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2017 Individual Nongrandfathered Health Plan 53732WA0780018
Plan Information
Plan Name: Bronze HDHP 6000 EPO EvergreenHealth Partners-Virginia Mason
HIOS Plan ID: 53732WA0780018
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 131.57 135.91 131.57 135.91
21 207.19 214.03 238.27 246.13
22 207.19 214.03 238.27 246.13
23 207.19 214.03 238.27 246.13
24 207.19 214.03 238.27 246.13
25 208.02 214.88 239.22 247.12
26 212.16 219.16 243.99 252.04
27 217.14 224.30 249.71 257.95
28 225.22 232.65 259.00 267.54
29 231.85 239.50 266.62 275.42
30 235.16 242.92 270.43 279.36
31 240.13 248.06 276.15 285.27
32 245.11 253.19 281.87 291.17
33 248.21 256.40 285.45 294.87
34 251.53 259.83 289.26 298.80
35 253.19 261.54 291.16 300.77
36 254.84 263.25 293.07 302.74
37 256.50 264.97 294.98 304.71
38 258.16 266.68 296.88 306.68
39 261.47 270.10 300.69 310.62
40 264.79 273.53 304.51 314.56
41 269.76 278.66 310.23 320.46
42 274.53 283.59 315.71 326.12
43 281.16 290.44 323.33 334.00
44 289.44 299.00 332.86 343.85
45 299.18 309.06 344.06 355.41
46 310.79 321.04 357.40 369.20
47 323.84 334.52 372.41 384.70
48 338.76 349.93 389.57 402.42
49 353.47 365.13 406.49 419.90
50 370.04 382.25 425.55 439.59
51 386.41 399.16 444.37 459.03
52 404.43 417.78 465.10 480.45
53 422.67 436.62 486.07 502.11
54 442.35 456.95 508.70 525.49
55 462.03 477.28 531.34 548.87
56 483.37 499.33 555.88 574.22
57 504.92 521.58 580.66 599.82
58 527.92 545.34 607.11 627.14
59 539.32 557.11 620.21 640.68
60 562.31 580.87 646.66 668.00
61 582.20 601.42 669.53 691.63
62 595.26 614.90 684.55 707.14
63 611.62 631.81 703.37 726.58
64 621.57 642.08 714.81 738.39
65 and over 621.57 642.08 714.81 738.39
N/A
N/A
BridgeSpan Health Company
RATE SCHEDULE
Non-Smoker Rates Smoker Rates
Counties where this plan is available
King
Snohomish
N/A
Page 1 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780017
Plan Information
Plan Name: Silver HDHP 3000 EPO EvergreenHealth Partners-Virginia Mason
HIOS Plan ID: 53732WA0780017
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 153.78 158.85 153.78 158.85
21 242.17 250.16 278.50 287.69
22 242.17 250.16 278.50 287.69
23 242.17 250.16 278.50 287.69
24 242.17 250.16 278.50 287.69
25 243.14 251.16 279.61 288.84
26 247.98 256.17 285.18 294.59
27 253.79 262.17 291.86 301.49
28 263.24 271.93 302.72 312.71
29 270.99 279.93 311.64 321.92
30 274.86 283.93 316.09 326.52
31 280.68 289.94 322.78 333.43
32 286.49 295.94 329.46 340.33
33 290.12 299.69 333.64 344.65
34 293.99 303.70 338.09 349.25
35 295.93 305.70 340.32 351.55
36 297.87 307.70 342.55 353.85
37 299.81 309.70 344.78 356.16
38 301.74 311.70 347.01 358.46
39 305.62 315.70 351.46 363.06
40 309.49 319.71 355.92 367.66
41 315.31 325.71 362.60 374.57
42 320.88 331.46 369.01 381.18
43 328.62 339.47 377.92 390.39
44 338.31 349.48 389.06 401.90
45 349.69 361.23 402.15 415.42
46 363.26 375.24 417.74 431.53
47 378.51 391.00 435.29 449.65
48 395.95 409.01 455.34 470.37
49 413.14 426.78 475.11 490.79
50 432.52 446.79 497.39 513.81
51 451.65 466.55 519.39 536.53
52 472.72 488.32 543.62 561.56
53 494.03 510.33 568.13 586.88
54 517.03 534.10 594.59 614.21
55 540.04 557.86 621.04 641.54
56 564.98 583.63 649.73 671.17
57 590.17 609.64 678.69 701.09
58 617.05 637.41 709.61 733.02
59 630.37 651.17 724.92 748.85
60 657.25 678.94 755.84 780.78
61 680.50 702.95 782.57 808.40
62 695.75 718.71 800.12 826.52
63 714.89 738.48 822.12 849.25
64 726.51 750.48 835.49 863.06
65 and over 726.51 750.48 835.49 863.06
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Snohomish
N/A
Page 2 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780016
Plan Information
Plan Name: Silver Align 4000 EPO EvergreenHealth Partners-Virginia Mason
HIOS Plan ID: 53732WA0780016
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 158.01 163.23 158.01 163.23
21 248.84 257.05 286.17 295.61
22 248.84 257.05 286.17 295.61
23 248.84 257.05 286.17 295.61
24 248.84 257.05 286.17 295.61
25 249.84 258.08 287.31 296.79
26 254.81 263.22 293.03 302.70
27 260.78 269.39 299.90 309.80
28 270.49 279.42 311.06 321.33
29 278.45 287.64 320.22 330.79
30 282.43 291.75 324.80 335.52
31 288.41 297.92 331.67 342.61
32 294.38 304.09 338.53 349.71
33 298.11 307.95 342.83 354.14
