.20
233.20
234.13
238.80
244.39
253.49
260.95
264.68
270.28
275.88
279.37
283.10
284.97
286.84
288.70
290.57
294.30
298.03
303.63
308.99
316.45
325.78
336.74
349.80
364.49
381.28
397.84
416.50
434.92
455.21
475.73
497.88
520.04
544.06
568.31
594.19
607.02
632.90
655.29
669.98
688.41
699.60
699.60
$ 157.95
248.74
248.74
248.74
248.74
249.73
254.71
260.68
270.38
278.34
282.32
288.29
294.26
297.99
301.97
303.96
305.95
307.94
309.93
313.91
317.89
323.86
329.58
337.54
347.49
359.18
373.11
388.78
406.69
424.35
444.25
463.90
485.54
507.43
531.06
554.69
580.31
606.18
633.79
647.47
675.08
698.96
714.63
734.28
746.22
746.22
$ 147.72
232.63
232.63
232.63
232.63
233.56
238.21
243.80
252.87
260.31
264.04
269.62
275.20
278.69
282.41
284.27
286.13
288.00
289.86
293.58
297.30
302.88
308.23
315.68
324.98
335.92
348.95
363.60
380.35
396.87
415.48
433.85
454.09
474.57
496.67
518.76
542.73
566.92
592.74
605.54
631.36
653.69
668.35
686.72
697.89
697.89
$ 153.37
241.53
241.53
241.53
241.53
242.50
247.33
253.12
262.54
270.27
274.14
279.93
285.73
289.35
293.22
295.15
297.08
299.01
300.95
304.81
308.68
314.47
320.03
327.76
337.42
348.77
362.30
377.51
394.90
412.05
431.37
450.45
471.47
492.72
515.67
538.61
563.49
588.61
615.42
628.70
655.51
678.70
693.92
713.00
724.59
724.59
$ 145.83
229.66
229.66
229.66
229.66
230.58
235.17
240.68
249.64
256.99
260.66
266.18
271.69
275.13
278.81
280.64
282.48
284.32
286.16
289.83
293.51
299.02
304.30
311.65
320.84
331.63
344.49
358.96
375.49
391.80
410.17
428.32
448.30
468.51
490.32
512.14
535.80
559.68
585.17
597.80
623.30
645.34
659.81
677.96
688.98
688.98
$ 161.63
254.54
254.54
254.54
254.54
255.56
260.65
266.76
276.68
284.83
288.90
295.01
301.12
304.94
309.01
311.05
313.08
315.12
317.16
321.23
325.30
331.41
337.27
345.41
355.59
367.56
381.81
397.85
416.17
434.25
454.61
474.72
496.86
519.26
543.44
567.62
593.84
620.31
648.57
662.57
690.82
715.26
731.29
751.40
763.62
763.62
$ 156.19
245.97
245.97
245.97
245.97
246.95
251.87
257.78
267.37
275.24
279.18
285.08
290.98
294.67
298.61
300.58
302.54
304.51
306.48
310.41
314.35
320.25
325.91
333.78
343.62
355.18
368.96
384.45
402.16
419.62
439.30
458.73
480.13
501.78
525.15
548.51
573.85
599.43
626.73
640.26
667.56
691.18
706.67
726.10
737.91
737.91
$ 163.39
257.30
257.30
257.30
257.30
258.33
263.48
269.65
279.69
287.92
292.04
298.21
304.39
308.25
312.36
314.42
316.48
318.54
320.60
324.71
328.83
335.00
340.92
349.16
359.45
371.54
385.95
402.16
420.69
438.95
459.54
479.86
502.25
524.89
549.34
573.78
600.28
627.04
655.60
669.75
698.31
723.01
739.22
759.55
771.90
771.90
$ 156.57
246.56
246.56
246.56
246.56
247.55
252.48
258.39
268.01
275.90
279.85
285.76
291.68
295.38
299.32
301.30
303.27
305.24
307.21
311.16
315.10
321.02
326.69
334.58
344.44
356.03
369.84
385.37
403.13
420.63
440.36
459.83
481.29
502.98
526.41
549.83
575.22
600.87
628.23
641.80
669.16
692.83
708.37
727.85
739.68
739.68
$ 147.92
232.95
232.95
232.95
232.95
233.88
238.54
244.13
253.22
260.67
264.40
269.99
275.58
279.07
282.80
284.66
286.53
288.39
290.26
293.98
297.71
303.30
308.66
316.11
325.43
336.38
349.43
364.10
380.87
397.41
416.05
434.45
454.72
475.22
497.35
519.48
543.47
567.70
593.56
606.37
632.23
654.59
669.27
687.67
698.85
698.85
$ 157.42
247.90
247.90
247.90
247.90
248.89
253.85
259.80
269.47
277.40
281.37
287.32
293.27
296.98
300.95
302.93
304.92
306.90
308.88
312.85
316.82
322.77
328.47
336.40
346.32
357.97
371.85
387.47
405.32
422.92
442.75
462.33
483.90
505.72
529.27
552.82
578.35
604.13
631.65
645.28
672.80
696.60
712.22
731.80
743.70
743.70
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
48
0W2V
88380VA0740008
Anthem HealthKeepers Essential Guided Access Plus gyoa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 148.67
234.12
234.12
234.12
234.12
235.06
239.74
245.36
254.49
261.98
265.73
271.35
276.96
280.48
284.22
286.09
287.97
289.84
291.71
295.46
299.21
304.82
310.21
317.70
327.07
338.07
351.18
365.93
382.79
399.41
418.14
436.63
457.00
477.60
499.85
522.09
546.20
570.55
596.54
609.41
635.40
657.88
672.63
691.12
702.36
702.36
$ 135.59
213.52
213.52
213.52
213.52
214.37
218.64
223.77
232.10
238.93
242.35
247.47
252.59
255.80
259.21
260.92
262.63
264.34
266.05
269.46
272.88
278.00
282.91
289.75
298.29
308.32
320.28
333.73
349.11
364.27
381.35
398.21
416.79
435.58
455.87
476.15
498.14
520.35
544.05
555.79
579.49
599.99
613.44
630.31
640.56
640.56
$ 140.41
221.12
221.12
221.12
221.12
222.00
226.43
231.73
240.36
247.43
250.97
256.28
261.58
264.90
268.44
270.21
271.98
273.75
275.52
279.05
282.59
287.90
292.98
300.06
308.90
319.30
331.68
345.61
361.53
377.23
394.92
412.39
431.63
451.08
472.09
493.10
515.87
538.87
563.41
575.58
600.12
621.35
635.28
652.75
663.36
663.36
$ 135.26
213.01
213.01
213.01
213.01
213.86
218.12
223.23
231.54
238.36
241.77
246.88
251.99
255.19
258.59
260.30
262.00
263.71
265.41
268.82
272.23
277.34
282.24
289.05
297.57
307.59
319.52
332.93
348.27
363.40
380.44
397.26
415.80
434.54
454.78
475.01
496.95
519.11
542.75
554.47
578.11
598.56
611.98
628.81
639.03
639.03
$ 137.69
216.83
216.83
216.83
216.83
217.70
222.03
227.24
235.69
242.63
246.10
251.31
256.51
259.76
263.23
264.97
266.70
268.44
270.17
273.64
277.11
282.31
287.30
294.24
302.91
313.10
325.25
338.91
354.52
369.91
387.26
404.39
423.25
442.33
462.93
483.53
505.86
528.41
552.48
564.41
588.48
609.29
622.95
640.08
650.49
650.49
$ 137.67
216.80
216.80
216.80
216.80
217.67
222.00
227.21
235.66
242.60
246.07
251.27
256.47
259.73
263.20
264.93
266.66
268.40
270.13
273.60
277.07
282.27
287.26
294.20
302.87
313.06
325.20
338.86
354.47
369.86
387.20
404.33
423.19
442.27
462.87
483.46
505.79
528.34
552.41
564.33
588.40
609.21
622.87
639.99
650.40
650.40
$ 143.42
225.86
225.86
225.86
225.86
226.76
231.28
236.70
245.51
252.74
256.35
261.77
267.19
270.58
274.19
276.00
277.81
279.61
281.42
285.04
288.65
294.07
299.26
306.49
315.53
326.14
338.79
353.02
369.28
385.32
403.39
421.23
440.88
460.75
482.21
503.67
526.93
550.42
575.49
587.91
612.98
634.67
648.90
666.74
677.58
677.58
$ 143.02
225.23
225.23
225.23
225.23
226.13
230.64
236.04
244.83
252.03
255.64
261.04
266.45
269.83
273.43
275.23
277.03
278.83
280.64
284.24
287.84
293.25
298.43
305.64
314.65
325.23
337.85
352.03
368.25
384.24
402.26
420.05
439.65
459.47
480.87
502.26
525.46
548.89
573.89
586.27
611.27
632.90
647.09
664.88
675.69
675.69
$ 139.43
219.57
219.57
219.57
219.57
220.45
224.84
230.11
238.67
245.70
249.21
254.48
259.75
263.04
266.56
268.31
270.07
271.83
273.58
277.10
280.61
285.88
290.93
297.96
306.74
317.06
329.36
343.19
359.00
374.59
392.15
409.50
428.60
447.92
468.78
489.64
512.26
535.09
559.46
571.54
595.91
616.99
630.82
648.17
658.71
658.71
$ 150.91
237.65
237.65
237.65
237.65
238.60
243.35
249.06
258.33
265.93
269.73
275.44
281.14
284.70
288.51
290.41
292.31
294.21
296.11
299.91
303.72
309.42
314.89
322.49
332.00
343.17
356.48
371.45
388.56
405.43
424.44
443.22
463.89
484.81
507.38
529.96
554.44
579.15
605.53
618.60
644.98
667.80
682.77
701.54
712.95
712.95
$ 138.23
217.68
217.68
217.68
217.68
218.55
222.90
228.13
236.62
243.58
247.07
252.29
257.52
260.78
264.26
266.00
267.75
269.49
271.23
274.71
278.20
283.42
288.43
295.39
304.10
314.33
326.52
340.23
355.91
371.36
388.78
405.97
424.91
444.07
464.75
485.43
507.85
530.49
554.65
566.62
590.78
611.68
625.39
642.59
653.04
653.04
$ 140.00
220.47
220.47
220.47
220.47
221.35
225.76
231.05
239.65
246.71
250.23
255.52
260.82
264.12
267.65
269.41
271.18
272.94
274.71
278.23
281.76
287.05
292.12
299.18
308.00
318.36
330.71
344.59
360.47
376.12
393.76
411.18
430.36
449.76
470.70
491.65
514.36
537.29
561.76
573.88
598.36
619.52
633.41
650.83
661.41
661.41
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
49
0W2W
88380VA0740007
Anthem HealthKeepers Essential Guided Access Plus gbpa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 150.38
236.82
236.82
236.82
236.82
237.77
242.50
248.19
257.42
265.00
268.79
274.47
280.16
283.71
287.50
289.39
291.29
293.18
295.08
298.87
302.66
308.34
313.79
321.36
330.84
341.97
355.23
370.15
387.20
404.01
422.96
441.67
462.27
483.11
505.61
528.11
552.50
577.13
603.42
616.44
642.73
665.46
680.38
699.09
710.46
710.46
$ 137.15
215.99
215.99
215.99
215.99
216.85
221.17
226.36
234.78
241.69
245.15
250.33
255.52
258.76
262.21
263.94
265.67
267.40
269.12
272.58
276.04
281.22
286.19
293.10
301.74
311.89
323.99
337.59
353.14
368.48
385.76
402.82
421.61
440.62
461.14
481.66
503.90
526.37
550.34
562.22
586.20
606.93
620.54
637.60
647.97
647.97
$ 142.03
223.67
223.67
223.67
223.67
224.56
229.04
234.41
243.13
250.29
253.87
259.23
264.60
267.96
271.54
273.32
275.11
276.90
278.69
282.27
285.85
291.22
296.36
303.52
312.47
322.98
335.51
349.60
365.70
381.58
399.47
417.14
436.60
456.29
477.54
498.78
521.82
545.08
569.91
582.21
607.04
628.51
642.60
660.27
671.01
671.01
$ 136.82
215.46
215.46
215.46
215.46
216.32
220.63
225.80
234.21
241.10
244.55
249.72
254.89
258.12
261.57
263.29
265.02
266.74
268.46
271.91
275.36
280.53
285.48
292.38
301.00
311.12
323.19
336.76
352.28
367.57
384.81
401.83
420.58
439.54
460.01
480.48
502.67
525.08
548.99
560.84
584.76
605.44
619.02
636.04
646.38
646.38
$ 139.27
219.33
219.33
219.33
219.33
220.21
224.59
229.86
238.41
245.43
248.94
254.20
259.47
262.76
266.27
268.02
269.78
271.53
273.29
276.79
280.30
285.57
290.61
297.63
306.40
316.71
329.00
342.81
358.60
374.18
391.72
409.05
428.13
447.43
468.27
489.11
511.70
534.51
558.85
570.92
595.26
616.32
630.14
647.46
657.99
657.99
$ 139.26
219.30
219.30
219.30
219.30
220.18
224.56
229.83
238.38
245.40
248.91
254.17
259.43
262.72
266.23
267.98
269.74
271.49
273.25
276.76
280.27
285.53
290.57
297.59
306.36
316.67
328.95
342.77
358.56
374.13
391.67
408.99
428.07
447.37
468.21
489.04
511.63
534.43
558.78
570.84
595.18
616.23
630.05
647.37
657.90
657.90
$ 145.07
228.46
228.46
228.46
228.46
229.37
233.94
239.43
248.34
255.65
259.30
264.79
270.27
273.70
277.35
279.18
281.01
282.83
284.66
288.32
291.97
297.45
302.71
310.02
319.16
329.90
342.69
357.08
373.53
389.75
408.03
426.08
445.95
466.06
487.76
509.47
533.00
556.76
582.12
594.68
620.04
641.97
656.37
674.41
685.38
685.38
$ 144.67
227.83
227.83
227.83
227.83
228.74
233.30
238.77
247.65
254.94
258.59
264.05
269.52
272.94
276.59
278.41
280.23
282.05
283.88
287.52
291.17
296.63
301.87
309.17
318.28
328.99
341.75
356.10
372.50
388.68
406.90
424.90
444.72
464.77
486.42
508.06
531.53
555.22
580.51
593.04
618.33
640.20
654.56
672.55
683.49
683.49
$ 141.03
222.10
222.10
222.10
222.10
222.99
227.43
232.76
241.42
248.53
252.08
257.41
262.74
266.08
269.63
271.41
273.18
274.96
276.74
280.29
283.84
289.17
294.28
301.39
310.27
320.71
333.15
347.14
363.13
378.90
396.67
414.22
433.54
453.08
474.18
495.28
518.16
541.26
565.91
578.13
602.78
624.10
638.09
655.64
666.30
666.30
$ 152.65
240.39
240.39
240.39
240.39
241.35
246.16
251.93
261.30
269.00
272.84
278.61
284.38
287.99
291.83
293.76
295.68
297.60
299.53
303.37
307.22
312.99
318.52
326.21
335.82
347.12
360.59
375.73
393.04
410.11
429.34
448.33
469.24
490.40
513.23
536.07
560.83
585.83
612.51
625.74
652.42
675.50
690.64
709.63
721.17
721.17
$ 139.82
220.19
220.19
220.19
220.19
221.07
225.47
230.76
239.35
246.39
249.92
255.20
260.48
263.79
267.31
269.07
270.83
272.60
274.36
277.88
281.40
286.69
291.75
298.80
307.61
317.95
330.29
344.16
360.01
375.64
393.26
410.65
429.81
449.19
470.11
491.02
513.70
536.60
561.04
573.15
597.60
618.73
632.61
650.00
660.57
660.57
$ 141.61
223.01
223.01
223.01
223.01
223.90
228.36
233.71
242.41
249.55
253.12
258.47
263.82
267.17
270.73
272.52
274.30
276.09
277.87
281.44
285.01
290.36
295.49
302.62
311.54
322.03
334.52
348.56
364.62
380.46
398.30
415.91
435.32
454.94
476.13
497.31
520.28
543.48
568.23
580.50
605.25
626.66
640.71
658.33
669.03
669.03
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
50
0VUB
88380VA0740010
Anthem HealthKeepers Essential Guided Access Plus w/Dental gcpa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 155.86
245.45
245.45
245.45
245.45
246.43
251.34
257.23
266.80
274.66
278.59
284.48
290.37
294.05
297.98
299.94
301.90
303.87
305.83
309.76
313.69
319.58
325.22
333.08
342.89
354.43
368.18
383.64
401.31
418.74
438.37
457.76
479.12
500.72
524.04
547.35
572.63
598.16
625.41
638.91
666.15
689.71
705.18
724.57
736.35
736.35
$ 142.14
223.85
223.85
223.85
223.85
224.75
229.22
234.59
243.32
250.49
254.07
259.44
264.81
268.17
271.75
273.54
275.34
277.13
278.92
282.50
286.08
291.45
296.60
303.76
312.72
323.24
335.78
349.88
365.99
381.89
399.80
417.48
436.96
456.65
477.92
499.19
522.24
545.52
570.37
582.68
607.53
629.02
643.12
660.81
671.55
671.55
$ 147.20
231.81
231.81
231.81
231.81
232.74
237.37
242.94
251.98
259.40
263.10
268.67
274.23
277.71
281.42
283.27
285.13
286.98
288.84
292.54
296.25
301.82
307.15
314.57
323.84
334.73
347.72
362.32
379.01
395.47
414.01
432.33
452.49
472.89
494.91
516.94
540.81
564.92
590.65
603.40
629.13
651.39
665.99
684.30
695.43
695.43
$ 141.80
223.31
223.31
223.31
223.31
224.20
228.67
234.03
242.74
249.88
253.46
258.82
264.18
267.53
271.10
272.88
274.67
276.46
278.24
281.82
285.39
290.75
295.89
303.03
311.96
322.46
334.97
349.03
365.11
380.97
398.83
416.47
435.90
455.55
476.77
497.98
520.98
544.21
568.99
581.28
606.06
627.50
641.57
659.21
669.93
669.93
$ 144.34
227.31
227.31
227.31
227.31
228.22
232.77
238.22
247.09
254.36
258.00
263.45
268.91
272.32
275.95
277.77
279.59
281.41
283.23
286.87
290.50
295.96
301.19
308.46
317.55
328.24
340.97
355.29
371.65
387.79
405.98
423.93
443.71
463.71
485.31
506.90
530.31
553.95
579.19
591.69
616.92
638.74
653.06
671.02
681.93
681.93
$ 144.33
227.29
227.29
227.29
227.29
228.20
232.74
238.20
247.06
254.34
257.97
263.43
268.88
272.29
275.93
277.75
279.57
281.39
283.20
286.84
290.48
295.93
301.16
308.43
317.52
328.21
340.94
355.25
371.62
387.76
405.94
423.90
443.67
463.67
485.26
506.86
530.27
553.91
579.13
591.64
616.87
638.68
653.00
670.96
681.87
681.87
$ 150.36
236.78
236.78
236.78
236.78
237.73
242.46
248.15
257.38
264.96
268.75
274.43
280.11
283.66
287.45
289.35
291.24
293.13
295.03
298.82
302.60
308.29
313.73
321.31
330.78
341.91
355.17
370.09
387.14
403.95
422.89
441.59
462.19
483.03
505.53
528.02
552.41
577.03
603.32
616.34
642.62
665.35
680.27
698.97
710.34
710.34
$ 149.94
236.12
236.12
236.12
236.12
237.06
241.79
247.45
256.66
264.22
268.00
273.66
279.33
282.87
286.65
288.54
290.43
292.32
294.21
297.98
301.76
307.43
312.86
320.41
329.86
340.96
354.18
369.06
386.06
402.82
421.71
440.36
460.91
481.68
504.12
526.55
550.87
575.42
601.63
614.62
640.83
663.50
678.37
697.03
708.36
708.36
$ 146.17
230.19
230.19
230.19
230.19
231.11
235.71
241.24
250.22
257.58
261.27
266.79
272.31
275.77
279.45
281.29
283.13
284.98
286.82
290.50
294.18
299.71
305.00
312.37
321.58
332.39
345.29
359.79
376.36
392.70
411.12
429.30
449.33
469.59
491.46
513.32
537.03
560.97
586.52
599.18
624.74
646.83
661.34
679.52
690.57
690.57
$ 158.20
249.14
249.14
249.14
249.14
250.14
255.12
261.10
270.82
278.79
282.77
288.75
294.73
298.47
302.46
304.45
306.44
308.44
310.43
314.41
318.40
324.38
330.11
338.08
348.05
359.76
373.71
389.41
407.34
425.03
444.96
464.65
486.32
508.25
531.91
555.58
581.24
607.15
634.81
648.51
676.17
700.08
715.78
735.46
747.42
747.42
$ 144.91
228.21
228.21
228.21
228.21
229.12
233.69
239.16
248.06
255.37
259.02
264.50
269.97
273.40
277.05
278.87
280.70
282.52
284.35
288.00
291.65
297.13
302.38
309.68
318.81
329.54
342.32
356.69
373.12
389.33
407.58
425.61
445.47
465.55
487.23
508.91
532.41
556.15
581.48
594.03
619.36
641.27
655.65
673.68
684.63
684.63
$ 146.77
231.13
231.13
231.13
231.13
232.05
236.68
242.22
251.24
258.63
262.33
267.88
273.43
276.89
280.59
282.44
284.29
286.14
287.99
291.69
295.38
300.93
306.25
313.64
322.89
333.75
346.70
361.26
377.90
394.31
412.80
431.06
451.17
471.51
493.46
515.42
539.23
563.26
588.92
601.63
627.29
649.48
664.04
682.30
693.39
693.39
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
51
0W2X
88380VA0740009
Anthem HealthKeepers Essential Guided Access Plus gcpa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 148.52
233.89
233.89
233.89
233.89
234.83
239.50
245.12
254.24
261.72
265.47
271.08
276.69
280.20
283.94
285.81
287.68
289.56
291.43
295.17
298.91
304.52
309.90
317.39
326.74
337.74
350.84
365.57
382.41
399.02
417.73
436.20
456.55
477.14
499.36
521.57
545.67
569.99
595.95
608.82
634.78
657.23
671.97
690.44
701.67
701.67
$ 135.45
213.31
213.31
213.31
213.31
214.16
218.43
223.55
231.87
238.69
242.11
247.23
252.35
255.55
258.96
260.66
262.37
264.08
265.78
269.20
272.61
277.73
282.64
289.46
297.99
308.02
319.97
333.40
348.76
363.91
380.97
397.82
416.38
435.15
455.42
475.68
497.65
519.84
543.51
555.25
578.92
599.40
612.84
629.69
639.93
639.93
$ 140.27
220.90
220.90
220.90
220.90
221.78
226.20
231.50
240.12
247.19
250.72
256.02
261.32
264.64
268.17
269.94
271.71
273.47
275.24
278.78
282.31
287.61
292.69
299.76
308.60
318.98
331.35
345.27
361.17
376.86
394.53
411.98
431.20
450.64
471.62
492.61
515.36
538.33
562.85
575.00
599.52
620.73
634.65
652.10
662.70
662.70
$ 135.13
212.80
212.80
212.80
212.80
213.65
217.91
223.01
231.31
238.12
241.53
246.64
251.74
254.93
258.34
260.04
261.74
263.45
265.15
268.55
271.96
277.07
281.96
288.77
297.28
307.28
319.20
332.61
347.93
363.04
380.06
396.87
415.39
434.11
454.33
474.54
496.46
518.59
542.21
553.92
577.54
597.97
611.37
628.19
638.40
638.40
$ 137.55
216.61
216.61
216.61
216.61
217.48
221.81
227.01
235.46
242.39
245.85
251.05
256.25
259.50
262.96
264.70
266.43
268.16
269.90
273.36
276.83
282.03
287.01
293.94
302.60
312.78
324.92
338.56
354.16
369.54
386.87
403.98
422.82
441.88
462.46
483.04
505.35
527.88
551.92
563.84
587.88
608.67
622.32
639.43
649.83
649.83
$ 137.53
216.59
216.59
216.59
216.59
217.46
221.79
226.99
235.43
242.36
245.83
251.03
256.23
259.47
262.94
264.67
266.41
268.14
269.87
273.34
276.80
282.00
286.98
293.91
302.58
312.76
324.89
338.53
354.12
369.50
386.83
403.94
422.78
441.84
462.42
483.00
505.30
527.83
551.87
563.78
587.83
608.62
622.26
639.37
649.77
649.77
$ 143.28
225.63
225.63
225.63
225.63
226.53
231.05
236.46
245.26
252.48
256.09
261.51
266.92
270.30
273.91
275.72
277.52
279.33
281.13
284.75
288.36
293.77
298.96
306.18
315.21
325.81
338.45
352.66
368.91
384.92
402.98
420.80
440.43
460.29
481.72
503.15
526.39
549.86
574.91
587.31
612.36
634.02
648.23
666.06
676.89
676.89
$ 142.88
225.00
225.00
225.00
225.00
225.90
230.40
235.80
244.58
251.78
255.38
260.78
266.18
269.55
273.15
274.95
276.75
278.55
280.35
283.95
287.55
292.95
298.13
305.33
314.33
324.90
337.50
351.68
367.88
383.85
401.85
419.63
439.20
459.00
480.38
501.75
524.93
548.33
573.30
585.68
610.65
632.25
646.43
664.20
675.00
675.00
$ 139.29
219.35
219.35
219.35
219.35
220.23
224.61
229.88
238.43
245.45
248.96
254.23
259.49
262.78
266.29
268.05
269.80
271.56
273.31
276.82
280.33
285.59
290.64
297.66
306.43
316.74
329.03
342.84
358.64
374.21
391.76
409.09
428.17
447.47
468.31
489.15
511.74
534.56
558.90
570.97
595.32
616.37
630.19
647.52
658.05
658.05
$ 150.76
237.42
237.42
237.42
237.42
238.37
243.12
248.82
258.08
265.67
269.47
275.17
280.87
284.43
288.23
290.13
292.03
293.93
295.83
299.62
303.42
309.12
314.58
322.18
331.68
342.83
356.13
371.09
388.18
405.04
424.03
442.79
463.44
484.34
506.89
529.45
553.90
578.59
604.95
618.00
644.36
667.15
682.11
700.86
712.26
712.26
$ 138.09
217.46
217.46
217.46
217.46
218.33
222.68
227.90
236.38
243.34
246.82
252.04
257.26
260.52
264.00
265.74
267.48
269.22
270.96
274.43
277.91
283.13
288.13
295.09
303.79
314.01
326.19
339.89
355.55
370.99
388.38
405.56
424.48
443.62
464.28
484.94
507.33
529.95
554.09
566.05
590.19
611.06
624.76
641.94
652.38
652.38
$ 139.86
220.25
220.25
220.25
220.25
221.13
225.54
230.82
239.41
246.46
249.98
255.27
260.56
263.86
267.38
269.15
270.91
272.67
274.43
277.96
281.48
286.77
291.83
298.88
307.69
318.04
330.38
344.25
360.11
375.75
393.37
410.77
429.93
449.31
470.23
491.16
513.84
536.75
561.20
573.31
597.76
618.90
632.78
650.18
660.75
660.75
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
52
0W2Y
88380VA0740104
Anthem HealthKeepers Essential Guided Access Plus gobf
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 154.51
243.33
243.33
243.33
243.33
244.30
249.17
255.01
264.50
272.29
276.18
282.02
287.86
291.51
295.40
297.35
299.30
301.24
303.19
307.08
310.98
316.82
322.41
330.20
339.93
351.37
365.00
380.32
397.84
415.12
434.59
453.81
474.98
496.39
519.51
542.63
567.69
593.00
620.00
633.39
660.40
683.76
699.09
718.31
729.99
729.99
$ 140.92
221.92
221.92
221.92
221.92
222.81
227.25
232.57
241.23
248.33
251.88
257.21
262.53
265.86
269.41
271.19
272.96
274.74
276.51
280.06
283.61
288.94
294.04
301.15
310.02
320.45
332.88
346.86
362.84
378.60
396.35
413.88
433.19
452.72
473.80
494.88
517.74
540.82
565.45
577.66
602.29
623.60
637.58
655.11
665.76
665.76
$ 145.93
229.81
229.81
229.81
229.81
230.73
235.33
240.84
249.80
257.16
260.83
266.35
271.87
275.31
278.99
280.83
282.67
284.50
286.34
290.02
293.70
299.21
304.50
311.85
321.04
331.85
344.72
359.19
375.74
392.06
410.44
428.60
448.59
468.81
490.64
512.48
536.15
560.05
585.56
598.20
623.70
645.77
660.24
678.40
689.43
689.43
$ 140.58
221.38
221.38
221.38
221.38
222.27
226.69
232.01
240.64
247.72
251.27
256.58
261.89
265.21
268.76
270.53
272.30
274.07
275.84
279.38
282.92
288.24
293.33
300.41
309.27
319.67
332.07
346.02
361.96
377.67
395.38
412.87
432.13
451.62
472.65
493.68
516.48
539.50
564.08
576.25
600.83
622.08
636.02
653.51
664.14
664.14
$ 143.10
225.35
225.35
225.35
225.35
226.25
230.76
236.17
244.96
252.17
255.77
261.18
266.59
269.97
273.57
275.38
277.18
278.98
280.79
284.39
288.00
293.41
298.59
305.80
314.81
325.41
338.03
352.22
368.45
384.45
402.48
420.28
439.88
459.71
481.12
502.53
525.74
549.18
574.19
586.59
611.60
633.23
647.43
665.23
676.05
676.05
$ 143.08
225.33
225.33
225.33
225.33
226.23
230.74
236.15
244.93
252.14
255.75
261.16
266.57
269.95
273.55
275.35
277.16
278.96
280.76
284.37
287.97
293.38
298.56
305.77
314.79
325.38
338.00
352.19
368.41
384.41
402.44
420.24
439.84
459.67
481.08
502.49
525.69
549.13
574.14
586.53
611.55
633.18
647.37
665.17
675.99
675.99
$ 149.06
234.74
234.74
234.74
234.74
235.68
240.37
246.01
255.16
262.67
266.43
272.06
277.70
281.22
284.97
286.85
288.73
290.61
292.49
296.24
300.00
305.63
311.03
318.54
327.93
338.96
352.11
366.90
383.80
400.47
419.25
437.79
458.21
478.87
501.17
523.47
547.65
572.06
598.12
611.03
637.08
659.62
674.41
692.95
704.22
704.22
$ 148.64
234.08
234.08
234.08
234.08
235.02
239.70
245.32
254.44
261.94
265.68
271.30
276.92
280.43
284.17
286.05
287.92
289.79
291.66
295.41
299.15
304.77
310.16
317.65
327.01
338.01
351.12
365.87
382.72
399.34
418.07
436.56
456.92
477.52
499.76
522.00
546.11
570.45
596.44
609.31
635.29
657.76
672.51
691.00
702.24
702.24
$ 144.91
228.20
228.20
228.20
228.20
229.11
233.68
239.15
248.05
255.36
259.01
264.48
269.96
273.38
277.03
278.86
280.69
282.51
284.34
287.99
291.64
297.12
302.37
309.67
318.80
329.52
342.30
356.68
373.11
389.31
407.57
425.59
445.45
465.53
487.21
508.89
532.39
556.12
581.45
594.00
619.33
641.24
655.62
673.65
684.60
684.60
$ 156.84
246.99
246.99
246.99
246.99
247.98
252.92
258.85
268.48
276.38
280.33
286.26
292.19
295.89
299.85
301.82
303.80
305.77
307.75
311.70
315.65
321.58
327.26
335.17
345.05
356.65
370.49
386.05
403.83
421.36
441.12
460.64
482.12
503.86
527.32
550.79
576.23
601.91
629.33
642.91
670.33
694.04
709.60
729.11
740.97
740.97
$ 143.66
226.24
226.24
226.24
226.24
227.14
231.67
237.10
245.92
253.16
256.78
262.21
267.64
271.04
274.66
276.47
278.28
280.09
281.90
285.51
289.13
294.56
299.77
307.01
316.06
326.69
339.36
353.61
369.90
385.97
404.06
421.94
441.62
461.53
483.02
504.52
527.82
551.35
576.46
588.90
614.02
635.73
649.99
667.86
678.72
678.72
$ 145.50
229.13
229.13
229.13
229.13
230.05
234.63
240.13
249.06
256.40
260.06
265.56
271.06
274.50
278.16
280.00
281.83
283.66
285.50
289.16
292.83
298.33
303.60
310.93
320.09
330.86
343.70
358.13
374.63
390.90
409.23
427.33
447.26
467.43
489.19
510.96
534.56
558.39
583.82
596.43
621.86
643.86
658.29
676.39
687.39
687.39
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
53
0SNP
88380VA0740042
Anthem HealthKeepers Essential DirectAccess ghia
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 153.50
241.73
241.73
241.73
241.73
242.70
247.53
253.33
262.76
270.50
274.36
280.17
285.97
289.59
293.46
295.39
297.33
299.26
301.20
305.06
308.93
314.73
320.29
328.03
337.70
349.06
362.60
377.82
395.23
412.39
431.73
450.83
471.86
493.13
516.09
539.06
563.96
589.10
615.93
629.22
656.06
679.26
694.49
713.59
725.19
725.19
$ 139.99
220.46
220.46
220.46
220.46
221.34
225.75
231.04
239.64
246.69
250.22
255.51
260.80
264.11
267.64
269.40
271.17
272.93
274.69
278.22
281.75
287.04
292.11
299.16
307.98
318.34
330.69
344.58
360.45
376.10
393.74
411.16
430.34
449.74
470.68
491.63
514.33
537.26
561.73
573.86
598.33
619.49
633.38
650.80
661.38
661.38
$ 144.97
228.30
228.30
228.30
228.30
229.21
233.78
239.26
248.16
255.47
259.12
264.60
270.08
273.50
277.16
278.98
280.81
282.64
284.46
288.11
291.77
297.25
302.50
309.80
318.94
329.67
342.45
356.83
373.27
389.48
407.74
425.78
445.64
465.73
487.42
509.11
532.62
556.37
581.71
594.26
619.61
641.52
655.91
673.94
684.90
684.90
$ 139.66
219.93
219.93
219.93
219.93
220.81
225.21
230.49
239.06
246.10
249.62
254.90
260.18
263.48
267.00
268.75
270.51
272.27
274.03
277.55
281.07
286.35
291.41
298.45
307.24
317.58
329.90
343.75
359.59
375.20
392.79
410.17
429.30
448.66
469.55
490.44
513.10
535.97
560.38
572.48
596.89
618.00
631.86
649.23
659.79
659.79
$ 142.16
223.87
223.87
223.87
223.87
224.77
229.24
234.62
243.35
250.51
254.09
259.47
264.84
268.20
271.78
273.57
275.36
277.15
278.94
282.52
286.11
291.48
296.63
303.79
312.75
323.27
335.81
349.91
366.03
381.92
399.83
417.52
436.99
456.69
477.96
499.23
522.29
545.57
570.42
582.73
607.58
629.07
643.18
660.86
671.61
671.61
$ 142.14
223.85
223.85
223.85
223.85
224.75
229.22
234.59
243.32
250.49
254.07
259.44
264.81
268.17
271.75
273.54
275.34
277.13
278.92
282.50
286.08
291.45
296.60
303.76
312.72
323.24
335.78
349.88
365.99
381.89
399.80
417.48
436.96
456.65
477.92
499.19
522.24
545.52
570.37
582.68
607.53
629.02
643.12
660.81
671.55
671.55
$ 148.08
233.20
233.20
233.20
233.20
234.13
238.80
244.39
253.49
260.95
264.68
270.28
275.88
279.37
283.10
284.97
286.84
288.70
290.57
294.30
298.03
303.63
308.99
316.45
325.78
336.74
349.80
364.49
381.28
397.84
416.50
434.92
455.21
475.73
497.88
520.04
544.06
568.31
594.19
607.02
632.90
655.29
669.98
688.41
699.60
699.60
$ 147.67
232.55
232.55
232.55
232.55
233.48
238.13
243.71
252.78
260.22
263.94
269.53
275.11
278.59
282.32
284.18
286.04
287.90
289.76
293.48
297.20
302.78
308.13
315.57
324.87
335.80
348.83
363.48
380.22
396.73
415.33
433.71
453.94
474.40
496.49
518.59
542.54
566.72
592.54
605.33
631.14
653.47
668.12
686.49
697.65
697.65
$ 143.95
226.70
226.70
226.70
226.70
227.61
232.14
237.58
246.42
253.68
257.30
262.75
268.19
271.59
275.21
277.03
278.84
280.65
282.47
286.10
289.72
295.16
300.38
307.63
316.70
327.35
340.05
354.33
370.65
386.75
404.89
422.80
442.52
462.47
484.00
505.54
528.89
552.47
577.63
590.10
615.26
637.03
651.31
669.22
680.10
680.10
$ 155.81
245.37
245.37
245.37
245.37
246.35
251.26
257.15
266.72
274.57
278.49
284.38
290.27
293.95
297.88
299.84
301.81
303.77
305.73
309.66
313.58
319.47
325.12
332.97
342.78
354.31
368.06
383.51
401.18
418.60
438.23
457.62
478.96
500.55
523.86
547.18
572.45
597.97
625.20
638.70
665.93
689.49
704.95
724.33
736.11
736.11
$ 142.72
224.75
224.75
224.75
224.75
225.65
230.14
235.54
244.30
251.50
255.09
260.49
265.88
269.25
272.85
274.64
276.44
278.24
280.04
283.63
287.23
292.62
297.79
304.99
313.98
324.54
337.13
351.28
367.47
383.42
401.40
419.16
438.71
458.49
479.84
501.19
524.34
547.72
572.66
585.02
609.97
631.55
645.71
663.46
674.25
674.25
$ 144.55
227.63
227.63
227.63
227.63
228.54
233.09
238.56
247.43
254.72
258.36
263.82
269.29
272.70
276.34
278.16
279.98
281.81
283.63
287.27
290.91
296.37
301.61
308.89
318.00
328.70
341.45
355.79
372.18
388.34
406.55
424.53
444.33
464.37
485.99
507.61
531.06
554.73
580.00
592.52
617.79
639.64
653.98
671.96
682.89
682.89
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
54
0SNM
88380VA0740043
Anthem HealthKeepers Essential DirectAccess gvia
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 149.00
234.65
234.65
234.65
234.65
235.59
240.28
245.91
255.06
262.57
266.33
271.96
277.59
281.11
284.87
286.74
288.62
290.50
292.37
296.13
299.88
305.51
310.91
318.42
327.81
338.83
351.98
366.76
383.65
400.31
419.08
437.62
458.04
478.69
500.98
523.27
547.44
571.84
597.89
610.79
636.84
659.37
674.15
692.69
703.95
703.95
$ 135.89
214.00
214.00
214.00
214.00
214.86
219.14
224.27
232.62
239.47
242.89
248.03
253.16
256.37
259.80
261.51
263.22
264.93
266.64
270.07
273.49
278.63
283.55
290.40
298.96
309.02