34 302.09 312.06 347.41 358.87
35 304.08 314.12 349.69 361.23
36 306.07 316.17 351.98 363.60
37 308.06 318.23 354.27 365.96
38 310.05 320.29 356.56 368.33
39 314.04 324.40 361.14 373.06
40 318.02 328.51 365.72 377.79
41 323.99 334.68 372.59 384.88
42 329.71 340.59 379.17 391.68
43 337.68 348.82 388.33 401.14
44 347.63 359.10 399.77 412.97
45 359.32 371.18 413.22 426.86
46 373.26 385.58 429.25 443.41
47 388.94 401.77 447.28 462.04
48 406.85 420.28 467.88 483.32
49 424.52 438.53 488.20 504.31
50 444.43 459.09 511.09 527.96
51 464.09 479.40 533.70 551.31
52 485.74 501.76 558.60 577.03
53 507.63 524.39 583.78 603.04
54 531.27 548.81 610.96 631.13
55 554.91 573.23 638.15 659.21
56 580.54 599.70 667.63 689.66
57 606.42 626.44 697.39 720.40
58 634.04 654.97 729.15 753.21
59 647.73 669.11 744.89 769.47
60 675.35 697.64 776.65 802.28
61 699.24 722.32 804.13 830.66
62 714.92 738.51 822.15 849.29
63 734.58 758.82 844.76 872.64
64 746.52 771.15 858.50 886.83
65 and over 746.52 771.15 858.50 886.83
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Snohomish
N/A
Page 3 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780015
Plan Information
Plan Name: Gold Align 1500 EPO EvergreenHealth Partners-Virginia Mason
HIOS Plan ID: 53732WA0780015
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Gold
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 203.46 210.17 203.46 210.17
21 320.41 330.98 368.47 380.63
22 320.41 330.98 368.47 380.63
23 320.41 330.98 368.47 380.63
24 320.41 330.98 368.47 380.63
25 321.69 332.31 369.95 382.15
26 328.10 338.93 377.31 389.77
27 335.79 346.87 386.16 398.90
28 348.29 359.78 400.53 413.75
29 358.54 370.37 412.32 425.93
30 363.67 375.67 418.22 432.02
31 371.36 383.61 427.06 441.15
32 379.05 391.55 435.90 450.29
33 383.85 396.52 441.43 456.00
34 388.98 401.81 447.32 462.09
35 391.54 404.46 450.27 465.13
36 394.10 407.11 453.22 468.18
37 396.67 409.76 456.17 471.22
38 399.23 412.41 459.12 474.27
39 404.36 417.70 465.01 480.36
40 409.48 423.00 470.91 486.45
41 417.17 430.94 479.75 495.58
42 424.54 438.55 488.22 504.34
43 434.80 449.14 500.02 516.52
44 447.61 462.38 514.75 531.74
45 462.67 477.94 532.07 549.63
46 480.62 496.48 552.71 570.95
47 500.80 517.33 575.92 594.93
48 523.87 541.16 602.45 622.33
49 546.62 564.66 628.61 649.36
50 572.25 591.14 658.09 679.81
51 597.56 617.28 687.20 709.88
52 625.44 646.08 719.26 742.99
53 653.64 675.21 751.68 776.49
54 684.08 706.65 786.69 812.65
55 714.51 738.09 821.69 848.81
56 747.52 772.18 859.64 888.01
57 780.84 806.61 897.97 927.60
58 816.40 843.35 938.87 969.85
59 834.03 861.55 959.13 990.78
60 869.59 898.29 1000.03 1033.03
61 900.35 930.06 1035.40 1069.57
62 920.54 950.92 1058.62 1093.55
63 945.85 977.06 1087.73 1123.62
64 961.23 992.94 1105.41 1141.89
65 and over 961.23 992.94 1105.41 1141.89
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Snohomish
N/A
Page 4 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780014
Plan Information
Plan Name: Bronze HDHP 6000 EPO UW Medicine
HIOS Plan ID: 53732WA0780014
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 132.62 132.62
21 208.85 240.18
22 208.85 240.18
23 208.85 240.18
24 208.85 240.18
25 209.69 241.14
26 213.86 245.94
27 218.87 251.71
28 227.02 261.07
29 233.70 268.76
30 237.04 272.60
31 242.06 278.37
32 247.07 284.13
33 250.20 287.73
34 253.54 291.58
35 255.21 293.50
36 256.89 295.42
37 258.56 297.34
38 260.23 299.26
39 263.57 303.10
40 266.91 306.95
41 271.92 312.71
42 276.73 318.24
43 283.41 325.92
44 291.76 335.53
45 301.58 346.82
46 313.28 360.27
47 326.43 375.40
48 341.47 392.69
49 356.30 409.74
50 373.01 428.96
51 389.51 447.93
52 407.68 468.83
53 426.05 489.96
54 445.89 512.78
55 465.74 535.60
56 487.25 560.33
57 508.97 585.31
58 532.15 611.97
59 543.64 625.18
60 566.82 651.84
61 586.87 674.90
62 600.03 690.03
63 616.53 709.00
64 626.55 720.53
65 and over 626.55 720.53
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 5 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780013
Plan Information
Plan Name: Silver HDHP 3000 EPO UW Medicine
HIOS Plan ID: 53732WA0780013
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 155.04 155.04
21 244.15 280.77
22 244.15 280.77
23 244.15 280.77
24 244.15 280.77
25 245.13 281.90
26 250.01 287.51
27 255.87 294.25