321.00
334.48
349.89
365.08
382.20
399.11
417.73
436.56
456.89
477.22
499.26
521.52
545.27
557.04
580.80
601.34
614.82
631.73
642.00
642.00
$ 140.72
221.61
221.61
221.61
221.61
222.50
226.93
232.25
240.89
247.98
251.53
256.85
262.16
265.49
269.03
270.81
272.58
274.35
276.13
279.67
283.22
288.54
293.63
300.72
309.59
320.00
332.42
346.38
362.33
378.07
395.80
413.30
432.58
452.08
473.14
494.19
517.02
540.06
564.66
576.85
601.45
622.72
636.69
654.19
664.83
664.83
$ 135.56
213.48
213.48
213.48
213.48
214.33
218.60
223.73
232.05
238.88
242.30
247.42
252.55
255.75
259.16
260.87
262.58
264.29
266.00
269.41
272.83
277.95
282.86
289.69
298.23
308.27
320.22
333.67
349.04
364.20
381.28
398.14
416.71
435.50
455.78
476.06
498.05
520.25
543.95
555.69
579.38
599.88
613.33
630.19
640.44
640.44
$ 137.99
217.31
217.31
217.31
217.31
218.18
222.53
227.74
236.22
243.17
246.65
251.86
257.08
260.34
263.81
265.55
267.29
269.03
270.77
274.25
277.72
282.94
287.94
294.89
303.58
313.80
325.97
339.66
355.30
370.73
388.12
405.28
424.19
443.31
463.96
484.60
506.98
529.58
553.71
565.66
589.78
610.64
624.33
641.50
651.93
651.93
$ 137.98
217.29
217.29
217.29
217.29
218.16
222.50
227.72
236.19
243.15
246.62
251.84
257.05
260.31
263.79
265.53
267.27
269.01
270.74
274.22
277.70
282.91
287.91
294.86
303.55
313.77
325.94
339.62
355.27
370.70
388.08
405.25
424.15
443.27
463.91
484.56
506.94
529.54
553.65
565.61
589.73
610.58
624.27
641.44
651.87
651.87
$ 143.74
226.36
226.36
226.36
226.36
227.27
231.79
237.23
246.05
253.30
256.92
262.35
267.78
271.18
274.80
276.61
278.42
280.23
282.04
285.67
289.29
294.72
299.93
307.17
316.22
326.86
339.54
353.80
370.10
386.17
404.28
422.16
441.85
461.77
483.28
504.78
528.10
551.64
576.77
589.22
614.34
636.07
650.33
668.21
679.08
679.08
$ 143.34
225.73
225.73
225.73
225.73
226.63
231.15
236.57
245.37
252.59
256.20
261.62
267.04
270.42
274.04
275.84
277.65
279.45
281.26
284.87
288.48
293.90
299.09
306.32
315.34
325.95
338.60
352.82
369.07
385.10
403.15
420.99
440.62
460.49
481.93
503.38
526.63
550.10
575.16
587.58
612.63
634.30
648.52
666.35
677.19
677.19
$ 139.74
220.06
220.06
220.06
220.06
220.94
225.34
230.62
239.21
246.25
249.77
255.05
260.33
263.63
267.15
268.91
270.67
272.43
274.19
277.72
281.24
286.52
291.58
298.62
307.42
317.77
330.09
343.95
359.80
375.42
393.03
410.41
429.56
448.92
469.83
490.73
513.40
536.29
560.71
572.82
597.24
618.37
632.23
649.62
660.18
660.18
$ 151.24
238.18
238.18
238.18
238.18
239.13
243.90
249.61
258.90
266.52
270.33
276.05
281.77
285.34
289.15
291.06
292.96
294.87
296.77
300.58
304.39
310.11
315.59
323.21
332.74
343.93
357.27
372.28
389.42
406.34
425.39
444.21
464.93
485.89
508.51
531.14
555.67
580.44
606.88
619.98
646.42
669.29
684.29
703.11
714.54
714.54
$ 138.54
218.17
218.17
218.17
218.17
219.04
223.41
228.64
237.15
244.13
247.62
252.86
258.10
261.37
264.86
266.60
268.35
270.09
271.84
275.33
278.82
284.06
289.08
296.06
304.78
315.04
327.26
341.00
356.71
372.20
389.65
406.89
425.87
445.07
465.79
486.52
508.99
531.68
555.90
567.90
592.11
613.06
626.80
644.04
654.51
654.51
$ 140.31
220.96
220.96
220.96
220.96
221.84
226.26
231.57
240.18
247.25
250.79
256.09
261.40
264.71
268.25
270.01
271.78
273.55
275.32
278.85
282.39
287.69
292.77
299.84
308.68
319.07
331.44
345.36
361.27
376.96
394.63
412.09
431.31
450.76
471.75
492.74
515.50
538.48
563.01
575.16
599.69
620.90
634.82
652.27
662.88
662.88
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
55
0SPB
16064VA1210023
Anthem Essential DirectAccess w/HSA gjsa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 177.90
280.16
280.16
280.16
280.16
281.28
286.88
293.61
304.53
313.50
317.98
324.71
331.43
335.63
340.11
342.36
344.60
346.84
349.08
353.56
358.04
364.77
371.21
380.18
391.38
404.55
420.24
437.89
458.06
477.95
500.37
522.50
546.87
571.53
598.14
624.76
653.61
682.75
713.85
729.26
760.35
787.25
804.90
827.03
840.48
840.48
$ 162.26
255.52
255.52
255.52
255.52
256.54
261.65
267.78
277.75
285.93
290.02
296.15
302.28
306.11
310.20
312.25
314.29
316.33
318.38
322.47
326.55
332.69
338.56
346.74
356.96
368.97
383.28
399.38
417.78
435.92
456.36
476.54
498.78
521.26
545.54
569.81
596.13
622.70
651.06
665.12
693.48
718.01
734.11
754.30
766.56
766.56
$ 173.07
272.55
272.55
272.55
272.55
273.64
279.09
285.63
296.26
304.98
309.34
315.89
322.43
326.51
330.88
333.06
335.24
337.42
339.60
343.96
348.32
354.86
361.13
369.85
380.75
393.56
408.83
426.00
445.62
464.97
486.77
508.31
532.02
556.00
581.89
607.79
635.86
664.20
694.46
709.45
739.70
765.87
783.04
804.57
817.65
817.65
$ 161.86
254.90
254.90
254.90
254.90
255.92
261.02
267.14
277.08
285.23
289.31
295.43
301.55
305.37
309.45
311.49
313.53
315.57
317.61
321.68
325.76
331.88
337.74
345.90
356.10
368.08
382.35
398.41
416.76
434.86
455.25
475.39
497.56
520.00
544.21
568.43
594.68
621.19
649.49
663.50
691.80
716.27
732.33
752.46
764.70
764.70
$ 168.05
264.65
264.65
264.65
264.65
265.71
271.00
277.35
287.67
296.14
300.38
306.73
313.08
317.05
321.29
323.40
325.52
327.64
329.75
333.99
338.22
344.57
350.66
359.13
369.72
382.15
396.98
413.65
432.70
451.49
472.66
493.57
516.60
539.89
565.03
590.17
617.43
644.95
674.33
688.88
718.26
743.67
760.34
781.25
793.95
793.95
$ 159.79
251.64
251.64
251.64
251.64
252.65
257.68
263.72
273.53
281.59
285.61
291.65
297.69
301.46
305.49
307.50
309.52
311.53
313.54
317.57
321.60
327.64
333.42
341.48
351.54
363.37
377.46
393.31
411.43
429.30
449.43
469.31
491.20
513.35
537.25
561.16
587.08
613.25
641.18
655.02
682.95
707.11
722.96
742.84
754.92
754.92
$ 177.11
278.91
278.91
278.91
278.91
280.03
285.60
292.30
303.18
312.10
316.56
323.26
329.95
334.13
338.60
340.83
343.06
345.29
347.52
351.98
356.45
363.14
369.56
378.48
389.64
402.75
418.37
435.94
456.02
475.82
498.13
520.17
544.43
568.98
595.47
621.97
650.70
679.70
710.66
726.00
756.96
783.74
801.31
823.34
836.73
836.73
$ 171.14
269.51
269.51
269.51
269.51
270.59
275.98
282.45
292.96
301.58
305.89
312.36
318.83
322.87
327.19
329.34
331.50
333.65
335.81
340.12
344.43
350.90
357.10
365.73
376.51
389.17
404.27
421.24
440.65
459.78
481.34
502.64
526.08
549.80
575.40
601.01
628.77
656.80
686.71
701.53
731.45
757.32
774.30
795.59
808.53
808.53
$ 179.02
281.92
281.92
281.92
281.92
283.05
288.69
295.45
306.45
315.47
319.98
326.75
333.51
337.74
342.25
344.51
346.76
349.02
351.27
355.78
360.29
367.06
373.54
382.57
393.84
407.09
422.88
440.64
460.94
480.96
503.51
525.78
550.31
575.12
601.90
628.68
657.72
687.04
718.33
733.84
765.13
792.20
809.96
832.23
845.76
845.76
$ 171.55
270.16
270.16
270.16
270.16
271.24
276.64
283.13
293.66
302.31
306.63
313.12
319.60
323.65
327.97
330.14
332.30
334.46
336.62
340.94
345.26
351.75
357.96
366.61
377.41
390.11
405.24
422.26
441.71
460.89
482.51
503.85
527.35
551.13
576.79
602.46
630.28
658.38
688.37
703.23
733.21
759.15
776.17
797.51
810.48
810.48
$ 162.08
255.25
255.25
255.25
255.25
256.27
261.38
267.50
277.46
285.62
289.71
295.83
301.96
305.79
309.87
311.92
313.96
316.00
318.04
322.13
326.21
332.34
338.21
346.37
356.58
368.58
382.88
398.96
417.33
435.46
455.88
476.04
498.25
520.71
544.96
569.21
595.50
622.04
650.38
664.42
692.75
717.25
733.33
753.50
765.75
765.75
$ 172.49
271.63
271.63
271.63
271.63
272.72
278.15
284.67
295.26
303.95
308.30
314.82
321.34
325.41
329.76
331.93
334.10
336.28
338.45
342.80
347.14
353.66
359.91
368.60
379.47
392.23
407.45
424.56
444.12
463.40
485.13
506.59
530.22
554.13
579.93
605.73
633.71
661.96
692.11
707.05
737.20
763.28
780.39
801.85
814.89
814.89
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
56
0SPD
16064VA1210024
Anthem Essential DirectAccess w/HSA gpsa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 164.48
259.02
259.02
259.02
259.02
260.06
265.24
271.45
281.55
289.84
293.99
300.20
306.42
310.31
314.45
316.52
318.59
320.67
322.74
326.88
331.03
337.24
343.20
351.49
361.85
374.02
388.53
404.85
423.50
441.89
462.61
483.07
505.61
528.40
553.01
577.61
604.29
631.23
659.98
674.23
702.98
727.85
744.16
764.63
777.06
777.06
$ 150.01
236.24
236.24
236.24
236.24
237.18
241.91
247.58
256.79
264.35
268.13
273.80
279.47
283.02
286.80
288.69
290.58
292.47
294.36
298.13
301.91
307.58
313.02
320.58
330.03
341.13
354.36
369.24
386.25
403.03
421.92
440.59
461.14
481.93
504.37
526.82
551.15
575.72
601.94
614.93
641.16
663.83
678.72
697.38
708.72
708.72
$ 160.01
251.98
251.98
251.98
251.98
252.99
258.03
264.08
273.90
281.97
286.00
292.04
298.09
301.87
305.90
307.92
309.94
311.95
313.97
318.00
322.03
328.08
333.87
341.94
352.02
363.86
377.97
393.84
411.99
429.88
450.04
469.94
491.86
514.04
537.98
561.92
587.87
614.08
642.05
655.90
683.87
708.06
723.94
743.84
755.94
755.94
$ 149.64
235.66
235.66
235.66
235.66
236.60
241.32
246.97
256.16
263.70
267.47
273.13
278.79
282.32
286.09
287.98
289.86
291.75
293.63
297.40
301.17
306.83
312.25
319.79
329.22
340.29
353.49
368.34
385.30
402.04
420.89
439.51
460.01
480.75
503.13
525.52
549.79
574.30
600.46
613.42
639.58
662.20
677.05
695.67
706.98
706.98
$ 155.37
244.68
244.68
244.68
244.68
245.66
250.55
256.42
265.97
273.80
277.71
283.58
289.46
293.13
297.04
299.00
300.96
302.91
304.87
308.79
312.70
318.57
324.20
332.03
341.82
353.32
367.02
382.43
400.05
417.42
437.00
456.33
477.62
499.15
522.39
545.64
570.84
596.29
623.44
636.90
664.06
687.55
702.97
722.30
734.04
734.04
$ 147.73
232.65
232.65
232.65
232.65
233.58
238.23
243.82
252.89
260.34
264.06
269.64
275.22
278.71
282.44
284.30
286.16
288.02
289.88
293.60
297.33
302.91
308.26
315.71
325.01
335.95
348.98
363.63
380.38
396.90
415.51
433.89
454.13
474.61
496.71
518.81
542.77
566.97
592.79
605.59
631.41
653.75
668.40
686.78
697.95
697.95
$ 163.74
257.86
257.86
257.86
257.86
258.89
264.05
270.24
280.29
288.55
292.67
298.86
305.05
308.92
313.04
315.10
317.17
319.23
321.29
325.42
329.55
335.73
341.66
349.92
360.23
372.35
386.79
403.04
421.60
439.91
460.54
480.91
503.34
526.03
550.53
575.03
601.59
628.40
657.03
671.21
699.83
724.59
740.83
761.20
773.58
773.58
$ 158.22
249.17
249.17
249.17
249.17
250.17
255.15
261.13
270.85
278.82
282.81
288.79
294.77
298.51
302.49
304.49
306.48
308.47
310.47
314.45
318.44
324.42
330.15
338.12
348.09
359.80
373.76
389.45
407.39
425.08
445.02
464.70
486.38
508.31
531.98
555.65
581.31
607.23
634.89
648.59
676.25
700.17
715.87
735.55
747.51
747.51
$ 165.51
260.65
260.65
260.65
260.65
261.69
266.91
273.16
283.33
291.67
295.84
302.09
308.35
312.26
316.43
318.51
320.60
322.68
324.77
328.94
333.11
339.37
345.36
353.70
364.13
376.38
390.98
407.40
426.16
444.67
465.52
486.11
508.79
531.73
556.49
581.25
608.10
635.20
664.14
678.47
707.40
732.43
748.85
769.44
781.95
781.95
$ 158.60
249.77
249.77
249.77
249.77
250.77
255.76
261.76
271.50
279.49
283.49
289.48
295.48
299.22
303.22
305.22
307.22
309.22
311.21
315.21
319.21
325.20
330.95
338.94
348.93
360.67
374.66
390.39
408.37
426.11
446.09
465.82
487.55
509.53
533.26
556.99
582.71
608.69
636.41
650.15
677.88
701.85
717.59
737.32
749.31
749.31
$ 149.85
235.99
235.99
235.99
235.99
236.93
241.65
247.32
256.52
264.07
267.85
273.51
279.18
282.72
286.49
288.38
290.27
292.16
294.04
297.82
301.60
307.26
312.69
320.24
329.68
340.77
353.99
368.85
385.84
402.60
421.48
440.12
460.65
481.42
503.84
526.26
550.56
575.11
601.30
614.28
640.48
663.13
678.00
696.64
707.97
707.97
$ 159.47
251.13
251.13
251.13
251.13
252.13
257.16
263.18
272.98
281.01
285.03
291.06
297.09
300.85
304.87
306.88
308.89
310.90
312.91
316.93
320.94
326.97
332.75
340.78
350.83
362.63
376.70
392.52
410.60
428.43
448.52
468.36
490.21
512.31
536.16
560.02
585.89
612.00
639.88
653.69
681.57
705.68
721.50
741.34
753.39
753.39
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
57
0SPF
16064VA1210025
Anthem Essential DirectAccess w/HRA ggta
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 149.83
235.96
235.96
235.96
235.96
236.90
241.62
247.29
256.49
264.04
267.81
273.48
279.14
282.68
286.46
288.34
290.23
292.12
294.01
297.78
301.56
307.22
312.65
320.20
329.64
340.73
353.94
368.81
385.79
402.55
421.42
440.07
460.59
481.36
503.77
526.19
550.49
575.03
601.23
614.20
640.40
663.05
677.91
696.55
707.88
707.88
$ 136.66
215.21
215.21
215.21
215.21
216.07
220.38
225.54
233.93
240.82
244.26
249.43
254.59
257.82
261.26
262.99
264.71
266.43
268.15
271.60
275.04
280.20
285.15
292.04
300.65
310.76
322.82
336.37
351.87
367.15
384.37
401.37
420.09
439.03
459.47
479.92
502.08
524.47
548.36
560.19
584.08
604.74
618.30
635.30
645.63
645.63
$ 145.76
229.55
229.55
229.55
229.55
230.47
235.06
240.57
249.52
256.87
260.54
266.05
271.56
275.00
278.67
280.51
282.35
284.18
286.02
289.69
293.36
298.87
304.15
311.50
320.68
331.47
344.33
358.79
375.31
391.61
409.98
428.11
448.08
468.28
490.09
511.90
535.54
559.41
584.89
597.52
623.00
645.04
659.50
677.63
688.65
688.65
$ 136.32
214.68
214.68
214.68
214.68
215.54
219.83
224.98
233.36
240.23
243.66
248.81
253.97
257.19
260.62
262.34
264.06
265.77
267.49
270.93
274.36
279.51
284.45
291.32
299.91
310.00
322.02
335.54
351.00
366.24
383.42
400.38
419.06
437.95
458.34
478.74
500.85
523.18
547.00
558.81
582.64
603.25
616.78
633.74
644.04
644.04
$ 141.54
222.89
222.89
222.89
222.89
223.78
228.24
233.59
242.28
249.41
252.98
258.33
263.68
267.02
270.59
272.37
274.15
275.94
277.72
281.29
284.85
290.20
295.33
302.46
311.38
321.85
334.34
348.38
364.43
380.25
398.08
415.69
435.08
454.70
475.87
497.04
520.00
543.18
567.92
580.18
604.92
626.32
640.36
657.97
668.67
668.67
$ 134.58
211.94
211.94
211.94
211.94
212.79
217.03
222.11
230.38
237.16
240.55
245.64
250.73
253.90
257.30
258.99
260.69
262.38
264.08
267.47
270.86
275.95
280.82
287.60
296.08
306.04
317.91
331.26
346.52
361.57
378.52
395.27
413.71
432.36
452.49
472.63
494.46
516.50
540.02
551.68
575.21
595.55
608.90
625.65
635.82
635.82
$ 149.16
234.90
234.90
234.90
234.90
235.84
240.54
246.18
255.34
262.85
266.61
272.25
277.89
281.41
285.17
287.05
288.93
290.81
292.69
296.44
300.20
305.84
311.24
318.76
328.16
339.20
352.35
367.15
384.06
400.74
419.53
438.09
458.52
479.20
501.51
523.83
548.02
572.45
598.53
611.44
637.52
660.07
674.87
693.42
704.70
704.70
$ 144.14
226.99
226.99
226.99
226.99
227.90
232.44
237.89
246.74
254.00
257.63
263.08
268.53
271.93
275.57
277.38
279.20
281.01
282.83
286.46
290.09
295.54
300.76
308.03
317.11
327.77
340.49
354.79
371.13
387.24
405.40
423.34
443.08
463.06
484.62
506.19
529.57
553.17
578.37
590.85
616.05
637.84
652.14
670.07
680.97
680.97
$ 150.77
237.44
237.44
237.44
237.44
238.39
243.14
248.84
258.10