28 265.39 305.20
29 273.20 314.18
30 277.11 318.68
31 282.97 325.42
32 288.83 332.15
33 292.49 336.37
34 296.40 340.86
35 298.35 343.10
36 300.30 345.35
37 302.26 347.60
38 304.21 349.84
39 308.12 354.33
40 312.02 358.83
41 317.88 365.57
42 323.50 372.02
43 331.31 381.01
44 341.08 392.24
45 352.55 405.44
46 366.23 421.16
47 381.61 438.85
48 399.19 459.06
49 416.52 479.00
50 436.05 501.46
51 455.34 523.64
52 476.58 548.07
53 498.07 572.78
54 521.26 599.45
55 544.45 626.12
56 569.60 655.04
57 594.99 684.24
58 622.09 715.41
59 635.52 730.85
60 662.62 762.02
61 686.06 788.97
62 701.44 806.66
63 720.73 828.84
64 732.45 842.31
65 and over 732.45 842.31
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 6 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780012
Plan Information
Plan Name: Silver Align 4000 EPO UW Medicine
HIOS Plan ID: 53732WA0780012
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 159.30 159.30
21 250.87 288.50
22 250.87 288.50
23 250.87 288.50
24 250.87 288.50
25 251.87 289.65
26 256.89 295.42
27 262.91 302.35
28 272.70 313.60
29 280.72 322.83
30 284.74 327.45
31 290.76 334.37
32 296.78 341.30
33 300.54 345.62
34 304.56 350.24
35 306.56 352.55
36 308.57 354.86
37 310.58 357.16
38 312.58 359.47
39 316.60 364.09
40 320.61 368.70
41 326.63 375.63
42 332.40 382.26
43 340.43 391.50
44 350.47 403.04
45 362.26 416.59
46 376.31 432.75
47 392.11 450.93
48 410.17 471.70
49 427.98 492.18
50 448.05 515.26
51 467.87 538.05
52 489.70 563.15
53 511.77 588.54
54 535.61 615.95
55 559.44 643.36
56 585.28 673.07
57 611.37 703.08
58 639.22 735.10
59 653.01 750.97
60 680.86 782.99
61 704.94 810.69
62 720.75 828.86
63 740.57 851.65
64 752.61 865.50
65 and over 752.61 865.50
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 7 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780011
Plan Information
Plan Name: Gold Align 1500 EPO UW Medicine
HIOS Plan ID: 53732WA0780011
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Gold
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 205.12 205.12
21 323.03 371.48
22 323.03 371.48
23 323.03 371.48
24 323.03 371.48
25 324.32 372.97
26 330.78 380.40
27 338.54 389.32
28 351.13 403.80
29 361.47 415.69
30 366.64 421.63
31 374.39 430.55
32 382.14 439.47
33 386.99 445.04
34 392.16 450.98
35 394.74 453.95
36 397.33 456.93
37 399.91 459.90
38 402.50 462.87
39 407.66 468.81
40 412.83 474.76
41 420.59 483.67
42 428.01 492.22
43 438.35 504.10
44 451.27 518.96
45 466.46 536.42
46 484.55 557.23
47 504.90 580.63
48 528.15 607.38
49 551.09 633.75
50 576.93 663.47
51 602.45 692.82
52 630.55 725.14
53 658.98 757.83
54 689.67 793.12
55 720.36 828.41
56 753.63 866.67
57 787.22 905.31
58 823.08 946.54
59 840.85 966.97
60 876.70 1008.21
61 907.71 1043.87
62 928.07 1067.27
63 953.58 1096.62
64 969.09 1114.44
65 and over 969.09 1114.44
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 8 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780030
Plan Information
Plan Name: Bronze HDHP 6000 EPO The Everett Clinic
HIOS Plan ID: 53732WA0780030
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 No
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 140.80 140.80
21 221.73 254.99
22 221.73 254.99
23 221.73 254.99
24 221.73 254.99
25 222.62 256.01
26 227.06 261.11
27 232.38 267.23
28 241.02 277.18
29 248.12 285.34
30 251.67 289.42
31 256.99 295.54
32 262.31 301.66
33 265.64 305.48
34 269.18 309.56
35 270.96 311.60
36 272.73 313.64
37 274.51 315.68
38 276.28 317.72
39 279.83 321.80
40 283.38 325.88
41 288.70 332.00
42 293.80 337.87
43 300.89 346.03
44 309.76 356.23
45 320.18 368.21
46 332.60 382.49
47 346.57 398.55
48 362.53 416.91
49 378.28 435.02
50 396.02 455.42
51 413.53 475.56
52 432.82 497.75
53 452.34 520.19
54 473.40 544.41
55 494.47 568.64
56 517.30 594.90
57 540.36 621.42
58 564.98 649.72
59 577.17 663.75
60 601.78 692.05
61 623.07 716.53
62 637.04 732.60
63 654.56 752.74
64 665.19 764.97
65 and over 665.19 764.97
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
Snohomish
N/A
Page 9 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780029
Plan Information
Plan Name: Silver HDHP 3000 EPO The Everett Clinic
HIOS Plan ID: 53732WA0780029
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 No
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 164.59 164.59