265.70
269.49
275.19
280.89
284.45
288.25
290.15
292.05
293.95
295.85
299.65
303.45
309.15
314.61
322.21
331.70
342.86
356.16
371.12
388.21
405.07
424.07
442.83
463.48
484.38
506.93
529.49
553.95
578.64
605.00
618.06
644.41
667.21
682.17
700.92
712.32
712.32
$ 144.49
227.54
227.54
227.54
227.54
228.45
233.00
238.46
247.34
254.62
258.26
263.72
269.18
272.59
276.23
278.05
279.87
281.69
283.51
287.16
290.80
296.26
301.49
308.77
317.87
328.57
341.31
355.65
372.03
388.18
406.39
424.36
444.16
464.18
485.80
507.41
530.85
554.51
579.77
592.29
617.54
639.39
653.72
671.70
682.62
682.62
$ 136.51
214.98
214.98
214.98
214.98
215.84
220.14
225.30
233.68
240.56
244.00
249.16
254.32
257.55
260.99
262.71
264.43
266.15
267.87
271.30
274.74
279.90
284.85
291.73
300.33
310.43
322.47
336.01
351.49
366.76
383.95
400.94
419.64
438.56
458.98
479.41
501.55
523.91
547.77
559.59
583.46
604.09
617.64
634.62
644.94
644.94
$ 145.27
228.77
228.77
228.77
228.77
229.69
234.26
239.75
248.67
255.99
259.65
265.14
270.63
274.07
277.73
279.56
281.39
283.22
285.05
288.71
292.37
297.86
303.12
310.44
319.59
330.34
343.16
357.57
374.04
390.28
408.58
426.66
446.56
466.69
488.42
510.16
533.72
557.51
582.91
595.49
620.88
642.84
657.26
675.33
686.31
686.31
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
58
0SPH
16064VA1210026
Anthem Essential DirectAccess w/HSA gjta
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 177.30
279.21
279.21
279.21
279.21
280.33
285.91
292.61
303.50
312.44
316.90
323.60
330.31
334.49
338.96
341.19
343.43
345.66
347.90
352.36
356.83
363.53
369.95
378.89
390.06
403.18
418.82
436.41
456.51
476.33
498.67
520.73
545.02
569.59
596.11
622.64
651.40
680.43
711.43
726.78
757.78
784.58
802.17
824.23
837.63
837.63
$ 161.71
254.66
254.66
254.66
254.66
255.68
260.77
266.88
276.82
284.96
289.04
295.15
301.26
305.08
309.16
311.19
313.23
315.27
317.31
321.38
325.46
331.57
337.42
345.57
355.76
367.73
381.99
398.03
416.37
434.45
454.82
474.94
497.10
519.51
543.70
567.89
594.12
620.61
648.87
662.88
691.15
715.59
731.64
751.76
763.98
763.98
$ 172.49
271.63
271.63
271.63
271.63
272.72
278.15
284.67
295.26
303.95
308.30
314.82
321.34
325.41
329.76
331.93
334.10
336.28
338.45
342.80
347.14
353.66
359.91
368.60
379.47
392.23
407.45
424.56
444.12
463.40
485.13
506.59
530.22
554.13
579.93
605.73
633.71
661.96
692.11
707.05
737.20
763.28
780.39
801.85
814.89
814.89
$ 161.32
254.04
254.04
254.04
254.04
255.06
260.14
266.23
276.14
284.27
288.34
294.43
300.53
304.34
308.40
310.44
312.47
314.50
316.53
320.60
324.66
330.76
336.60
344.73
354.89
366.83
381.06
397.06
415.36
433.39
453.72
473.78
495.89
518.24
542.38
566.51
592.68
619.10
647.29
661.27
689.46
713.85
729.86
749.93
762.12
762.12
$ 167.49
263.76
263.76
263.76
263.76
264.82
270.09
276.42
286.71
295.15
299.37
305.70
312.03
315.98
320.20
322.31
324.42
326.53
328.64
332.87
337.09
343.42
349.48
357.92
368.47
380.87
395.64
412.26
431.25
449.97
471.08
491.91
514.86
538.07
563.13
588.18
615.35
642.78
672.06
686.57
715.84
741.17
757.78
778.62
791.28
791.28
$ 159.25
250.79
250.79
250.79
250.79
251.79
256.81
262.83
272.61
280.63
284.65
290.67
296.68
300.45
304.46
306.47
308.47
310.48
312.48
316.50
320.51
326.53
332.30
340.32
350.35
362.14
376.19
391.98
410.04
427.85
447.91
467.72
489.54
511.61
535.44
559.26
585.09
611.18
639.01
652.81
680.64
704.72
720.52
740.33
752.37
752.37
$ 176.51
277.97
277.97
277.97
277.97
279.08
284.64
291.31
302.15
311.05
315.50
322.17
328.84
333.01
337.46
339.68
341.90
344.13
346.35
350.80
355.25
361.92
368.31
377.21
388.32
401.39
416.96
434.47
454.48
474.22
496.45
518.41
542.60
567.06
593.47
619.87
648.50
677.41
708.27
723.56
754.41
781.10
798.61
820.57
833.91
833.91
$ 170.56
268.60
268.60
268.60
268.60
269.67
275.05
281.49
291.97
300.56
304.86
311.31
317.75
321.78
326.08
328.23
330.38
332.53
334.68
338.97
343.27
349.72
355.90
364.49
375.23
387.86
402.90
419.82
439.16
458.23
479.72
500.94
524.31
547.94
573.46
598.98
626.64
654.58
684.39
699.17
728.98
754.77
771.69
792.91
805.80
805.80
$ 178.42
280.97
280.97
280.97
280.97
282.09
287.71
294.46
305.41
314.41
318.90
325.64
332.39
336.60
341.10
343.35
345.59
347.84
350.09
354.58
359.08
365.82
372.29
381.28
392.52
405.72
421.46
439.16
459.39
479.33
501.81
524.01
548.45
573.18
599.87
626.56
655.50
684.72
715.91
731.36
762.55
789.53
807.23
829.42
842.91
842.91
$ 170.97
269.25
269.25
269.25
269.25
270.33
275.71
282.17
292.67
301.29
305.60
312.06
318.52
322.56
326.87
329.02
331.18
333.33
335.49
339.79
344.10
350.56
356.76
365.37
376.14
388.80
403.88
420.84
440.22
459.34
480.88
502.15
525.58
549.27
574.85
600.43
628.16
656.16
686.05
700.86
730.74
756.59
773.56
794.83
807.75
807.75
$ 161.54
254.39
254.39
254.39
254.39
255.41
260.50
266.60
276.52
284.66
288.73
294.84
300.94
304.76
308.83
310.86
312.90
314.93
316.97
321.04
325.11
331.22
337.07
345.21
355.38
367.34
381.59
397.61
415.93
433.99
454.34
474.44
496.57
518.96
543.12
567.29
593.49
619.95
648.19
662.18
690.41
714.84
730.86
750.96
763.17
763.17
$ 171.90
270.71
270.71
270.71
270.71
271.79
277.21
283.70
294.26
302.92
307.26
313.75
320.25
324.31
328.64
330.81
332.97
335.14
337.30
341.64
345.97
352.46
358.69
367.35
378.18
390.91
406.07
423.12
442.61
461.83
483.49
504.87
528.43
552.25
577.97
603.68
631.57
659.72
689.77
704.66
734.71
760.70
777.75
799.14
812.13
812.13
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
59
0SPK
16064VA1210027
Anthem Essential DirectAccess w/HSA gkta
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 163.22
257.04
257.04
257.04
257.04
258.07
263.21
269.38
279.40
287.63
291.74
297.91
304.08
307.93
312.05
314.10
316.16
318.22
320.27
324.38
328.50
334.67
340.58
348.80
359.08
371.17
385.56
401.75
420.26
438.51
459.07
479.38
501.74
524.36
548.78
573.20
599.67
626.41
654.94
669.08
697.61
722.28
738.48
758.78
771.12
771.12
$ 148.86
234.43
234.43
234.43
234.43
235.37
240.06
245.68
254.83
262.33
266.08
271.70
277.33
280.85
284.60
286.47
288.35
290.22
292.10
295.85
299.60
305.23
310.62
318.12
327.50
338.52
351.65
366.41
383.29
399.94
418.69
437.21
457.61
478.24
500.51
522.78
546.93
571.31
597.33
610.22
636.24
658.75
673.52
692.04
703.29
703.29
$ 158.79
250.06
250.06
250.06
250.06
251.06
256.06
262.06
271.82
279.82
283.82
289.82
295.82
299.57
303.57
305.57
307.57
309.57
311.57
315.58
319.58
325.58
331.33
339.33
349.33
361.09
375.09
390.84
408.85
426.60
446.61
466.36
488.12
510.12
533.88
557.63
583.39
609.40
637.15
650.91
678.66
702.67
718.42
738.18
750.18
750.18
$ 148.50
233.86
233.86
233.86
233.86
234.80
239.47
245.09
254.21
261.69
265.43
271.04
276.66
280.16
283.91
285.78
287.65
289.52
291.39
295.13
298.87
304.49
309.86
317.35
326.70
337.69
350.79
365.52
382.36
398.97
417.67
436.15
456.49
477.07
499.29
521.51
545.60
569.92
595.88
608.74
634.70
657.15
671.88
690.35
701.58
701.58
$ 154.18
242.81
242.81
242.81
242.81
243.78
248.64
254.46
263.93
271.70
275.59
281.42
287.24
290.89
294.77
296.71
298.66
300.60
302.54
306.43
310.31
316.14
321.72
329.49
339.21
350.62
364.22
379.51
396.99
414.23
433.66
452.84
473.97
495.33
518.40
541.47
566.48
591.73
618.68
632.03
658.99
682.30
697.59
716.78
728.43
728.43
$ 146.60
230.87
230.87
230.87
230.87
231.79
236.41
241.95
250.96
258.34
262.04
267.58
273.12
276.58
280.28
282.12
283.97
285.82
287.66
291.36
295.05
300.59
305.90
313.29
322.53
333.38
346.31
360.85
377.47
393.86
412.33
430.57
450.66
470.97
492.91
514.84
538.62
562.63
588.26
600.95
626.58
648.74
663.29
681.53
692.61
692.61
$ 162.49
255.89
255.89
255.89
255.89
256.91
262.03
268.17
278.15
286.34
290.44
296.58
302.72
306.56
310.65
312.70
314.74
316.79
318.84
322.93
327.03
333.17
339.05
347.24
357.48
369.51
383.84
399.96
418.38
436.55
457.02
477.23
499.50
522.02
546.33
570.63
596.99
623.60
652.01
666.08
694.49
719.05
735.17
755.39
767.67
767.67
$ 157.02
247.27
247.27
247.27
247.27
248.26
253.20
259.14
268.78
276.70
280.65
286.59
292.52
296.23
300.19
302.16
304.14
306.12
308.10
312.05
316.01
321.95
327.63
335.55
345.44
357.06
370.91
386.48
404.29
421.84
441.62
461.16
482.67
504.43
527.92
551.41
576.88
602.60
630.04
643.64
671.09
694.83
710.41
729.94
741.81
741.81
$ 164.25
258.66
258.66
258.66
258.66
259.69
264.87
271.08
281.16
289.44
293.58
299.79
305.99
309.87
314.01
316.08
318.15
320.22
322.29
326.43
330.57
336.78
342.72
351.00
361.35
373.51
387.99
404.29
422.91
441.27
461.97
482.40
504.90
527.67
552.24
576.81
603.45
630.35
659.07
673.29
702.00
726.83
743.13
763.56
775.98
775.98
$ 157.40
247.87
247.87
247.87
247.87
248.86
253.82
259.77
269.43
277.37
281.33
287.28
293.23
296.95
300.91
302.90
304.88
306.86
308.85
312.81
316.78
322.73
328.43
336.36
346.27
357.92
371.81
387.42
405.27
422.87
442.70
462.28
483.84
505.65
529.20
552.75
578.28
604.06
631.57
645.21
672.72
696.51
712.13
731.71
743.61
743.61
$ 148.70
234.18
234.18
234.18
234.18
235.12
239.80
245.42
254.55
262.05
265.79
271.41
277.03
280.55
284.29
286.17
288.04
289.91
291.79
295.54
299.28
304.90
310.29
317.78
327.15
338.16
351.27
366.02
382.88
399.51
418.25
436.75
457.12
477.73
499.97
522.22
546.34
570.70
596.69
609.57
635.56
658.05
672.80
691.30
702.54
702.54
$ 158.25
249.21
249.21
249.21
249.21
250.21
255.19
261.17
270.89
278.87
282.85
288.83
294.82
298.55
302.54
304.53
306.53
308.52
310.52
314.50
318.49
324.47
330.20
338.18
348.15
359.86
373.82
389.52
407.46
425.15
445.09
464.78
486.46
508.39
532.06
555.74
581.41
607.32
634.99
648.69
676.36
700.28
715.98
735.67
747.63
747.63
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
60
0SPM
16064VA1210022
Anthem Essential DirectAccess w/HSA gdsa
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 168.15
264.80
264.80
264.80
264.80
265.86
271.16
277.51
287.84
296.31
300.55
306.90
313.26
317.23
321.47
323.59
325.70
327.82
329.94
334.18
338.41
344.77
350.86
359.33
369.93
382.37
397.20
413.88
432.95
451.75
472.93
493.85
516.89
540.19
565.35
590.50
617.78
645.32
674.71
689.27
718.67
744.09
760.77
781.69
794.40
794.40
$ 153.36
241.51
241.51
241.51
241.51
242.48
247.31
253.10
262.52
270.25
274.11
279.91
285.71
289.33
293.19
295.13
297.06
298.99
300.92
304.79
308.65
314.45
320.00
327.73
337.39
348.74
362.27
377.48
394.87
412.02
431.34
450.42
471.43
492.68
515.62
538.57
563.44
588.56
615.37
628.65
655.46
678.64
693.86
712.94
724.53
724.53
$ 163.58
257.61
257.61
257.61
257.61
258.64
263.79
269.98
280.02
288.27
292.39
298.57
304.75
308.62
312.74
314.80
316.86
318.92
320.98
325.10
329.23
335.41
341.33
349.58
359.88
371.99
386.42
402.64
421.19
439.48
460.09
480.44
502.85
525.52
550.00
574.47
601.00
627.80
656.39
670.56
699.15
723.88
740.11
760.46
772.83
772.83
$ 152.98
240.92
240.92
240.92
240.92
241.88
246.70
252.48
261.88
269.59
273.44
279.23
285.01
288.62
292.48
294.40
296.33
298.26
300.19
304.04
307.90
313.68
319.22
326.93
336.57
347.89
361.38
376.56
393.90
411.01
430.28
449.32
470.28
491.48
514.36
537.25
562.07
587.12
613.86
627.11
653.86
676.99
692.16
711.20
722.76
722.76
$ 158.84
250.14
250.14
250.14
250.14
251.14
256.14
262.15
271.90
279.91
283.91
289.91
295.92
299.67
303.67
305.67
307.67
309.67
311.67
315.68
319.68
325.68
331.44
339.44
349.45
361.20
375.21
390.97
408.98
426.74
446.75
466.51
488.27
510.29
534.05
557.81
583.58
609.59
637.36
651.11
678.88
702.89
718.65
738.41
750.42
750.42
$ 151.03
237.84
237.84
237.84
237.84
238.79
243.55
249.26
258.53
266.14
269.95
275.66
281.36
284.93
288.74
290.64
292.54
294.45
296.35
300.15
303.96
309.67
315.14
322.75
332.26
343.44
356.76
371.74
388.87
405.76
424.78
443.57
464.26
485.19
507.79
530.38
554.88
579.62
606.02
619.10
645.50
668.33
683.31
702.10
713.52
713.52
$ 167.39
263.61
263.61
263.61
263.61
264.66
269.94
276.26
286.54
294.98
299.20
305.52
311.85
315.80
320.02
322.13
324.24
326.35
328.46
332.68
336.89
343.22
349.28
357.72
368.26
380.65
395.42
412.02
431.00
449.72
470.81
491.63
514.57
537.76
562.81
587.85
615.00
642.42
671.68
686.18
715.44
740.74
757.35
778.18
790.83
790.83
$ 161.75
254.73
254.73
254.73
254.73
255.75
260.84
266.96
276.89
285.04
289.12
295.23
301.35
305.17
309.24
311.28
313.32
315.36
317.39
321.47
325.54
331.66
337.52
345.67
355.86
367.83
382.10
398.14
416.48
434.57
454.95
475.07
497.23
519.65
543.85
568.05
594.29
620.78
649.05
663.06
691.34
715.79
731.84
751.96
764.19
764.19
$ 169.20
266.46
266.46
266.46
266.46
267.53
272.86
279.25
289.64
298.17
302.43
308.83
315.22
319.22
323.48
325.61
327.75
329.88
332.01
336.27
340.54
346.93
353.06
361.59
372.24
384.77
399.69
416.48
435.66
454.58
475.90
496.95
520.13
543.58
568.89
594.21
621.65
649.36
678.94
693.60
723.17
748.75
765.54
786.59
799.38
799.38
$ 162.15
255.35
255.35
255.35
255.35
256.37
261.48
267.61
277.57
285.74
289.82
295.95
302.08
305.91
309.99
312.04
314.08
316.12
318.17
322.25
326.34
332.47
338.34
346.51
356.72
368.73
383.03
399.11
417.50
435.63
456.06
476.23
498.44
520.91
545.17
569.43
595.73
622.29
650.63
664.68
693.02
717.53
733.62
753.79
766.05
766.05
$ 153.19
241.25
241.25
241.25
241.25
242.22
247.04
252.83
262.24
269.96
273.82
279.61
285.40
289.02
292.88
294.81
296.74
298.67
300.60
304.46
308.32
314.11
319.66
327.38
337.03
348.37
361.88
377.07
394.44
411.57
430.87
449.93
470.92
492.15
515.07
537.99
562.84
587.93
614.71
627.97
654.75
677.91
693.11
712.17
723.75
723.75
$ 163.02
256.73
256.73
256.73
256.73
257.76
262.89
269.05
279.07
287.28
291.39
297.55
303.71
307.56
311.67
313.72
315.78
317.83
319.89
323.99
328.10
334.26
340.17
348.38
358.65
370.72
385.10
401.27
419.75
437.98
458.52
478.80
501.14
523.73
548.12
572.51
598.95
625.65
654.15
668.27
696.77
721.41
737.59
757.87
770.19
770.19
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
61
0W33
88380VA0740014
Anthem HealthKeepers Essential Guided Access Plus w/HSA gzeb
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 155.09
244.23
244.23
244.23
244.23
245.21
250.09
255.95
265.48
273.29
277.20
283.06
288.92
292.59
296.50
298.45
300.40
302.36
304.31
308.22
312.13
317.99
323.60
331.42
341.19
352.67
366.35
381.73
399.32
416.66
436.19
455.49
476.74
498.23
521.43
544.63
569.79
595.19
622.30
635.73
662.84
686.29
701.67
720.97
732.69
732.69
$ 141.44
222.74
222.74
222.74
222.74
223.63
228.09
233.43
242.12
249.25
252.81
258.16
263.50
266.84
270.41
272.19
273.97
275.75
277.53
281.10
284.66
290.01
295.13
302.26
311.17
321.64
334.11
348.14
364.18
379.99
397.81
415.41
434.79
454.39
475.55
496.71
519.65
542.82
567.54
579.79
604.52
625.90
639.93
657.53
668.22
668.22
$ 146.47
230.66
230.66
230.66
230.66
231.58
236.20
241.73
250.73
258.11
261.80
267.33