21 259.19 298.07
22 259.19 298.07
23 259.19 298.07
24 259.19 298.07
25 260.23 299.26
26 265.41 305.22
27 271.63 312.38
28 281.74 324.00
29 290.03 333.54
30 294.18 338.31
31 300.40 345.46
32 306.62 352.62
33 310.51 357.09
34 314.66 361.86
35 316.73 364.24
36 318.80 366.62
37 320.88 369.01
38 322.95 371.39
39 327.10 376.16
40 331.24 380.93
41 337.47 388.09
42 343.43 394.94
43 351.72 404.48
44 362.09 416.40
45 374.27 430.41
46 388.79 447.10
47 405.11 465.88
48 423.78 487.34
49 442.18 508.50
50 462.91 532.35
51 483.39 555.90
52 505.94 581.83
53 528.75 608.06
54 553.37 636.38
55 577.99 664.69
56 604.69 695.39
57 631.65 726.39
58 660.42 759.48
59 674.67 775.87
60 703.44 808.96
61 728.32 837.57
62 744.65 856.35
63 765.13 879.90
64 777.57 894.21
65 and over 777.57 894.21
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
Snohomish
N/A
Page 10 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780028
Plan Information
Plan Name: Silver Align 4000 EPO The Everett Clinic
HIOS Plan ID: 53732WA0780028
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 No
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 169.12 169.12
21 266.33 306.28
22 266.33 306.28
23 266.33 306.28
24 266.33 306.28
25 267.39 307.50
26 272.72 313.63
27 279.11 320.98
28 289.50 332.92
29 298.02 342.72
30 302.28 347.62
31 308.67 354.98
32 315.07 362.33
33 319.06 366.92
34 323.32 371.82
35 325.45 374.27
36 327.58 376.72
37 329.71 379.17
38 331.84 381.62
39 336.11 386.52
40 340.37 391.42
41 346.76 398.77
42 352.88 405.82
43 361.41 415.62
44 372.06 427.87
45 384.58 442.26
46 399.49 459.42
47 416.27 478.71
48 435.45 500.76
49 454.36 522.51
50 475.66 547.01
51 496.70 571.21
52 519.87 597.85
53 543.31 624.81
54 568.61 653.90
55 593.91 683.00
56 621.34 714.54
57 649.04 746.40
58 678.60 780.39
59 693.25 797.24
60 722.81 831.24
61 748.38 860.64
62 765.16 879.93
63 786.20 904.13
64 798.98 918.83
65 and over 798.98 918.83
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
Snohomish
N/A
Page 11 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780027
Plan Information
Plan Name: Gold Align 1500 EPO The Everett Clinic
HIOS Plan ID: 53732WA0780027
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Gold
Plan Geographic Availability
Area Number Available in area?
1 No
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 217.75 217.75
21 342.91 394.35
22 342.91 394.35
23 342.91 394.35
24 342.91 394.35
25 344.29 395.93
26 351.14 403.82
27 359.37 413.28
28 372.75 428.66
29 383.72 441.28
30 389.21 447.59
31 397.44 457.05
32 405.67 466.52
33 410.81 472.43
34 416.30 478.74
35 419.04 481.90
36 421.79 485.05
37 424.53 488.21
38 427.27 491.36
39 432.76 497.67
40 438.24 503.98
41 446.47 513.45
42 454.36 522.52
43 465.34 535.14
44 479.05 550.91
45 495.17 569.44
46 514.37 591.53
47 535.98 616.37
48 560.67 644.77
49 585.01 672.76
50 612.45 704.31
51 639.54 735.47
52 669.37 769.77
53 699.55 804.48
54 732.12 841.94
55 764.70 879.40
56 800.02 920.02
57 835.68 961.04
58 873.75 1004.81
59 892.61 1026.50
60 930.67 1070.27
61 963.59 1108.13
62 985.19 1132.97
63 1012.28 1164.13
64 1028.73 1183.05
65 and over 1028.73 1183.05
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
Snohomish
N/A
Page 12 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780026
Plan Information
Plan Name: Bronze HDHP 6000 EPO Providence-Swedish Health
HIOS Plan ID: 53732WA0780026
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 138.35 138.35
21 217.87 250.55
22 217.87 250.55
23 217.87 250.55
24 217.87 250.55
25 218.74 251.55
26 223.10 256.56
27 228.33 262.58
28 236.82 272.35
29 243.80 280.37
30 247.28 284.37
31 252.51 290.39
32 257.74 296.40
33 261.01 300.16
34 264.49 304.17
35 266.24 306.17
36 267.98 308.18
37 269.72 310.18
38 271.47 312.19
39 274.95 316.19
40 278.44 320.20
41 283.67 326.22
42 288.68 331.98
43 295.65 340.00
44 304.36 350.02
45 314.60 361.79
46 326.81 375.83
47 340.53 391.61
48 356.22 409.65
49 371.69 427.44
50 389.12 447.48
51 406.33 467.28
52 425.28 489.07
53 444.45 511.12
54 465.15 534.93
55 485.85 558.73
56 508.29 584.53
57 530.95 610.59
58 555.13 638.40
59 567.12 652.18
60 591.30 679.99
61 612.21 704.05
62 625.94 719.83
63 643.15 739.63
64 653.61 751.65
65 and over 653.61 751.65
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 13 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780025
Plan Information
Plan Name: Silver HDHP 3000 EPO Providence-Swedish Health
HIOS Plan ID: 53732WA0780025
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 161.70 161.70
21 254.64 292.84
22 254.64 292.84
23 254.64 292.84
24 254.64 292.84
25 255.66 294.01
26 260.75 299.86
27 266.86 306.89
28 276.79 318.31
29 284.94 327.68
30 289.02 332.37
31 295.13 339.40
32 301.24 346.42
33 305.06 350.82
34 309.13 355.50
35 311.17 357.85
36 313.21 360.19
37 315.24 362.53
38 317.28 364.87
39 321.36 369.56
40 325.43 374.24
41 331.54 381.27
42 337.40 388.01
43 345.55 397.38
44 355.73 409.09
45 367.70 422.86
46 381.96 439.25
47 398.00 457.70
48 416.34 478.79
49 434.42 499.58
50 454.79 523.01
51 474.90 546.14
52 497.06 571.62
53 519.47 597.39
54 543.66 625.20
55 567.85 653.02
56 594.08 683.19
57 620.56 713.64
58 648.82 746.15
59 662.83 762.25
60 691.09 794.76
61 715.54 822.87
62 731.58 841.32
63 751.70 864.45
64 763.92 878.51
65 and over 763.92 878.51
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 14 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780024
Plan Information
Plan Name: Silver Align 4000 EPO Providence-Swedish Health
HIOS Plan ID: 53732WA0780024
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 166.17 166.17
21 261.68 300.93
22 261.68 300.93
23 261.68 300.93
24 261.68 300.93
25 262.73 302.14
26 267.96 308.15
27 274.24 315.38
28 284.45 327.11
29 292.82 336.74
30 297.01 341.56
31 303.29 348.78
32 309.57 356.00
33 313.49 360.52
34 317.68 365.33
35 319.77 367.74
36 321.87 370.15
37 323.96 372.55
38 326.05 374.96
39 330.24 379.78
40 334.43 384.59
41 340.71 391.81
42 346.73 398.73
43 355.10 408.36
44 365.57 420.40
45 377.87 434.55
46 392.52 451.40
47 409.01 470.36
48 427.85 492.02
49 446.43 513.39
50 467.36 537.46
51 488.03 561.24
52 510.80 587.42
53 533.83 613.90
54 558.69 642.49
55 583.55 671.08
56 610.50 702.07
57 637.71 733.37
58 666.76 766.77
59 681.15 783.33
60 710.20 816.73
61 735.32 845.62
62 751.81 864.58
63 772.48 888.35
64 785.04 902.79
65 and over 785.04 902.79
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 15 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780023
Plan Information
Plan Name: Gold Align 1500 EPO Providence-Swedish Health
HIOS Plan ID: 53732WA0780023
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Gold
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 No
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 213.92 213.92
21 336.88 387.41
22 336.88 387.41
23 336.88 387.41
24 336.88 387.41
25 338.23 388.96
26 344.97 396.71
27 353.05 406.01
28 366.19 421.12
29 376.97 433.51
30 382.36 439.71
31 390.44 449.01
32 398.53 458.31
33 403.58 464.12
34 408.97 470.32
35 411.67 473.42
36 414.36 476.52
37 417.06 479.62
38 419.75 482.72
39 425.14 488.91
40 430.53 495.11
41 438.62 504.41
42 446.37 513.32
43 457.15 525.72
44 470.62 541.21
45 486.45 559.42
46 505.32 581.12
47 526.54 605.52
48 550.80 633.42
49 574.72 660.92
50 601.67 691.92
51 628.28 722.52
52 657.59 756.23
53 687.24 790.32
54 719.24 827.12
55 751.24 863.93
56 785.94 903.83
57 820.98 944.12
58 858.37 987.13
59 876.90 1008.43
60 914.29 1051.44
61 946.63 1088.63
62 967.86 1113.03
63 994.47 1143.64
64 1010.64 1162.23
65 and over 1010.64 1162.23
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
N/A
N/A
Page 16 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780022
Plan Information
Plan Name: Bronze HDHP 6000 EPO MultiCare Connected Care
HIOS Plan ID: 53732WA0780022
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 140.68 145.33 140.68 145.33
21 221.55 228.86 254.78 263.19
22 221.55 228.86 254.78 263.19
23 221.55 228.86 254.78 263.19
24 221.55 228.86 254.78 263.19
25 222.44 229.78 255.80 264.24
26 226.87 234.35 260.90 269.51
27 232.18 239.85 267.01 275.82
28 240.82 248.77 276.95 286.09
29 247.91 256.10 285.10 294.51
30 251.46 259.76 289.18 298.72
31 256.78 265.25 295.29 305.04
32 262.09 270.74 301.41 311.35
33 265.42 274.18 305.23 315.30
34 268.96 277.84 309.31 319.51
35 270.73 279.67 311.34 321.62
36 272.51 281.50 313.38 323.72
37 274.28 283.33 315.42 325.83
38 276.05 285.16 317.46 327.94
39 279.60 288.82 321.54 332.15
40 283.14 292.48 325.61 336.36
41 288.46 297.98 331.73 342.67
42 293.55 303.24 337.59 348.73