272.87
276.33
280.02
281.87
283.71
285.56
287.40
291.09
294.78
300.32
305.62
313.01
322.23
333.07
345.99
360.52
377.13
393.51
411.96
430.18
450.25
470.55
492.46
514.37
538.13
562.12
587.72
600.41
626.01
648.15
662.69
680.91
691.98
691.98
$ 141.10
222.20
222.20
222.20
222.20
223.09
227.53
232.87
241.53
248.64
252.20
257.53
262.86
266.20
269.75
271.53
273.31
275.08
276.86
280.42
283.97
289.30
294.42
301.53
310.41
320.86
333.30
347.30
363.30
379.07
396.85
414.40
433.73
453.29
474.40
495.51
518.39
541.50
566.17
578.39
603.05
624.38
638.38
655.93
666.60
666.60
$ 143.62
226.18
226.18
226.18
226.18
227.08
231.61
237.04
245.86
253.10
256.71
262.14
267.57
270.96
274.58
276.39
278.20
280.01
281.82
285.44
289.06
294.49
299.69
306.93
315.97
326.60
339.27
353.52
369.80
385.86
403.96
421.83
441.50
461.41
482.89
504.38
527.68
551.20
576.31
588.75
613.85
635.57
649.82
667.68
678.54
678.54
$ 143.61
226.16
226.16
226.16
226.16
227.06
231.59
237.02
245.84
253.07
256.69
262.12
267.55
270.94
274.56
276.37
278.18
279.99
281.80
285.41
289.03
294.46
299.66
306.90
315.95
326.58
339.24
353.49
369.77
385.83
403.92
421.79
441.46
461.37
482.85
504.34
527.63
551.15
576.26
588.69
613.80
635.51
649.76
667.62
678.48
678.48
$ 149.61
235.60
235.60
235.60
235.60
236.54
241.25
246.91
256.10
263.64
267.41
273.06
278.71
282.25
286.02
287.90
289.79
291.67
293.56
297.33
301.10
306.75
312.17
319.71
329.13
340.21
353.40
368.24
385.21
401.93
420.78
439.39
459.89
480.62
503.01
525.39
549.65
574.16
600.31
613.27
639.42
662.04
676.88
695.49
706.80
706.80
$ 149.19
234.95
234.95
234.95
234.95
235.89
240.59
246.23
255.39
262.91
266.67
272.31
277.95
281.47
285.23
287.11
288.99
290.87
292.75
296.51
300.27
305.90
311.31
318.83
328.23
339.27
352.43
367.23
384.14
400.82
419.62
438.18
458.62
479.30
501.62
523.94
548.14
572.57
598.65
611.57
637.65
660.21
675.01
693.57
704.85
704.85
$ 145.44
229.04
229.04
229.04
229.04
229.96
234.54
240.03
248.97
256.30
259.96
265.46
270.95
274.39
278.05
279.89
281.72
283.55
285.38
289.05
292.71
298.21
303.48
310.81
319.97
330.73
343.56
357.99
374.48
390.74
409.07
427.16
447.09
467.24
489.00
510.76
534.35
558.17
583.59
596.19
621.61
643.60
658.03
676.13
687.12
687.12
$ 157.42
247.91
247.91
247.91
247.91
248.90
253.86
259.81
269.48
277.41
281.38
287.33
293.28
297.00
300.96
302.95
304.93
306.91
308.90
312.86
316.83
322.78
328.48
336.41
346.33
357.98
371.87
387.48
405.33
422.93
442.77
462.35
483.92
505.74
529.29
552.84
578.37
604.16
631.67
645.31
672.83
696.63
712.25
731.83
743.73
743.73
$ 144.19
227.07
227.07
227.07
227.07
227.98
232.52
237.97
246.83
254.09
257.72
263.17
268.62
272.03
275.66
277.48
279.30
281.11
282.93
286.56
290.20
295.65
300.87
308.13
317.22
327.89
340.61
354.91
371.26
387.38
405.55
423.49
443.24
463.22
484.79
506.37
529.75
553.37
578.57
591.06
616.27
638.07
652.37
670.31
681.21
681.21
$ 146.04
229.98
229.98
229.98
229.98
230.90
235.50
241.02
249.99
257.35
261.03
266.55
272.07
275.52
279.20
281.04
282.88
284.72
286.56
290.23
293.91
299.43
304.72
312.08
321.28
332.09
344.97
359.46
376.02
392.35
410.74
428.91
448.92
469.16
491.01
512.86
536.54
560.46
585.99
598.64
624.17
646.24
660.73
678.90
689.94
689.94
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
62
0W34
88380VA0740013
Anthem HealthKeepers Essential Guided Access Plus w/HSA gqeb
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 151.23
238.16
238.16
238.16
238.16
239.11
243.88
249.59
258.88
266.50
270.31
276.03
281.74
285.32
289.13
291.03
292.94
294.84
296.75
300.56
304.37
310.08
315.56
323.18
332.71
343.90
357.24
372.24
389.39
406.30
425.35
444.17
464.89
485.85
508.47
531.10
555.63
580.40
606.83
619.93
646.37
669.23
684.23
703.05
714.48
714.48
$ 137.92
217.20
217.20
217.20
217.20
218.07
222.41
227.63
236.10
243.05
246.52
251.73
256.95
260.21
263.68
265.42
267.16
268.89
270.63
274.11
277.58
282.79
287.79
294.74
303.43
313.64
325.80
339.48
355.12
370.54
387.92
405.08
423.97
443.09
463.72
484.36
506.73
529.32
553.43
565.37
589.48
610.33
624.02
641.17
651.60
651.60
$ 142.83
224.93
224.93
224.93
224.93
225.83
230.33
235.73
244.50
251.70
255.30
260.69
266.09
269.47
273.07
274.86
276.66
278.46
280.26
283.86
287.46
292.86
298.03
305.23
314.23
324.80
337.40
351.57
367.76
383.73
401.72
419.49
439.06
458.86
480.23
501.59
524.76
548.15
573.12
585.49
610.46
632.05
646.22
663.99
674.79
674.79
$ 137.59
216.68
216.68
216.68
216.68
217.55
221.88
227.08
235.53
242.46
245.93
251.13
256.33
259.58
263.05
264.78
266.52
268.25
269.98
273.45
276.92
282.12
287.10
294.03
302.70
312.89
325.02
338.67
354.27
369.66
386.99
404.11
422.96
442.03
462.61
483.20
505.51
528.05
552.10
564.02
588.07
608.87
622.52
639.64
650.04
650.04
$ 140.06
220.56
220.56
220.56
220.56
221.44
225.85
231.15
239.75
246.81
250.34
255.63
260.92
264.23
267.76
269.52
271.29
273.05
274.82
278.35
281.88
287.17
292.24
299.30
308.12
318.49
330.84
344.74
360.62
376.28
393.92
411.34
430.53
449.94
470.90
491.85
514.57
537.50
561.99
574.12
598.60
619.77
633.67
651.09
661.68
661.68
$ 140.04
220.54
220.54
220.54
220.54
221.42
225.83
231.13
239.73
246.78
250.31
255.61
260.90
264.21
267.74
269.50
271.26
273.03
274.79
278.32
281.85
287.14
292.22
299.27
308.09
318.46
330.81
344.70
360.58
376.24
393.88
411.31
430.49
449.90
470.85
491.80
514.52
537.46
561.94
574.07
598.55
619.72
633.61
651.03
661.62
661.62
$ 145.89
229.75
229.75
229.75
229.75
230.67
235.26
240.78
249.74
257.09
260.77
266.28
271.79
275.24
278.92
280.75
282.59
284.43
286.27
289.94
293.62
299.13
304.42
311.77
320.96
331.76
344.63
359.10
375.64
391.95
410.33
428.48
448.47
468.69
490.52
512.34
536.01
559.90
585.40
598.04
623.54
645.60
660.07
678.22
689.25
689.25
$ 145.48
229.11
229.11
229.11
229.11
230.03
234.61
240.11
249.04
256.37
260.04
265.54
271.04
274.47
278.14
279.97
281.81
283.64
285.47
289.14
292.80
298.30
303.57
310.90
320.07
330.83
343.67
358.10
374.59
390.86
409.19
427.29
447.22
467.38
489.15
510.92
534.51
558.34
583.77
596.37
621.80
643.80
658.23
676.33
687.33
687.33
$ 141.83
223.35
223.35
223.35
223.35
224.24
228.71
234.07
242.78
249.93
253.50
258.86
264.22
267.57
271.15
272.93
274.72
276.51
278.29
281.87
285.44
290.80
295.94
303.09
312.02
322.52
335.03
349.10
365.18
381.04
398.90
416.55
435.98
455.63
476.85
498.07
521.08
544.30
569.10
581.38
606.17
627.61
641.68
659.33
670.05
670.05
$ 153.51
241.75
241.75
241.75
241.75
242.72
247.55
253.35
262.78
270.52
274.39
280.19
285.99
289.62
293.48
295.42
297.35
299.29
301.22
305.09
308.96
314.76
320.32
328.05
337.72
349.09
362.63
377.86
395.26
412.43
431.77
450.86
471.90
493.17
516.14
539.10
564.00
589.14
615.98
629.28
656.11
679.32
694.55
713.65
725.25
725.25
$ 140.61
221.43
221.43
221.43
221.43
222.32
226.74
232.06
240.69
247.78
251.32
256.64
261.95
265.27
268.82
270.59
272.36
274.13
275.90
279.44
282.99
288.30
293.39
300.48
309.34
319.74
332.15
346.10
362.04
377.76
395.47
412.97
432.23
451.72
472.75
493.79
516.60
539.62
564.20
576.38
600.96
622.22
636.17
653.66
664.29
664.29
$ 142.41
224.27
224.27
224.27
224.27
225.17
229.65
235.03
243.78
250.96
254.55
259.93
265.31
268.68
272.26
274.06
275.85
277.65
279.44
283.03
286.62
292.00
297.16
304.33
313.31
323.85
336.41
350.53
366.68
382.60
400.55
418.26
437.78
457.51
478.82
500.12
523.22
546.55
571.44
583.77
608.67
630.20
644.33
662.05
672.81
672.81
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
63
0W38
88380VA0740012
Anthem HealthKeepers Essential Guided Access Plus w/HSA gybb
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 151.27
238.22
238.22
238.22
238.22
239.17
243.94
249.65
258.95
266.57
270.38
276.10
281.81
285.39
289.20
291.10
293.01
294.92
296.82
300.63
304.45
310.16
315.64
323.26
332.79
343.99
357.33
372.34
389.49
406.40
425.46
444.28
465.01
485.97
508.60
531.23
555.77
580.54
606.98
620.09
646.53
669.40
684.41
703.23
714.66
714.66
$ 137.96
217.26
217.26
217.26
217.26
218.13
222.47
227.69
236.16
243.11
246.59
251.80
257.02
260.28
263.75
265.49
267.23
268.97
270.71
274.18
277.66
282.87
287.87
294.82
303.51
313.72
325.89
339.58
355.22
370.65
388.03
405.19
424.09
443.21
463.85
484.49
506.87
529.46
553.58
565.53
589.64
610.50
624.19
641.35
651.78
651.78
$ 142.86
224.98
224.98
224.98
224.98
225.88
230.38
235.78
244.55
251.75
255.35
260.75
266.15
269.53
273.13
274.93
276.73
278.53
280.33
283.92
287.52
292.92
298.10
305.30
314.30
324.87
337.47
351.64
367.84
383.82
401.81
419.59
439.16
458.96
480.33
501.71
524.88
548.28
573.25
585.62
610.60
632.19
646.37
664.14
674.94
674.94
$ 137.62
216.73
216.73
216.73
216.73
217.60
221.93
227.13
235.59
242.52
245.99
251.19
256.39
259.64
263.11
264.84
266.58
268.31
270.05
273.51
276.98
282.18
287.17
294.10
302.77
312.96
325.10
338.75
354.35
369.74
387.08
404.20
423.06
442.13
462.72
483.31
505.63
528.17
552.23
564.15
588.21
609.01
622.67
639.79
650.19
650.19
$ 140.09
220.62
220.62
220.62
220.62
221.50
225.91
231.21
239.81
246.87
250.40
255.70
260.99
264.30
267.83
269.60
271.36
273.13
274.89
278.42
281.95
287.25
292.32
299.38
308.21
318.58
330.93
344.83
360.71
376.38
394.03
411.46
430.65
450.06
471.02
491.98
514.71
537.65
562.14
574.27
598.76
619.94
633.84
651.27
661.86
661.86
$ 140.07
220.59
220.59
220.59
220.59
221.47
225.88
231.18
239.78
246.84
250.37
255.66
260.96
264.27
267.80
269.56
271.33
273.09
274.86
278.38
281.91
287.21
292.28
299.34
308.16
318.53
330.89
344.78
360.66
376.33
393.97
411.40
430.59
450.00
470.96
491.92
514.64
537.58
562.06
574.20
598.68
619.86
633.76
651.18
661.77
661.77
$ 145.93
229.81
229.81
229.81
229.81
230.73
235.33
240.84
249.80
257.16
260.83
266.35
271.87
275.31
278.99
280.83
282.67
284.50
286.34
290.02
293.70
299.21
304.50
311.85
321.04
331.85
344.72
359.19
375.74
392.06
410.44
428.60
448.59
468.81
490.64
512.48
536.15
560.05
585.56
598.20
623.70
645.77
660.24
678.40
689.43
689.43
$ 145.52
229.17
229.17
229.17
229.17
230.09
234.67
240.17
249.11
256.44
260.11
265.61
271.11
274.55
278.21
280.05
281.88
283.71
285.55
289.21
292.88
298.38
303.65
310.98
320.15
330.92
343.76
358.19
374.69
390.96
409.30
427.40
447.34
467.51
489.28
511.05
534.65
558.49
583.93
596.53
621.97
643.97
658.41
676.51
687.51
687.51
$ 141.87
223.41
223.41
223.41
223.41
224.30
228.77
234.13
242.85
250.00
253.57
258.93
264.29
267.65
271.22
273.01
274.79
276.58
278.37
281.94
285.52
290.88
296.02
303.17
312.10
322.60
335.12
349.19
365.28
381.14
399.01
416.66
436.10
455.76
476.98
498.20
521.22
544.45
569.25
581.54
606.33
627.78
641.86
659.51
670.23
670.23
$ 153.55
241.81
241.81
241.81
241.81
242.78
247.61
253.42
262.85
270.59
274.45
280.26
286.06
289.69
293.56
295.49
297.43
299.36
301.30
305.16
309.03
314.84
320.40
328.14
337.81
349.17
362.72
377.95
395.36
412.53
431.87
450.98
472.01
493.29
516.26
539.24
564.14
589.29
616.13
629.43
656.27
679.49
694.72
713.82
725.43
725.43
$ 140.65
221.49
221.49
221.49
221.49
222.38
226.81
232.12
240.76
247.85
251.39
256.71
262.02
265.35
268.89
270.66
272.43
274.20
275.98
279.52
283.06
288.38
293.47
300.56
309.42
319.83
332.24
346.19
362.14
377.86
395.58
413.08
432.35
451.84
472.88
493.92
516.74
539.77
564.36
576.54
601.12
622.39
636.34
653.84
664.47
664.47
$ 142.44
224.32
224.32
224.32
224.32
225.22
229.70
235.09
243.84
251.01
254.60
259.99
265.37
268.74
272.32
274.12
275.91
277.71
279.50
283.09
286.68
292.06
297.22
304.40
313.38
323.92
336.48
350.61
366.76
382.69
400.64
418.36
437.87
457.61
478.92
500.23
523.34
546.67
571.57
583.90
608.80
630.34
644.47
662.19
672.96
672.96
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
64
0W39
88380VA0740015
Anthem HealthKeepers Essential Guided Access Plus w/HRA gpcb
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 136.58
215.08
215.08
215.08
215.08
215.94
220.24
225.40
233.79
240.67
244.12
249.28
254.44
257.67
261.11
262.83
264.55
266.27
267.99
271.43
274.87
280.03
284.98
291.86
300.47
310.58
322.62
336.17
351.66
366.93
384.13
401.12
419.84
438.76
459.20
479.63
501.78
524.15
548.02
559.85
583.73
604.37
617.92
634.92
645.24
645.24
$ 124.56
196.15
196.15
196.15
196.15
196.93
200.86
205.57
213.22
219.49
222.63
227.34
232.05
234.99
238.13
239.70
241.26
242.83
244.40
247.54
250.68
255.39
259.90
266.18
274.02
283.24
294.23
306.58
320.71
334.63
350.32
365.82
382.88
400.15
418.78
437.41
457.62
478.02
499.79
510.58
532.35
551.18
563.54
579.03
588.45
588.45
$ 128.99
203.13
203.13
203.13
203.13
203.94
208.01
212.88
220.80
227.30
230.55
235.43
240.30
243.35
246.60
248.22
249.85
251.47
253.10
256.35
259.60
264.48
269.15
275.65
283.77
293.32
304.70
317.49
332.12
346.54
362.79
378.84
396.51
414.39
433.68
452.98
473.90
495.03
517.58
528.75
551.29
570.80
583.59
599.64
609.39
609.39
$ 124.26
195.68
195.68
195.68
195.68
196.46
200.38
205.07
212.70
218.97
222.10
226.79
231.49
234.42
237.56
239.12
240.69
242.25
243.82
246.95
250.08
254.78
259.28
265.54
273.36
282.56
293.52
305.85
319.94
333.83
349.48
364.94
381.97
399.19
417.78
436.37
456.52
476.87
498.59
509.36
531.08
549.86
562.19
577.65
587.04
587.04
$ 126.49
199.19
199.19
199.19
199.19
199.99
203.97
208.75
216.52
222.89
226.08
230.86
235.64
238.63
241.82
243.41
245.00
246.60
248.19
251.38
254.56
259.35
263.93
270.30
278.27
287.63
298.79
311.33
325.68
339.82
355.75
371.49
388.82
406.35
425.27
444.19
464.71
485.43
507.54
518.49
540.60
559.72
572.27
588.01
597.57
597.57
$ 126.47
199.17
199.17
199.17
199.17
199.97
203.95
208.73
216.50
222.87
226.06
230.84
235.62
238.61
241.79
243.39
244.98
246.57
248.17
251.35
254.54
259.32
263.90
270.27
278.24
287.60
298.76
311.30
325.64
339.78
355.72
371.45
388.78
406.31
425.23
444.15
464.66
485.38
507.49
518.44
540.55
559.67
572.22
587.95
597.51
597.51
$ 131.75
207.48
207.48
207.48
207.48
208.31
212.46
217.44
225.53
232.17
235.49
240.47
245.45
248.56
251.88
253.54
255.20
256.86
258.52
261.84
265.16
270.14
274.91
281.55
289.85
299.60
311.22
324.29
339.23
353.96
370.56
386.95
405.00
423.26
442.97
462.68
484.05
505.63
528.66
540.07
563.10
583.02
596.09
612.48
622.44
622.44
$ 131.39
206.91
206.91
206.91
206.91
207.74
211.88
216.84
224.91
231.53
234.84
239.81
244.77
247.88
251.19
252.84
254.50
256.15
257.81
261.12
264.43
269.40
274.16
280.78
289.05
298.78
310.37
323.40
338.30
352.99
369.54
385.89
403.89
422.10
441.75
461.41
482.72
504.24
527.21
538.59
561.55
581.42
594.45
610.80
620.73
620.73
$ 128.09
201.71
201.71
201.71
201.71
202.52
206.55
211.39
219.26
225.71
228.94
233.78
238.62
241.65
244.88
246.49
248.10
249.72
251.33
254.56
257.79
262.63
267.27
273.72
281.79
291.27
302.57
315.27
329.80
344.12
360.25
376.19
393.74