43 300.64 310.56 345.74 357.15
44 309.51 319.72 355.93 367.68
45 319.92 330.48 367.91 380.05
46 332.33 343.29 382.17 394.79
47 346.28 357.71 398.23 411.37
48 362.23 374.19 416.57 430.32
49 377.96 390.44 434.66 449.00
50 395.69 408.75 455.04 470.06
51 413.19 426.83 475.17 490.85
52 432.47 446.74 497.34 513.75
53 451.96 466.88 519.76 536.91
54 473.01 488.62 543.96 561.91
55 494.06 510.36 568.16 586.91
56 516.88 533.93 594.41 614.02
57 539.92 557.73 620.90 641.39
58 564.51 583.14 649.19 670.61
59 576.69 595.73 663.20 685.08
60 601.29 621.13 691.48 714.30
61 622.56 643.10 715.94 739.56
62 636.51 657.52 731.99 756.15
63 654.02 675.60 752.12 776.94
64 664.65 686.58 764.34 789.57
65 and over 664.65 686.58 764.34 789.57
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Pierce
N/A
Page 17 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780021
Plan Information
Plan Name: Silver HDHP 3000 EPO MultiCare Connected Care
HIOS Plan ID: 53732WA0780021
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 164.47 169.90 164.47 169.90
21 259.01 267.56 297.86 307.69
22 259.01 267.56 297.86 307.69
23 259.01 267.56 297.86 307.69
24 259.01 267.56 297.86 307.69
25 260.05 268.63 299.05 308.92
26 265.23 273.98 305.01 315.08
27 271.44 280.40 312.16 322.46
28 281.54 290.83 323.78 334.46
29 289.83 299.40 333.31 344.31
30 293.98 303.68 338.07 349.23
31 300.19 310.10 345.22 356.61
32 306.41 316.52 352.37 364.00
33 310.29 320.53 356.84 368.61
34 314.44 324.81 361.60 373.54
35 316.51 326.96 363.99 376.00
36 318.58 329.10 366.37 378.46
37 320.65 331.24 368.75 380.92
38 322.73 333.38 371.14 383.38
39 326.87 337.66 375.90 388.31
40 331.01 341.94 380.67 393.23
41 337.23 348.36 387.82 400.61
42 343.19 354.51 394.67 407.69
43 351.48 363.08 404.20 417.54
44 361.84 373.78 416.11 429.84
45 374.01 386.35 430.11 444.31
46 388.52 401.34 446.79 461.54
47 404.83 418.19 465.56 480.92
48 423.48 437.46 487.00 503.07
49 441.87 456.45 508.15 524.92
50 462.59 477.86 531.98 549.54
51 483.05 498.99 555.51 573.84
52 505.59 522.27 581.43 600.61
53 528.38 545.82 607.64 627.69
54 552.99 571.23 635.93 656.92
55 577.59 596.65 664.23 686.15
56 604.27 624.21 694.91 717.84
57 631.21 652.04 725.89 749.84
58 659.96 681.74 758.95 784.00
59 674.20 696.45 775.33 800.92
60 702.95 726.15 808.40 835.07
61 727.82 751.84 836.99 864.61
62 744.14 768.69 855.76 884.00
63 764.60 789.83 879.29 908.30
64 777.03 802.67 893.58 923.07
65 and over 777.03 802.67 893.58 923.07
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Pierce
N/A
Page 18 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780020
Plan Information
Plan Name: Silver Align 4000 EPO MultiCare Connected Care
HIOS Plan ID: 53732WA0780020
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 169.01 174.58 169.01 174.58
21 266.15 274.93 306.07 316.17
22 266.15 274.93 306.07 316.17
23 266.15 274.93 306.07 316.17
24 266.15 274.93 306.07 316.17
25 267.21 276.03 307.30 317.44
26 272.54 281.53 313.42 323.76
27 278.93 288.13 320.76 331.35
28 289.31 298.85 332.70 343.68
29 297.82 307.65 342.50 353.80
30 302.08 312.05 347.39 358.86
31 308.47 318.65 354.74 366.44
32 314.86 325.25 362.08 374.03
33 318.85 329.37 366.67 378.78
34 323.11 333.77 371.57 383.83
35 325.24 335.97 374.02 386.36
36 327.36 338.17 376.47 388.89
37 329.49 340.37 378.92 391.42
38 331.62 342.57 381.37 393.95
39 335.88 346.97 386.26 399.01
40 340.14 351.36 391.16 404.07
41 346.53 357.96 398.51 411.66
42 352.65 364.29 405.55 418.93
43 361.17 373.08 415.34 429.05
44 371.81 384.08 427.58 441.69
45 384.32 397.00 441.97 456.55
46 399.23 412.40 459.11 474.26
47 415.99 429.72 478.39 494.18
48 435.16 449.52 500.43 516.94
49 454.05 469.04 522.16 539.39
50 475.34 491.03 546.65 564.68
51 496.37 512.75 570.83 589.66
52 519.52 536.67 597.45 617.17
53 542.95 560.86 624.39 644.99
54 568.23 586.98 653.46 675.03
55 593.51 613.10 682.54 705.07
56 620.93 641.42 714.07 737.63
57 648.61 670.01 745.90 770.51
58 678.15 700.53 779.87 805.61
59 692.79 715.65 796.71 823.00
60 722.33 746.17 830.68 858.09
61 747.88 772.56 860.06 888.45
62 764.65 789.88 879.35 908.36
63 785.67 811.60 903.53 933.34
64 798.45 824.79 918.21 948.51
65 and over 798.45 824.79 918.21 948.51
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Pierce
N/A
Page 19 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780019
Plan Information
Plan Name: Gold Align 1500 EPO MultiCare Connected Care
HIOS Plan ID: 53732WA0780019
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Gold
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 217.60 224.78 217.60 224.78
21 342.68 353.99 394.08 407.09
22 342.68 353.99 394.08 407.09
23 342.68 353.99 394.08 407.09
24 342.68 353.99 394.08 407.09
25 344.05 355.40 395.66 408.72
26 350.90 362.48 403.54 416.86
27 359.13 370.98 413.00 426.63
28 372.49 384.79 428.37 442.50
29 383.46 396.11 440.98 455.53
30 388.94 401.78 447.28 462.04
31 397.17 410.27 456.74 471.81
32 405.39 418.77 466.20 481.58
33 410.53 424.08 472.11 487.69
34 416.01 429.74 478.42 494.20
35 418.75 432.57 481.57 497.46
36 421.50 435.41 484.72 500.72
37 424.24 438.24 487.87 503.97
38 426.98 441.07 491.03 507.23
39 432.46 446.73 497.33 513.74
40 437.95 452.40 503.64 520.26
41 446.17 460.89 513.09 530.03
42 454.05 469.03 522.16 539.39
43 465.02 480.36 534.77 552.42
44 478.72 494.52 550.53 568.70
45 494.83 511.16 569.05 587.83
46 514.02 530.98 591.12 610.63
47 535.61 553.28 615.95 636.28
48 560.28 578.77 644.32 665.59
49 584.61 603.90 672.30 694.49
50 612.03 632.22 703.83 727.06
51 639.10 660.19 734.96 759.22
52 668.91 690.99 769.25 794.63
53 699.07 722.14 803.93 830.46
54 731.62 755.77 841.37 869.13
55 764.18 789.39 878.80 907.80
56 799.47 825.86 919.39 949.73
57 835.11 862.67 960.38 992.07
58 873.15 901.96 1004.12 1037.26
59 892.00 921.43 1025.80 1059.65
60 930.03 960.72 1069.54 1104.83
61 962.93 994.71 1107.37 1143.91
62 984.52 1017.01 1132.20 1169.56
63 1011.59 1044.97 1163.33 1201.72
64 1028.04 1061.97 1182.24 1221.26
65 and over 1028.04 1061.97 1182.24 1221.26
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Pierce
N/A
Page 20 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780010
Plan Information
Plan Name: Bronze HDHP 6000 EPO PeaceHealth
HIOS Plan ID: 53732WA0780010
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 No
2 No
3 Yes
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 138.78 138.78
21 218.55 251.34
22 218.55 251.34
23 218.55 251.34
24 218.55 251.34
25 219.43 252.34
26 223.80 257.37
27 229.04 263.40
28 237.57 273.20
29 244.56 281.25
30 248.06 285.27
31 253.30 291.30
32 258.55 297.33
33 261.83 301.10
34 265.32 305.12
35 267.07 307.13
36 268.82 309.14
37 270.57 311.16
38 272.32 313.17
39 275.82 317.19
40 279.31 321.21
41 284.56 327.24
42 289.58 333.02
43 296.58 341.06
44 305.32 351.12
45 315.59 362.93
46 327.83 377.01
47 341.60 392.84
48 357.34 410.94
49 372.85 428.78
50 390.34 448.89
51 407.60 468.74
52 426.62 490.61
53 445.85 512.73
54 466.61 536.60
55 487.38 560.48
56 509.89 586.37
57 532.62 612.51
58 556.88 640.41
59 568.90 654.23
60 593.16 682.13
61 614.14 706.26
62 627.91 722.09
63 645.17 741.95
64 655.65 754.01
65 and over 655.65 754.01
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
N/A
Clark
Page 21 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780008
Plan Information
Plan Name: Bronze Essential 7150 EPO PeaceHealth
HIOS Plan ID: 53732WA0780008
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 No
2 No
3 Yes
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 148.25 148.25
21 233.47 268.49
22 233.47 268.49
23 233.47 268.49
24 233.47 268.49
25 234.40 269.57
26 239.07 274.93
27 244.68 281.38
28 253.78 291.85
29 261.25 300.44
30 264.99 304.74
31 270.59 311.18
32 276.20 317.62
33 279.70 321.65
34 283.43 325.95
35 285.30 328.10
36 287.17 330.24
37 289.04 332.39
38 290.90 334.54
39 294.64 338.84
40 298.38 343.13
41 303.98 349.58
42 309.35 355.75
43 316.82 364.34
44 326.16 375.08
45 337.13 387.70
46 350.21 402.74
47 364.91 419.65
48 381.72 438.98
49 398.30 458.05
50 416.98 479.53
51 435.42 500.74
52 455.73 524.09
53 476.28 547.72
54 498.46 573.23
55 520.64 598.74
56 544.69 626.39
57 568.97 654.31
58 594.88 684.12
59 607.72 698.88
60 633.64 728.68
61 656.05 754.46
62 670.76 771.37
63 689.20 792.59
64 700.41 805.47
65 and over 700.41 805.47
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
N/A
Clark
Page 22 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780009
Plan Information
Plan Name: Silver HDHP 3000 EPO PeaceHealth
HIOS Plan ID: 53732WA0780009
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 No
2 No
3 Yes