411.49
430.65
449.81
470.59
491.57
513.96
525.05
547.44
566.81
579.51
595.45
605.13
605.13
$ 138.63
218.32
218.32
218.32
218.32
219.19
223.56
228.80
237.31
244.30
247.79
253.03
258.27
261.55
265.04
266.79
268.53
270.28
272.03
275.52
279.01
284.25
289.27
296.26
304.99
315.25
327.48
341.23
356.95
372.45
389.92
407.17
426.16
445.37
466.11
486.85
509.34
532.05
556.28
568.29
592.52
613.48
627.23
644.48
654.96
654.96
$ 126.98
199.97
199.97
199.97
199.97
200.77
204.77
209.57
217.37
223.77
226.97
231.77
236.56
239.56
242.76
244.36
245.96
247.56
249.16
252.36
255.56
260.36
264.96
271.36
279.36
288.76
299.96
312.55
326.95
341.15
357.15
372.94
390.34
407.94
426.94
445.93
466.53
487.33
509.52
520.52
542.72
561.92
574.51
590.31
599.91
599.91
$ 128.61
202.53
202.53
202.53
202.53
203.34
207.39
212.25
220.15
226.63
229.87
234.73
239.59
242.63
245.87
247.49
249.11
250.73
252.35
255.59
258.83
263.69
268.35
274.83
282.93
292.45
303.80
316.55
331.14
345.52
361.72
377.72
395.34
413.16
432.40
451.64
472.50
493.57
516.05
527.19
549.67
569.11
581.87
597.87
607.59
607.59
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
65
0SPC
88380VA0740045
Anthem HealthKeepers Essential DirectAccess w/HSA gjsa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 167.90
264.41
264.41
264.41
264.41
265.47
270.76
277.10
287.41
295.87
300.11
306.45
312.80
316.76
320.99
323.11
325.22
327.34
329.45
333.69
337.92
344.26
350.34
358.80
369.38
381.81
396.62
413.27
432.31
451.08
472.24
493.12
516.13
539.40
564.52
589.63
616.87
644.37
673.72
688.26
717.61
742.99
759.65
780.54
793.23
793.23
$ 153.12
241.14
241.14
241.14
241.14
242.10
246.93
252.71
262.12
269.84
273.69
279.48
285.27
288.89
292.74
294.67
296.60
298.53
300.46
304.32
308.18
313.96
319.51
327.23
336.87
348.21
361.71
376.90
394.26
411.38
430.68
449.73
470.71
491.93
514.83
537.74
562.58
587.66
614.42
627.69
654.45
677.60
692.80
711.85
723.42
723.42
$ 158.57
249.72
249.72
249.72
249.72
250.72
255.71
261.71
271.45
279.44
283.43
289.43
295.42
299.16
303.16
305.16
307.16
309.15
311.15
315.15
319.14
325.14
330.88
338.87
348.86
360.60
374.58
390.31
408.29
426.02
446.00
465.73
487.45
509.43
533.15
556.88
582.60
608.57
636.29
650.02
677.74
701.71
717.45
737.17
749.16
749.16
$ 152.76
240.56
240.56
240.56
240.56
241.52
246.33
252.11
261.49
269.19
273.04
278.81
284.58
288.19
292.04
293.96
295.89
297.81
299.74
303.59
307.44
313.21
318.74
326.44
336.06
347.37
360.84
376.00
393.32
410.40
429.64
448.64
469.57
490.74
513.60
536.45
561.23
586.24
612.95
626.18
652.88
675.97
691.13
710.13
721.68
721.68
$ 155.49
244.87
244.87
244.87
244.87
245.85
250.75
256.62
266.17
274.01
277.93
283.80
289.68
293.35
297.27
299.23
301.19
303.15
305.11
309.03
312.94
318.82
324.45
332.29
342.08
353.59
367.31
382.73
400.36
417.75
437.34
456.68
477.99
499.53
522.80
546.06
571.28
596.75
623.93
637.40
664.58
688.08
703.51
722.86
734.61
734.61
$ 155.48
244.85
244.85
244.85
244.85
245.83
250.73
256.60
266.15
273.99
277.90
283.78
289.66
293.33
297.25
299.21
301.17
303.12
305.08
309.00
312.92
318.79
324.43
332.26
342.06
353.56
367.28
382.70
400.33
417.71
437.30
456.65
477.95
499.49
522.75
546.02
571.24
596.70
623.88
637.34
664.52
688.03
703.45
722.80
734.55
734.55
$ 161.97
255.07
255.07
255.07
255.07
256.09
261.19
267.31
277.26
285.42
289.50
295.63
301.75
305.57
309.65
311.70
313.74
315.78
317.82
321.90
325.98
332.10
337.97
346.13
356.33
368.32
382.61
398.67
417.04
435.15
455.56
475.71
497.90
520.34
544.57
568.81
595.08
621.61
649.92
663.95
692.26
716.75
732.82
752.97
765.21
765.21
$ 161.52
254.36
254.36
254.36
254.36
255.38
260.46
266.57
276.49
284.63
288.70
294.80
300.91
304.72
308.79
310.83
312.86
314.90
316.93
321.00
325.07
331.18
337.03
345.17
355.34
367.30
381.54
397.56
415.88
433.94
454.29
474.38
496.51
518.89
543.06
567.22
593.42
619.88
648.11
662.10
690.33
714.75
730.78
750.87
763.08
763.08
$ 157.46
247.97
247.97
247.97
247.97
248.96
253.92
259.87
269.54
277.48
281.45
287.40
293.35
297.07
301.04
303.02
305.00
306.99
308.97
312.94
316.91
322.86
328.56
336.50
346.41
358.07
371.96
387.58
405.43
423.04
442.87
462.46
484.04
505.86
529.42
552.97
578.51
604.30
631.83
645.47
672.99
696.80
712.42
732.01
743.91
743.91
$ 170.43
268.39
268.39
268.39
268.39
269.46
274.83
281.27
291.74
300.33
304.62
311.06
317.51
321.53
325.83
327.97
330.12
332.27
334.41
338.71
343.00
349.44
355.62
364.21
374.94
387.56
402.59
419.49
438.82
457.87
479.34
500.55
523.90
547.52
573.01
598.51
626.15
654.07
683.86
698.62
728.41
754.18
771.08
792.29
805.17
805.17
$ 156.10
245.83
245.83
245.83
245.83
246.81
251.73
257.63
267.22
275.08
279.02
284.92
290.82
294.50
298.44
300.40
302.37
304.34
306.30
310.24
314.17
320.07
325.72
333.59
343.42
354.98
368.75
384.23
401.93
419.39
439.05
458.47
479.86
501.49
524.85
548.20
573.52
599.09
626.37
639.90
667.18
690.78
706.27
725.69
737.49
737.49
$ 158.10
248.98
248.98
248.98
248.98
249.98
254.96
260.93
270.64
278.61
282.59
288.57
294.54
298.28
302.26
304.25
306.25
308.24
310.23
314.21
318.20
324.17
329.90
337.87
347.83
359.53
373.47
389.16
407.08
424.76
444.68
464.35
486.01
507.92
531.57
555.23
580.87
606.76
634.40
648.09
675.73
699.63
715.32
734.99
746.94
746.94
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
66
0SPE
88380VA0740046
Anthem HealthKeepers Essential DirectAccess w/HSA gpsa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 155.23
244.46
244.46
244.46
244.46
245.44
250.33
256.19
265.73
273.55
277.46
283.33
289.20
292.86
296.77
298.73
300.69
302.64
304.60
308.51
312.42
318.29
323.91
331.73
341.51
353.00
366.69
382.09
399.69
417.05
436.61
455.92
477.19
498.70
521.92
545.15
570.33
595.75
622.88
636.33
663.46
686.93
702.33
721.65
733.38
733.38
$ 141.57
222.95
222.95
222.95
222.95
223.84
228.30
233.65
242.35
249.48
253.05
258.40
263.75
267.09
270.66
272.44
274.23
276.01
277.80
281.36
284.93
290.28
295.41
302.54
311.46
321.94
334.43
348.47
364.52
380.35
398.19
415.80
435.20
454.82
476.00
497.18
520.14
543.33
568.08
580.34
605.09
626.49
640.54
658.15
668.85
668.85
$ 146.61
230.88
230.88
230.88
230.88
231.80
236.42
241.96
250.97
258.35
262.05
267.59
273.13
276.59
280.29
282.14
283.98
285.83
287.68
291.37
295.06
300.61
305.92
313.30
322.54
333.39
346.32
360.87
377.49
393.88
412.35
430.59
450.68
471.00
492.93
514.86
538.64
562.65
588.28
600.98
626.61
648.77
663.32
681.56
692.64
692.64
$ 141.23
222.41
222.41
222.41
222.41
223.30
227.75
233.09
241.76
248.88
252.44
257.77
263.11
266.45
270.01
271.79
273.56
275.34
277.12
280.68
284.24
289.58
294.69
301.81
310.71
321.16
333.62
347.63
363.64
379.43
397.22
414.79
434.14
453.72
474.85
495.97
518.88
542.01
566.70
578.93
603.62
624.97
638.98
656.55
667.23
667.23
$ 143.76
226.40
226.40
226.40
226.40
227.31
231.83
237.27
246.10
253.34
256.96
262.40
267.83
271.23
274.85
276.66
278.47
280.28
282.09
285.72
289.34
294.77
299.98
307.22
316.28
326.92
339.60
353.86
370.16
386.24
404.35
422.24
441.93
461.86
483.36
504.87
528.19
551.74
576.87
589.32
614.45
636.18
650.45
668.33
679.20
679.20
$ 143.75
226.38
226.38
226.38
226.38
227.29
231.81
237.25
246.08
253.32
256.94
262.37
267.81
271.20
274.83
276.64
278.45
280.26
282.07
285.69
289.31
294.75
299.95
307.20
316.25
326.89
339.57
353.83
370.13
386.20
404.31
422.20
441.89
461.82
483.32
504.83
528.14
551.69
576.82
589.27
614.40
636.13
650.39
668.27
679.14
679.14
$ 149.75
235.83
235.83
235.83
235.83
236.77
241.49
247.15
256.35
263.89
267.67
273.33
278.99
282.52
286.30
288.18
290.07
291.96
293.84
297.62
301.39
307.05
312.47
320.02
329.45
340.54
353.75
368.60
385.58
402.33
421.19
439.82
460.34
481.09
503.50
525.90
550.19
574.72
600.89
613.87
640.04
662.68
677.54
696.17
707.49
707.49
$ 149.33
235.17
235.17
235.17
235.17
236.11
240.81
246.46
255.63
263.16
266.92
272.56
278.21
281.73
285.50
287.38
289.26
291.14
293.02
296.78
300.55
306.19
311.60
319.13
328.53
339.59
352.76
367.57
384.50
401.20
420.01
438.59
459.05
479.75
502.09
524.43
548.65
573.11
599.21
612.15
638.25
660.83
675.64
694.22
705.51
705.51
$ 145.58
229.26
229.26
229.26
229.26
230.18
234.76
240.26
249.21
256.54
260.21
265.71
271.21
274.65
278.32
280.16
281.99
283.82
285.66
289.33
292.99
298.50
303.77
311.11
320.28
331.05
343.89
358.33
374.84
391.12
409.46
427.57
447.52
467.69
489.47
511.25
534.86
558.71
584.15
596.76
622.21
644.22
658.66
676.78
687.78
687.78
$ 157.57
248.14
248.14
248.14
248.14
249.13
254.10
260.05
269.73
277.67
281.64
287.59
293.55
297.27
301.24
303.23
305.21
307.20
309.18
313.15
317.12
323.08
328.79
336.73
346.65
358.31
372.21
387.84
405.71
423.33
443.18
462.78
484.37
506.21
529.78
553.35
578.91
604.72
632.26
645.91
673.45
697.27
712.91
732.51
744.42
744.42
$ 144.33
227.29
227.29
227.29
227.29
228.20
232.74
238.20
247.06
254.34
257.97
263.43
268.88
272.29
275.93
277.75
279.57
281.39
283.20
286.84
290.48
295.93
301.16
308.43
317.52
328.21
340.94
355.25
371.62
387.76
405.94
423.90
443.67
463.67
485.26
506.86
530.27
553.91
579.13
591.64
616.87
638.68
653.00
670.96
681.87
681.87
$ 146.18
230.20
230.20
230.20
230.20
231.12
235.72
241.25
250.23
257.59
261.28
266.80
272.33
275.78
279.46
281.30
283.15
284.99
286.83
290.51
294.20
299.72
305.02
312.38
321.59
332.41
345.30
359.80
376.38
392.72
411.14
429.32
449.35
469.61
491.48
513.35
537.06
561.00
586.55
599.21
624.76
646.86
661.36
679.55
690.60
690.60
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
67
0SPG
88380VA0740047
Anthem HealthKeepers Essential DirectAccess w/HRA ggta
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 141.40
222.68
222.68
222.68
222.68
223.57
228.02
233.37
242.05
249.18
252.74
258.09
263.43
266.77
270.33
272.11
273.90
275.68
277.46
281.02
284.59
289.93
295.05
302.18
311.08
321.55
334.02
348.05
364.08
379.89
397.71
415.30
434.67
454.27
475.42
496.58
519.51
542.67
567.39
579.64
604.35
625.73
639.76
657.35
668.04
668.04
$ 128.96
203.09
203.09
203.09
203.09
203.90
207.96
212.84
220.76
227.26
230.51
235.38
240.26
243.30
246.55
248.18
249.80
251.43
253.05
256.30
259.55
264.42
269.09
275.59
283.72
293.26
304.64
317.43
332.05
346.47
362.72
378.76
396.43
414.30
433.60
452.89
473.81
494.93
517.47
528.64
551.19
570.68
583.48
599.52
609.27
609.27
$ 133.55
210.31
210.31
210.31
210.31
211.15
215.36
220.40
228.61
235.34
238.70
243.75
248.80
251.95
255.32
257.00
258.68
260.36
262.05
265.41
268.78
273.82
278.66
285.39
293.80
303.69
315.47
328.71
343.86
358.79
375.61
392.23
410.53
429.03
449.01
468.99
490.65
512.53
535.87
547.44
570.78
590.97
604.22
620.84
630.93
630.93
$ 128.65
202.60
202.60
202.60
202.60
203.41
207.46
212.32
220.23
226.71
229.95
234.81
239.68
242.71
245.96
247.58
249.20
250.82
252.44
255.68
258.92
263.79
268.45
274.93
283.03
292.55
303.90
316.66
331.25
345.64
361.84
377.85
395.48
413.30
432.55
451.80
472.67
493.74
516.22
527.37
549.86
569.31
582.07
598.08
607.80
607.80
$ 130.96
206.23
206.23
206.23
206.23
207.05
211.18
216.13
224.17
230.77
234.07
239.02
243.97
247.06
250.36
252.01
253.66
255.31
256.96
260.26
263.56
268.51
273.25
279.85
288.10
297.80
309.35
322.34
337.19
351.83
368.33
384.62
402.56
420.71
440.30
459.89
481.13
502.58
525.47
536.82
559.71
579.51
592.50
608.79
618.69
618.69
$ 130.94
206.21
206.21
206.21
206.21
207.03
211.16
216.11
224.15
230.75
234.05
239.00
243.95
247.04
250.34
251.99
253.64
255.29
256.94
260.24
263.54
268.49
273.23
279.83
288.08
297.77
309.32
322.31
337.15
351.79
368.29
384.58
402.52
420.67
440.26
459.85
481.09
502.53
525.42
536.76
559.65
579.45
592.44
608.73
618.63
618.63
$ 136.41
214.82
214.82
214.82
214.82
215.68
219.98
225.13
233.51
240.38
243.82
248.98
254.13
257.35
260.79
262.51
264.23
265.95
267.67
271.10
274.54
279.70
284.64
291.51
300.10
310.20
322.23
335.76
351.23
366.48
383.67
400.64
419.33
438.23
458.64
479.05
501.18
523.52
547.36
559.18
583.02
603.64
617.18
634.15
644.46
644.46
$ 136.03
214.22
214.22
214.22
214.22
215.08
219.36
224.50
232.86
239.71
243.14
248.28
253.42
256.64
260.06
261.78
263.49
265.20
266.92
270.35
273.77
278.91
283.84
290.70
299.27
309.33
321.33
334.83
350.25
365.46
382.60
399.52
418.16
437.01
457.36
477.71
499.78
522.05
545.83
557.61
581.39
601.96
615.45
632.38
642.66
642.66
$ 132.61
208.84
208.84
208.84
208.84
209.68
213.85
218.86
227.01
233.69
237.03
242.05
247.06
250.19
253.53
255.20
256.87
258.54
260.21
263.56
266.90
271.91
276.71
283.40
291.75
301.56
313.26
326.42
341.45
356.28
372.99
389.49
407.66
426.03
445.87
465.71
487.22
508.94
532.12
543.61
566.79
586.84
600.00
616.50
626.52
626.52
$ 143.54
226.04
226.04
226.04
226.04
226.94
231.46
236.89
245.71
252.94
256.56
261.98
267.41
270.80
274.41
276.22
278.03
279.84
281.65
285.26
288.88
294.30
299.50
306.74
315.78
326.40
339.06
353.30
369.58
385.62
403.71
421.56
441.23
461.12
482.60
504.07
527.35
550.86
575.95
588.38
613.47
635.17
649.41
667.27
678.12
678.12
$ 131.47
207.04
207.04
207.04
207.04
207.87
212.01
216.98
225.05
231.68
234.99
239.96
244.93
248.03
251.35
253.00
254.66
256.32
257.97
261.28
264.60
269.57
274.33
280.95
289.23
298.97
310.56
323.60
338.51
353.21
369.77
386.13
404.14
422.36
442.03
461.70
483.02
504.56
527.54
538.93
561.91
581.78
594.83
611.18
621.12
621.12
$ 133.15
209.69
209.69
209.69
209.69
210.53
214.72
219.76
227.93
234.64
238.00
243.03
248.06
251.21
254.56
256.24
257.92
259.60
261.27
264.63
267.98
273.02
277.84
284.55
292.94
302.79
314.54
327.75
342.84
357.73
374.51
391.07
409.31
427.77
447.69
467.61
489.21
511.01
534.29
545.82
569.10
589.23
602.44
619.00
629.07
629.07
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
68
0SPJ
88380VA0740048
Anthem HealthKeepers Essential DirectAccess w/HSA gjta
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 167.31
263.48
263.48
263.48
263.48
264.53
269.80
276.13
286.40
294.83
299.05
305.37
311.70
315.65
319.86
321.97
324.08
326.19
328.30
332.51
336.73
343.05
349.11
357.54
368.08
380.47
395.22
411.82
430.79
449.50
470.58
491.39
514.31
537.50
562.53
587.56
614.70
642.10
671.35
685.84
715.08
740.38
756.98
777.79
790.44
790.44
$ 152.58
240.29
240.29
240.29
240.29
241.25
246.06
251.82
261.20
268.88
272.73
278.50
284.26
287.87
291.71
293.63
295.56
297.48
299.40
303.25
307.09
312.86
318.38
326.07
335.69
346.98
360.44
375.57
392.87
409.93
429.16
448.14
469.05
490.19
513.02
535.85
560.60
585.59
612.26
625.47
652.15
675.21
690.35
709.34
720.87
720.87
$ 158.01
248.84
248.84
248.84
248.84
249.84
254.81
260.78
270.49
278.45
282.43
288.41
294.38
298.11
302.09
304.08
306.07
308.06
310.05
314.04
318.02
323.99
329.71
337.68
347.63
359.32
373.26
388.94
406.85
424.52
444.43
464.09
485.74
507.63
531.27
554.91
580.54
606.42
634.04
647.73
675.35
699.24
714.92
734.58
746.52
746.52
$ 152.22
239.71
239.71
239.71
239.71
240.67
245.46
251.22
260.56
268.24
272.07
277.82
283.58
287.17
291.01
292.93
294.84
296.76
298.68
302.51
306.35
312.10
317.62
325.29
334.87
346.14
359.57
374.67
391.93
408.95
428.12
447.06
467.91
489.01
511.78
534.55
559.24
584.17
610.78
623.97
650.57
673.59
688.69
707.62
719.13
719.13
$ 154.95
244.01
244.01
244.01
244.01
244.99
249.87
255.72
265.24
273.05
276.95
282.81
288.66
292.32
296.23
298.18
300.13
302.08
304.04
307.94
311.84
317.70
323.31
331.12
340.88
352.35
366.02
381.39
398.96
416.28
435.80
455.08
476.31
497.78
520.96
544.14
569.28
594.65
621.74
635.16
662.24
685.67
701.04
720.32
732.03
732.03
$ 154.93
243.99
243.99
243.99
243.99
244.97
249.85
255.70
265.22
273.02
276.93
282.78
288.64
292.30
296.20
298.16
300.11
302.06
304.01
307.92
311.82
317.67
323.29
331.09
340.85
352.32
365.99
381.36
398.92
416.25
435.77
455.04
476.27
497.74
520.92
544.10
569.23
594.60
621.69
635.11
662.19
685.61
700.98
720.26
731.97
731.97
$ 161.40
254.17
254.17
254.17
254.17
255.19
260.27
266.37
276.28
284.42
288.48
294.58
300.68
304.50
308.56
310.60
312.63
314.66
316.70
320.76
324.83
330.93
336.78
344.91
355.08
367.02
381.26
397.27
415.57
433.61
453.95
474.03
496.14
518.51
542.65
566.80
592.98
619.41
647.63
661.60
689.82
714.22
730.23
750.31
762.51
762.51
$ 160.95
253.47
253.47
253.47
253.47
254.48
259.55
265.64
275.52
283.63
287.69
293.77
299.86
303.66
307.71
309.74
311.77
313.80
315.82
319.88
323.93
330.02
335.85
343.96
354.10
366.01
380.21
396.17
414.42
432.42
452.70
472.72
494.77
517.08
541.16
565.24
591.35
617.71
645.84
659.78
687.92
712.25
728.22
748.24
760.41
760.41
$ 156.90
247.09
247.09
247.09
247.09
248.08
253.02
258.95
268.59
276.49
280.45
286.38
292.31
296.01
299.97
301.94
303.92
305.90
307.87
311.83
315.78
321.71
327.39
335.30
345.18
356.80
370.64
386.20
403.99
421.54
441.30
460.82
482.32
504.06
527.54
551.01
576.46
602.16
629.59
643.18
670.60
694.32
709.89
729.41
741.27
741.27
$ 169.83
267.45
267.45
267.45
267.45
268.52
273.87
280.29
290.72
299.28
303.56
309.97
316.39
320.41
324.68
326.82
328.96
331.10
333.24
337.52
341.80
348.22
354.37
362.93
373.63
386.20
401.18
418.02
437.28
456.27
477.67
498.79
522.06
545.60
571.01
596.41
623.96
651.78
681.46
696.17
725.86
751.53
768.38
789.51
802.35
802.35
$ 155.56
244.97
244.97
244.97
244.97
245.95
250.85
256.73
266.28
274.12
278.04
283.92
289.80
293.47
297.39
299.35
301.31
303.27
305.23
309.15
313.07
318.95
324.59
332.42
342.22
353.74
367.46
382.89
400.53
417.92
437.52
456.87
478.18
499.74
523.01
546.28
571.52
596.99
624.18
637.66
664.85
688.37
703.80
723.15
734.91
734.91
$ 157.55
248.11
248.11
248.11
248.11
249.10
254.06
260.02
269.70
277.64
281.60
287.56
293.51
297.24
301.21
303.19
305.18
307.16
309.15
313.11
317.08
323.04
328.75
336.69
346.61
358.27
372.17
387.80
405.66
423.28
443.12
462.73
484.31
506.14
529.71
553.29
578.84
604.64
632.18
645.83
673.37
697.19
712.82
732.42
744.33
744.33
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
69
0SPL
88380VA0740049
Anthem HealthKeepers Essential DirectAccess w/HSA gkta
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 154.05
242.60
242.60
242.60
242.60
243.57
248.42
254.24
263.71
271.47
275.35
281.17
287.00
290.63
294.52
296.46
298.40
300.34
302.28
306.16
310.04
315.87
321.45
329.21
338.91
350.31
363.90
379.18
396.65
413.88
433.28
452.45
473.56
494.90
517.95
541.00
565.99
591.22
618.14
631.49
658.42
681.71
696.99
716.16
727.80
727.80
$ 140.50
221.26
221.26
221.26
221.26
222.15
226.57
231.88
240.51
247.59
251.13
256.44
261.75
265.07
268.61
270.38
272.15
273.92
275.69
279.23
282.77
288.08
293.17
300.25
309.10
319.50
331.89
345.83
361.76
377.47
395.17
412.65
431.90
451.37
472.39
493.41
516.20
539.21
563.77
575.94
600.50
621.74
635.68
653.16
663.78
663.78
$ 145.49
229.12
229.12
229.12
229.12
230.04
234.62
240.12
249.05
256.39
260.05
265.55
271.05
274.49
278.15
279.98
281.82
283.65
285.48
289.15
292.82
298.31
303.58
310.92
320.08
330.85
343.68
358.11
374.61
390.88
409.21
427.31
447.24
467.40
489.17
510.94
534.54
558.37
583.80
596.40
621.83
643.83
658.26
676.36
687.36
687.36
$ 140.16
220.72
220.72
220.72
220.72
221.60
226.02
231.31
239.92
246.99
250.52
255.81
261.11
264.42
267.95
269.72
271.49
273.25
275.02
278.55
282.08
287.38
292.45
299.52
308.35
318.72
331.08
344.99
360.88
376.55
394.21
411.64
430.85
450.27
471.24
492.21
514.94
537.89
562.39
574.53
599.03
620.22
634.13
651.57
662.16
662.16
$ 142.67
224.68
224.68
224.68
224.68
225.58
230.07
235.46
244.23
251.42
255.01
260.40
265.80
269.17
272.76
274.56
276.36
278.15
279.95
283.55
287.14
292.53
297.70
304.89
313.88
324.44
337.02
351.17
367.35
383.30
401.28
419.03
438.58
458.35
479.69
501.04
524.18
547.55
572.48
584.84
609.78
631.35
645.51
663.26
674.04
674.04
$ 142.65
224.65
224.65
224.65
224.65
225.55
230.04
235.43
244.19
251.38
254.98
260.37
265.76
269.13
272.73
274.52
276.32
278.12
279.91
283.51
287.10
292.49
297.66
304.85
313.84
324.39
336.98
351.13
367.30
383.25
401.22
418.97
438.52
458.29
479.63
500.97
524.11
547.47
572.41
584.76
609.70
631.27
645.42
663.17
673.95
673.95
$ 148.62
234.04
234.04
234.04
234.04
234.98
239.66
245.27
254.40
261.89
265.64
271.25
276.87
280.38
284.12
286.00
287.87
289.74
291.61
295.36
299.10
304.72
310.10
317.59
326.95
337.95
351.06
365.80
382.66
399.27
418.00
436.48
456.85
477.44
499.68
521.91
546.02
570.36
596.33
609.21
635.18
657.65
672.40
690.89
702.12
702.12
$ 148.20
233.38
233.38
233.38
233.38
234.31
238.98
244.58
253.68
261.15
264.89
270.49
276.09
279.59
283.32
285.19
287.06
288.92
290.79
294.53
298.26
303.86
309.23
316.70
326.03
337.00
350.07
364.77
381.58
398.15
416.82
435.25
455.56
476.10
498.27
520.44
544.48
568.75
594.65
607.49
633.39
655.80
670.50
688.94
700.14
700.14
$ 144.48
227.52
227.52
227.52
227.52
228.43
232.98
238.44
247.31
254.59
258.24
263.70
269.16
272.57
276.21
278.03
279.85
281.67
283.49
287.13
290.77
296.23
301.46
308.74
317.85
328.54
341.28
355.61
372.00
388.15
406.35
424.32
444.12
464.14
485.76
507.37
530.80
554.47
579.72
592.23
617.49
639.33
653.66
671.64
682.56
682.56
$ 156.38
246.26
246.26
246.26
246.26
247.25
252.17
258.08
267.68
275.56
279.51
285.42
291.33
295.02
298.96
300.93
302.90
304.87
306.84
310.78
314.72
320.63
326.29
334.17
344.03
355.60
369.39
384.90
402.64
420.12
439.82
459.27
480.70
502.37
525.77
549.16
574.52
600.14
627.47
641.01
668.35
691.99
707.50
726.96
738.78
738.78
$ 143.23
225.56
225.56
225.56
225.56
226.46
230.97
236.39
245.18
252.40
256.01
261.42
266.84
270.22
273.83
275.63
277.44
279.24
281.05
284.66
288.27
293.68
298.87
306.08
315.11
325.71
338.34
352.55
368.79
384.81
402.85
420.67
440.29
460.14
481.57
503.00
526.23
549.69
574.73
587.13
612.17
633.82
648.03
665.85
676.68
676.68
$ 145.07
228.45
228.45
228.45
228.45
229.36
233.93
239.42
248.33
255.64
259.29
264.77
270.26
273.68
277.34
279.17
280.99
282.82
284.65
288.30
291.96
297.44
302.70
310.01
319.14
329.88
342.68
357.07
373.52
389.74
408.01
426.06
445.93
466.04
487.74
509.44
532.97
556.73
582.09
594.66
620.01
641.94
656.34
674.38
685.35
685.35
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
70
0SN1
88380VA0740044
Anthem HealthKeepers Essential DirectAccess w/HSA gdsa
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 158.68
249.89
249.89
249.89
249.89
250.89
255.89
261.88
271.63
279.63
283.63
289.62
295.62
299.37
303.37
305.37
307.36
309.36
311.36
315.36
319.36
325.36
331.10
339.10
349.10
360.84
374.84
390.58
408.57
426.31
446.30
466.04
487.79
509.78
533.52
557.25
582.99
608.98
636.72
650.46
678.20
702.19
717.93
737.68
749.67
749.67
$ 144.72
227.90
227.90
227.90
227.90
228.81
233.37
238.84
247.73
255.02
258.67
264.14
269.61
273.02
276.67
278.49
280.32
282.14
283.96
287.61
291.26
296.73
301.97
309.26
318.38
329.09
341.85
356.21
372.62
388.80
407.03
425.03
444.86
464.92
486.57
508.22
531.69
555.39
580.69
593.22
618.52
640.40
654.76
672.76
683.70
683.70
$ 149.87
236.01
236.01
236.01
236.01
236.95
241.67
247.34
256.54
264.10
267.87
273.54
279.20
282.74
286.52
288.40
290.29
292.18
294.07
297.84
301.62
307.29
312.71
320.27
329.71
340.80
354.02
368.88
385.88
402.63
421.51
440.16
460.69
481.46
503.88
526.30
550.61
575.16
601.35
614.33
640.53
663.19
678.06
696.70
708.03
708.03
$ 144.37
227.35
227.35
227.35
227.35
228.26
232.81
238.26
247.13
254.40
258.04
263.50
268.96
272.37
276.00
277.82
279.64
281.46
283.28
286.92
290.55
296.01
301.24
308.51
317.61
328.29
341.03
355.35
371.72
387.86
406.05
424.01
443.79
463.79
485.39
506.99
530.41
554.05
579.29
591.79
617.03
638.85
653.18
671.14
682.05
682.05
$ 146.96
231.43
231.43
231.43
231.43
232.36
236.98
242.54
251.56
258.97
262.67
268.23
273.78
277.25
280.96
282.81
284.66
286.51
288.36
292.06
295.77
301.32
306.64
314.05
323.31
334.18
347.15
361.73
378.39
394.82
413.33
431.62
451.75
472.12
494.10
516.09
539.93
563.99
589.68
602.41
628.10
650.32
664.90
683.18
694.29
694.29
$ 146.94
231.40
231.40
231.40
231.40
232.33
236.95
242.51
251.53
258.94
262.64
268.19
273.75
277.22
280.92
282.77
284.62
286.47
288.32
292.03
295.73
301.28
306.61
314.01
323.27
334.14
347.10
361.68
378.34
394.77
413.28
431.56
451.69
472.06
494.04
516.02
539.86
563.92
589.61
602.33
628.02
650.23
664.81
683.09
694.20
694.20
$ 153.08
241.07
241.07
241.07
241.07
242.03
246.86
252.64
262.04
269.76
273.61
279.40
285.19
288.80
292.66
294.59
296.52
298.44
300.37
304.23
308.09
313.87
319.42
327.13
336.77
348.11
361.61
376.79
394.15
411.27
430.55
449.60
470.57
491.78
514.68
537.59
562.42
587.49
614.25
627.51
654.26
677.41
692.59
711.64
723.21
723.21
$ 152.65
240.39
240.39
240.39
240.39
241.35
246.16
251.93
261.30
269.00
272.84
278.61
284.38
287.99
291.83
293.76
295.68
297.60
299.53
303.37
307.22
312.99
318.52
326.21
335.82
347.12
360.59
375.73
393.04
410.11
429.34
448.33
469.24
490.40
513.23
536.07
560.83
585.83
612.51
625.74
652.42
675.50
690.64
709.63
721.17
721.17
$ 148.81
234.35
234.35
234.35
234.35
235.29
239.97
245.60
254.74
262.24
265.99
271.61
277.24
280.75
284.50
286.38
288.25
290.13
292.00
295.75
299.50
305.12
310.51
318.01
327.39
338.40
351.53
366.29
383.16
399.80
418.55
437.06
457.45
478.07
500.34
522.60
546.74
571.11
597.12
610.01
636.03
658.52
673.29
691.80
703.05
703.05
$ 161.07
253.65
253.65
253.65
253.65
254.66
259.74
265.83
275.72
283.83
287.89
293.98
300.07
303.87
307.93
309.96
311.99
314.02
316.05
320.11
324.16
330.25
336.09
344.20
354.35
366.27
380.48
396.45
414.72
432.73
453.02
473.06
495.12
517.45
541.54
565.64
591.77
618.15
646.30
660.25
688.41
712.76
728.74
748.77
760.95
760.95
$ 147.54
232.34
232.34
232.34
232.34
233.27
237.92
243.49
252.55
259.99
263.71
269.28
274.86
278.34
282.06
283.92
285.78
287.64
289.50
293.21
296.93
302.51
307.85
315.29
324.58
335.50
348.51
363.15
379.88
396.37
414.96
433.31
453.53
473.97
496.05
518.12
542.05
566.21
592.00
604.78
630.57
652.88
667.51
685.87
697.02
697.02
$ 149.42
235.31
235.31
235.31
235.31
236.25
240.96
246.60
255.78
263.31
267.08
272.72
278.37
281.90
285.67
287.55
289.43
291.31
293.20
296.96
300.73
306.37
311.79
319.32
328.73
339.79
352.97
367.79
384.73
401.44
420.26
438.85
459.33
480.03
502.39
524.74
548.98
573.45
599.57
612.51
638.63
661.22
676.05
694.64
705.93
705.93
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
71
0YQJ
88380VA0740017
Anthem HealthKeepers Core Guided Access Plus gznb
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 123.06
193.80
193.80
193.80
193.80
194.58
198.45
203.10
210.66
216.86
219.96
224.61
229.27
232.17
235.27
236.82
238.37
239.92
241.47
244.58
247.68
252.33
256.79
262.99
270.74
279.85
290.70
302.91
316.86
330.62
346.13
361.44
378.30
395.35
413.76
432.17
452.14
472.29
493.80
504.46
525.97
544.58
556.79
572.10
581.40
581.40
$ 112.24
176.75
176.75
176.75
176.75
177.46
180.99
185.23
192.13
197.78
200.61
204.85
209.10
211.75
214.57
215.99
217.40
218.82
220.23
223.06
225.89
230.13
234.19
239.85
246.92
255.23
265.13
276.26
288.99
301.54
315.68
329.64
345.02
360.57
377.36
394.15
412.36
430.74
450.36
460.08
479.70
496.67
507.80
521.77
530.25
530.25
$ 116.22
183.03
183.03
183.03
183.03
183.76
187.42
191.82
198.95
204.81
207.74
212.13
216.52
219.27
222.20
223.66
225.13
226.59
228.06
230.98
233.91
238.31
242.51
248.37
255.69
264.30
274.55
286.08
299.25
312.25
326.89
341.35
357.27
373.38
390.77
408.16
427.01
446.04
466.36
476.43
496.74
514.31
525.85
540.30
549.09
549.09
$ 111.96
176.32
176.32
176.32
176.32
177.03
180.55
184.78
191.66
197.30
200.12
204.35
208.59
211.23
214.05
215.46
216.87
218.28
219.69
222.52
225.34
229.57
233.62
239.27
246.32
254.61
264.48
275.59
288.28
300.80
314.91
328.84
344.18
359.69
376.44
393.19
411.35
429.69
449.26
458.96
478.53
495.46
506.57
520.50
528.96
528.96
$ 113.97
179.48
179.48
179.48
179.48
180.20
183.79
188.10
195.09
200.84
203.71
208.02
212.32
215.02
217.89
219.32
220.76
222.20
223.63
226.50
229.38
233.68
237.81
243.55
250.73
259.17
269.22
280.53
293.45
306.19
320.55
334.73
350.34
366.14
383.19
400.24
418.73
437.39
457.32
467.19
487.11
504.34
515.65
529.82
538.44
538.44
$ 113.96
179.46
179.46
179.46
179.46
180.18
183.77
188.07
195.07
200.82
203.69
207.99
212.30
214.99
217.86
219.30
220.74
222.17
223.61
226.48
229.35
233.66
237.78
243.53
250.71
259.14
269.19
280.50
293.42
306.16
320.52
334.69
350.31
366.10
383.15
400.20
418.68
437.34
457.26
467.13
487.05
504.28
515.59
529.77
538.38
538.38
$ 118.71
186.95
186.95
186.95
186.95
187.70
191.44
195.92
203.21
209.20
212.19
216.68
221.16
223.97
226.96
228.45
229.95
231.44
232.94
235.93
238.92
243.41
247.71
253.69
261.17
269.96
280.43
292.20
305.66
318.94
333.89
348.66
364.93
381.38
399.14
416.90
436.15
455.60
476.35
486.63
507.38
525.33
537.11
551.88
560.85
560.85
$ 118.38
186.43
186.43
186.43
186.43
187.18
190.90
195.38
202.65
208.62
211.60
216.07
220.55
223.34
226.33
227.82
229.31
230.80
232.29
235.27
238.26
242.73
247.02
252.99
260.44
269.20
279.65
291.39
304.81
318.05
332.96
347.69
363.91
380.32
398.03
415.74
434.94
454.33
475.02
485.28
505.97
523.87
535.61
550.34
559.29
559.29
$ 115.41
181.75
181.75
181.75
181.75
182.48
186.11
190.47
197.56
203.38
206.29
210.65
215.01
217.74
220.64
222.10
223.55
225.01
226.46
229.37
232.28
236.64
240.82
246.63
253.90
262.45
272.63
284.08
297.16
310.07
324.61
338.96
354.78
370.77
388.04
405.30
424.02
442.92
463.10
473.10
493.27
510.72
522.17
536.53
545.25
545.25
$ 124.92
196.72
196.72
196.72
196.72
197.51
201.44
206.16
213.83
220.13
223.28
228.00
232.72
235.67
238.82
240.39
241.97
243.54
245.11
248.26
251.41
256.13
260.65
266.95
274.82
284.06
295.08
307.47
321.64
335.60
351.34
366.88
384.00
401.31
420.00
438.69
458.95
479.41
501.24
512.06
533.90
552.78
565.18
580.72
590.16
590.16
$ 114.42
180.19
180.19
180.19
180.19
180.91
184.51
188.84
195.87
201.63
204.52
208.84
213.16
215.87
218.75
220.19
221.63
223.08
224.52
227.40
230.28
234.61
238.75
244.52
251.73
260.19
270.29
281.64
294.61
307.40
321.82
336.05
351.73
367.59
384.71
401.82
420.38
439.12
459.12
469.03
489.04
506.33
517.69
531.92
540.57
540.57
$ 115.88
182.49
182.49
182.49
182.49
183.22
186.87
191.25
198.37
204.21
207.13
211.51
215.89
218.62
221.54
223.00
224.46
225.92
227.38
230.30
233.22
237.60
241.80
247.64
254.94
263.52
273.74
285.23
298.37
311.33
325.93
340.34
356.22
372.28
389.62
406.95
425.75
444.73
464.98
475.02
495.28
512.80
524.29
538.71
547.47
547.47
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
72
0W2S
88380VA0740016
Anthem HealthKeepers Core Guided Access Plus gwnb
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 134.90
212.44
212.44
212.44
212.44
213.29
217.54
222.64
230.92
237.72
241.12
246.22
251.32
254.50
257.90
259.60
261.30
263.00
264.70
268.10
271.50
276.60
281.48
288.28
296.78
306.76
318.66
332.04
347.34
362.42
379.42
396.20
414.68
433.38
453.56
473.74
495.62
517.72
541.30
552.98
576.56
596.96
610.34
627.12
637.32
637.32
$ 123.02
193.74
193.74
193.74
193.74
194.51
198.39
203.04
210.60
216.80
219.89
224.54
229.19
232.10
235.20
236.75
238.30
239.85
241.40
244.50
247.60
252.25
256.71
262.91
270.65
279.76
290.61
302.82
316.76
330.52
346.02
361.33
378.18
395.23
413.63
432.04
452.00
472.14
493.65
504.31
525.81
544.41
556.62
571.92
581.22
581.22
$ 127.40
200.63
200.63
200.63
200.63
201.43
205.45
210.26
218.08
224.50
227.72
232.53
237.35
240.35
243.56
245.17
246.77
248.38
249.98
253.20
256.41
261.22
265.83
272.25
280.28
289.71
300.95
313.58
328.03
342.27
358.33
374.17
391.63
409.29
428.35
447.40
468.07
488.94
511.21
522.24
544.51
563.77
576.41
592.26
601.89
601.89
$ 122.73
193.28
193.28
193.28
193.28
194.05
197.92
202.56
210.10
216.28
219.37
224.01
228.65
231.55
234.64
236.19
237.73
239.28
240.83
243.92
247.01
251.65
256.10
262.28
270.01
279.10
289.92
302.10
316.01
329.74
345.20
360.47
377.28
394.29
412.65
431.01
450.92
471.02
492.48
503.11
524.56
543.12
555.29
570.56
579.84
579.84
$ 124.93
196.74
196.74
196.74
196.74
197.53
201.46
206.18
213.86
220.15
223.30
228.02
232.74
235.69
238.84
240.42
241.99
243.56
245.14
248.29
251.43
256.16
260.68
266.98
274.85
284.09
295.11
307.50
321.67
335.64
351.38
366.92
384.04
401.35
420.04
438.73
458.99
479.46
501.29
512.11
533.95
552.84
565.23
580.78
590.22
590.22
$ 124.92
196.72
196.72
196.72
196.72
197.51
201.44
206.16
213.83
220.13
223.28
228.00
232.72
235.67
238.82
240.39
241.97
243.54
245.11
248.26
251.41
256.13
260.65
266.95
274.82
284.06
295.08
307.47
321.64
335.60
351.34
366.88
384.00
401.31
420.00
438.69
458.95
479.41
501.24
512.06
533.90
552.78
565.18
580.72
590.16
590.16
$ 130.14
204.94
204.94
204.94
204.94
205.76
209.86
214.78
222.77
229.33
232.61
237.53
242.44
245.52
248.80
250.44
252.08
253.72
255.36
258.63
261.91
266.83
271.55
278.10
286.30
295.93
307.41
320.32
335.08
349.63
366.02
382.21
400.04
418.08
437.55
457.02
478.13
499.44
522.19
533.46
556.21
575.88
588.79
604.98
614.82
614.82
$ 129.77
204.36
204.36
204.36
204.36
205.18
209.26
214.17
222.14
228.68
231.95
236.85
241.76
244.82
248.09
249.73
251.36
253.00
254.63
257.90
261.17
266.08
270.78
277.32
285.49
295.10
306.54
319.41
334.13
348.64
364.99
381.13
398.91
416.89
436.31
455.72
476.77
498.03
520.71
531.95
554.63
574.25
587.13
603.27
613.08
613.08
$ 126.51
199.23
199.23
199.23
199.23
200.03
204.01
208.79
216.56
222.94
226.13
230.91
235.69
238.68
241.87
243.46
245.05
246.65
248.24
251.43
254.62
259.40
263.98
270.36
278.32
287.69
298.85
311.40
325.74
339.89
355.82
371.56
388.90
406.43
425.36
444.28
464.80
485.52
507.64
518.60
540.71
559.84
572.39
588.13
597.69
597.69
$ 136.93
215.64
215.64
215.64
215.64
216.50
220.82
225.99
234.40
241.30
244.75
249.93
255.10
258.34
261.79
263.51
265.24
266.96
268.69
272.14
275.59
280.76
285.72
292.62
301.25
311.38
323.46
337.05
352.57
367.88
385.13
402.17
420.93
439.91
460.39
480.88
503.09
525.51
549.45
561.31
585.25
605.95
619.53
636.57
646.92
646.92
$ 125.43
197.52
197.52
197.52
197.52
198.31
202.26
207.00
214.70
221.02
224.19
228.93
233.67
236.63
239.79
241.37
242.95
244.53
246.11
249.27
252.43
257.17
261.71
268.03
275.94
285.22
296.28
308.72
322.95
336.97
352.77
368.37
385.56
402.94
421.71
440.47
460.81
481.36
503.28
514.14
536.07
555.03
567.47
583.08
592.56
592.56
$ 127.03
200.04
200.04
200.04
200.04
200.84
204.84
209.64
217.44
223.84
227.05
231.85
236.65
239.65
242.85
244.45
246.05
247.65
249.25
252.45
255.65
260.45
265.05
271.45
279.46
288.86
300.06
312.66
327.07
341.27
357.27
373.07
390.48
408.08
427.09
446.09
466.69
487.50
509.70
520.70
542.91
562.11
574.71
590.52
600.12
600.12
®
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
73
0SNS
16064VA1210028
Anthem Core DirectAccess w/HSA gmua
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 141.27
222.48
222.48
222.48
222.48
223.37
227.82
233.16
241.84
248.96
252.51
257.85
263.19
266.53
270.09
271.87
273.65
275.43
277.21
280.77
284.33
289.67
294.79
301.91
310.80
321.26
333.72
347.74
363.75
379.55
397.35
414.93
434.28
453.86
474.99
496.13
519.05
542.18
566.88
579.12
603.81
625.17
639.19
656.76
667.44
667.44
$ 128.85
202.92
202.92
202.92
202.92
203.73
207.79
212.66
220.57
227.07
230.31
235.18
240.05
243.10
246.34
247.97
249.59
251.21
252.84
256.09
259.33
264.20
268.87
275.36
283.48
293.02
304.38
317.16
331.77
346.18
362.42
378.45
396.10
413.96
433.23
452.51
473.41
494.52
517.04
528.20
550.72
570.21
582.99
599.02
608.76
608.76
$ 137.44
216.44
216.44
216.44
216.44
217.31
221.63
226.83
235.27
242.20
245.66
250.85
256.05
259.30
262.76
264.49
266.22
267.95
269.68
273.15
276.61
281.80
286.78
293.71
302.37
312.54
324.66
338.30
353.88
369.25
386.56
403.66
422.49
441.54
462.10
482.66
504.95
527.46
551.49
563.39
587.42
608.20
621.83
638.93
649.32
649.32
$ 128.54
202.42
202.42
202.42
202.42
203.23
207.28
212.14
220.03
226.51
229.75
234.60
239.46
242.50
245.74
247.36
248.98
250.60
252.22
255.45
258.69
263.55
268.21
274.68
282.78
292.29
303.63
316.38
330.96
345.33
361.52
377.51
395.12
412.94
432.17
451.40
472.25
493.30
515.77
526.90
549.37
568.80
581.55
597.54
607.26
607.26
$ 133.45
210.16
210.16
210.16
210.16
211.00
215.20
220.25
228.44
235.17
238.53
243.58
248.62
251.77
255.13
256.82
258.50
260.18
261.86
265.22
268.58
273.63
278.46
285.19
293.59
303.47
315.24
328.48
343.61
358.53
375.35
391.95
410.23
428.73
448.69
468.66
490.30
512.16
535.49
547.05
570.37
590.55
603.79
620.39
630.48
630.48
$ 126.89
199.83
199.83
199.83
199.83
200.63
204.63
209.42
217.22
223.61
226.81
231.60
236.40
239.40
242.59
244.19
245.79
247.39
248.99
252.19
255.38
260.18
264.77
271.17
279.16
288.55
299.75
312.33
326.72
340.91
356.90
372.68
390.07
407.65
426.64
445.62
466.20
486.99
509.17
520.16
542.34
561.52
574.11
589.90
599.49
599.49
$ 140.65
221.49
221.49
221.49
221.49
222.38
226.81
232.12
240.76
247.85
251.39
256.71
262.02
265.35
268.89
270.66
272.43
274.20
275.98
279.52
283.06
288.38
293.47
300.56
309.42
319.83
332.24
346.19
362.14
377.86
395.58
413.08
432.35
451.84
472.88
493.92
516.74
539.77
564.36
576.54
601.12
622.39
636.34
653.84
664.47
664.47
$ 135.90
214.02
214.02
214.02
214.02
214.88
219.16
224.29
232.64
239.49
242.91
248.05
253.19
256.40
259.82
261.53
263.24
264.96
266.67
270.09
273.52
278.65
283.58
290.43
298.99
309.04
321.03
334.51
349.92
365.12
382.24
399.15
417.77
436.60
456.93
477.26
499.31
521.57
545.32
557.09
580.85
601.40
614.88
631.79
642.06
642.06
$ 142.16
223.88
223.88
223.88
223.88
224.78
229.25
234.63
243.36
250.52
254.10
259.48
264.85
268.21
271.79
273.58
275.37
277.16
278.95
282.54
286.12
291.49
296.64
303.81
312.76
323.28
335.82
349.92
366.04
381.94
399.85
417.54
437.01
456.72
477.98
499.25
522.31
545.60
570.45
582.76
607.61
629.10
643.21
660.89
671.64
671.64
$ 136.23
214.54
214.54
214.54
214.54
215.40
219.69
224.84
233.20
240.07
243.50
248.65
253.80
257.02
260.45
262.17
263.88
265.60
267.32
270.75
274.18
279.33
284.27
291.13
299.71
309.80
321.81
335.33
350.77
366.01
383.17
400.12
418.78
437.66
458.04
478.42
500.52
522.83
546.65
558.45
582.26
602.86
616.37
633.32
643.62
643.62
$ 128.71
202.70
202.70
202.70
202.70
203.51
207.56
212.43
220.33
226.82
230.06
234.93
239.79
242.83
246.08
247.70
249.32
250.94
252.56
255.81
259.05
263.92
268.58
275.06
283.17
292.70
304.05
316.82
331.41
345.81
362.02
378.04
395.67
413.51
432.76
452.02
472.90
493.98
516.48
527.63
550.13
569.59
582.36
598.37
608.10
608.10
$ 136.98
215.71
215.71
215.71
215.71
216.57
220.89
226.06
234.48
241.38
244.83
250.01
255.18
258.42
261.87
263.60
265.32
267.05
268.77
272.23
275.68
280.85
285.82
292.72
301.35
311.49
323.57
337.15
352.69
368.00
385.26
402.30
421.07
440.05
460.54
481.03
503.25
525.69
549.63
561.49
585.44
606.15
619.73
636.78
647.13
647.13
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
74
0SNQ
16064VA1210029
Anthem Core DirectAccess w/HSA gyua
Calendar Year
Off Exchange
N
Rating Area
Member Age
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
$ 141.27
222.48
222.48
222.48
222.48
223.37
227.82
233.16
241.84
248.96
252.51
257.85
263.19
266.53
270.09
271.87
273.65
275.43
277.21
280.77
284.33
289.67
294.79
301.91
310.80
321.26
333.72
347.74
363.75
379.55
397.35
414.93
434.28
453.86
474.99
496.13
519.05
542.18
566.88
579.12
603.81
625.17
639.19
656.76
667.44
667.44
$ 128.85
202.92
202.92
202.92
202.92
203.73
207.79
212.66
220.57
227.07
230.31
235.18
240.05
243.10
246.34
247.97
249.59
251.21
252.84
256.09
259.33
264.20
268.87
275.36
283.48
293.02
304.38
317.16
331.77
346.18
362.42
378.45
396.10
413.96
433.23
452.51
473.41
494.52
517.04
528.20
550.72
570.21
582.99
599.02
608.76
608.76
$ 137.44
216.44
216.44
216.44
216.44
217.31
221.63
226.83
235.27
242.20
245.66
250.85
256.05
259.30
262.76
264.49
266.22
267.95
269.68
273.15
276.61
281.80
286.78
293.71
302.37
312.54
324.66
338.30
353.88
369.25
386.56
403.66
422.49
441.54
462.10
482.66
504.95
527.46
551.49
563.39
587.42
608.20
621.83
638.93
649.32
649.32
$ 128.54
202.42
202.42
202.42
202.42
203.23
207.28
212.14
220.03
226.51
229.75
234.60
239.46
242.50
245.74
247.36
248.98
250.60
252.22
255.45
258.69
263.55
268.21
274.68
282.78
292.29
303.63
316.38
330.96
345.33
361.52
377.51
395.12
412.94
432.17
451.40
472.25
493.30
515.77
526.90
549.37
568.80
581.55
597.54
607.26
607.26
$ 133.45
210.16
210.16
210.16
210.16
211.00
215.20
220.25
228.44
235.17
238.53
243.58
248.62
251.77
255.13
256.82
258.50
260.18
261.86
265.22
268.58
273.63
278.46
285.19
293.59
303.47
315.24
328.48
343.61
358.53
375.35
391.95
410.23
428.73
448.69
468.66
490.30
512.16
535.49
547.05
570.37
590.55
603.79
620.39
630.48
630.48
$ 126.89
199.83
199.83
199.83
199.83
200.63
204.63
209.42
217.22
223.61
226.81
231.60
236.40
239.40
242.59
244.19
245.79
247.39
248.99
252.19
255.38
260.18
264.77
271.17
279.16
288.55
299.75
312.33
326.72
340.91
356.90
372.68
390.07
407.65
426.64
445.62
466.20
486.99
509.17
520.16
542.34
561.52
574.11
589.90
599.49
599.49
$ 140.65
221.49
221.49
221.49
221.49
222.38
226.81
232.12
240.76
247.85
251.39
256.71
262.02
265.35
268.89
270.66
272.43
274.20
275.98
279.52
283.06
288.38
293.47
300.56
309.42
319.83
332.24
346.19
362.14
377.86
395.58
413.08
432.35
451.84
472.88
493.92
516.74
539.77
564.36
576.54
601.12
622.39
636.34
653.84
664.47
664.47
$ 135.90
214.02
214.02
214.02
214.02
214.88
219.16
224.29
232.64
239.49
242.91
248.05
253.19
256.40
259.82
261.53
263.24
264.96
266.67
270.09
273.52
278.65
283.58
290.43
298.99
309.04
321.03
334.51
349.92
365.12
382.24
399.15
417.77
436.60
456.93
477.26
499.31
521.57
545.32
557.09
580.85
601.40
614.88
631.79
642.06
642.06
$ 142.16
223.88
223.88
223.88
223.88
224.78
229.25
234.63
243.36
250.52
254.10
259.48
264.85
268.21
271.79
273.58
275.37
277.16
278.95
282.54
286.12
291.49
296.64
303.81
312.76
323.28
335.82
349.92
366.04
381.94
399.85
417.54
437.01
456.72
477.98
499.25
522.31
545.60
570.45
582.76
607.61
629.10
643.21
660.89
671.64
671.64
$ 136.23
214.54
214.54
214.54
214.54
215.40
219.69
224.84
233.20
240.07
243.50
248.65
253.80
257.02
260.45
262.17
263.88
265.60
267.32
270.75
274.18
279.33
284.27
291.13
299.71
309.80
321.81
335.33
350.77
366.01
383.17
400.12
418.78
437.66
458.04
478.42
500.52
522.83
546.65
558.45
582.26
602.86
616.37
633.32
643.62
643.62
$ 128.71
202.70
202.70
202.70
202.70
203.51
207.56
212.43
220.33
226.82
230.06
234.93
239.79
242.83
246.08
247.70
249.32
250.94
252.56
255.81
259.05
263.92
268.58
275.06
283.17
292.70
304.05
316.82
331.41
345.81
362.02
378.04
395.67
413.51
432.76
452.02
472.90
493.98
516.48
527.63
550.13
569.59
582.36
598.37
608.10
608.10
$ 136.98
215.71
215.71
215.71
215.71
216.57
220.89
226.06
234.48
241.38
244.83
250.01
255.18
258.42
261.87
263.60
265.32
267.05
268.77
272.23
275.68
280.85
285.82
292.72
301.35
311.49
323.57
337.15
352.69
368.00
385.26
402.30
421.07
440.05
460.54
481.03
503.25
525.69
549.63
561.49
585.44
606.15
619.73
636.78
647.13
647.13
Anthem Core Plans – CDHP/POS
Contract Code:
HIOS Plan ID:
Plan Name:
Network:
Plan Type:
On/Off Exhange:
Bariatric Rider:
75
0SNT
88380VA0740050
Anthem HealthKeepers Core DirectAccess w/HSA gmua
Calendar Year
Off Exchange
N
Rating Area
Member Age
0‐20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 and over
Rating Area 1
Rating Area 2
Rating Area 3
Rating Area 4
Rating Area 5
Rating Area 6
Rating Area 7
Rating Area 8
Rating Area 9
Rating Area 10
Rating Area 11
Rating Area 12
$ 133.33
209.97
209.97
209.97
209.97
210.81
215.01
220.05
228.24
234.96
238.32
243.36
248.39
251.54
254.90
256.58
258.26
259.94
261.62
264.98
268.34
273.38
278.21
284.93
293.33
303.20
314.96
328.18
343.30
358.21
375.01
391.59
409.86
428.34
448.29
468.23
489.86
511.70
535.00
546.55
569.86
590.02
603.24
619.83
629.91
629.91
$ 121.60
191.49
191.49
191.49
191.49
192.26
196.09
200.68
208.15
214.28
217.34
221.94
226.53
229.41
232.47
234.00
235.53
237.06
238.60
241.66
244.72
249.32
253.72
259.85
267.51
276.51
287.24
299.30
313.09
326.68
342.00
357.13
373.79
390.64
408.83
427.02
4

WP-29576-ABCBS Second Quarter 2014 Small Group Rates

Transcription

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