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 162.23 162.23
21 255.48 293.80
22 255.48 293.80
23 255.48 293.80
24 255.48 293.80
25 256.50 294.97
26 261.61 300.85
27 267.74 307.90
28 277.70 319.36
29 285.88 328.76
30 289.97 333.46
31 296.10 340.51
32 302.23 347.56
33 306.06 351.97
34 310.15 356.67
35 312.19 359.02
36 314.24 361.37
37 316.28 363.72
38 318.32 366.07
39 322.41 370.77
40 326.50 375.47
41 332.63 382.53
42 338.51 389.28
43 346.68 398.68
44 356.90 410.44
45 368.91 424.25
46 383.22 440.70
47 399.31 459.21
48 417.71 480.36
49 435.84 501.22
50 456.28 524.72
51 476.46 547.93
52 498.69 573.50
53 521.17 599.35
54 545.44 627.26
55 569.71 655.17
56 596.03 685.43
57 622.60 715.99
58 650.96 748.60
59 665.01 764.76
60 693.36 797.37
61 717.89 825.57
62 733.99 844.08
63 754.17 867.29
64 766.43 881.40
65 and over 766.43 881.40
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
N/A
Clark
Page 23 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780007
Plan Information
Plan Name: Silver Essential 3500 EPO PeaceHealth
HIOS Plan ID: 53732WA0780007
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 No
2 No
3 Yes
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 170.64 170.64
21 268.72 309.03
22 268.72 309.03
23 268.72 309.03
24 268.72 309.03
25 269.80 310.27
26 275.17 316.45
27 281.62 323.87
28 292.10 335.92
29 300.70 345.81
30 305.00 350.75
31 311.45 358.17
32 317.90 365.59
33 321.93 370.22
34 326.23 375.17
35 328.38 377.64
36 330.53 380.11
37 332.68 382.58
38 334.83 385.06
39 339.13 390.00
40 343.43 394.94
41 349.88 402.36
42 356.06 409.47
43 364.66 419.36
44 375.41 431.72
45 388.04 446.24
46 403.09 463.55
47 420.02 483.02
48 439.36 505.27
49 458.44 527.21
50 479.94 551.93
51 501.17 576.35
52 524.55 603.23
53 548.20 630.43
54 573.73 659.79
55 599.26 689.14
56 626.93 720.97
57 654.88 753.11
58 684.71 787.42
59 699.49 804.41
60 729.32 838.72
61 755.12 868.38
62 772.04 887.85
63 793.27 912.27
64 806.16 927.09
65 and over 806.16 927.09
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
N/A
Clark
Page 24 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780006
Plan Information
Plan Name: Gold Essential 1200 EPO PeaceHealth
HIOS Plan ID: 53732WA0780006
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Gold
Plan Geographic Availability
Area Number Available in area?
1 No
2 No
3 Yes
4 No
5 No
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 212.77 212.77
21 335.07 385.33
22 335.07 385.33
23 335.07 385.33
24 335.07 385.33
25 336.41 386.87
26 343.11 394.58
27 351.15 403.82
28 364.22 418.85
29 374.94 431.18
30 380.30 437.35
31 388.34 446.60
32 396.39 455.84
33 401.41 461.62
34 406.77 467.79
35 409.45 470.87
36 412.13 473.95
37 414.81 477.04
38 417.50 480.12
39 422.86 486.28
40 428.22 492.45
41 436.26 501.70
42 443.97 510.56
43 454.69 522.89
44 468.09 538.30
45 483.84 556.41
46 502.60 577.99
47 523.71 602.27
48 547.84 630.01
49 571.63 657.37
50 598.43 688.20
51 624.90 718.64
52 654.05 752.16
53 683.54 786.07
54 715.37 822.68
55 747.20 859.28
56 781.71 898.97
57 816.56 939.05
58 853.75 981.82
59 872.18 1003.01
60 909.38 1045.78
61 941.54 1082.77
62 962.65 1107.05
63 989.12 1137.49
64 1005.20 1155.99
65 and over 1005.20 1155.99
N/A
N/A
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
N/A
N/A
Clark
Page 25 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780005
Plan Information
Plan Name: Bronze HDHP 6000 EPO RealValue
HIOS Plan ID: 53732WA0780005
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 Yes
5 Yes
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 142.06 146.74 138.93 150.44 142.06 146.74 138.93 150.44
21 223.71 231.09 218.79 236.91 257.27 265.76 251.61 272.45
22 223.71 231.09 218.79 236.91 257.27 265.76 251.61 272.45
23 223.71 231.09 218.79 236.91 257.27 265.76 251.61 272.45
24 223.71 231.09 218.79 236.91 257.27 265.76 251.61 272.45
25 224.60 232.02 219.66 237.86 258.30 266.82 252.61 273.54
26 229.08 236.64 224.04 242.59 263.44 272.13 257.65 278.98
27 234.45 242.18 229.29 248.28 269.62 278.51 263.68 285.52
28 243.17 251.20 237.82 257.52 279.65 288.88 273.50 296.15
29 250.33 258.59 244.82 265.10 287.88 297.38 281.55 304.87
30 253.91 262.29 248.32 268.89 292.00 301.63 285.57 309.23
31 259.28 267.84 253.58 274.58 298.17 308.01 291.61 315.76
32 264.65 273.38 258.83 280.26 304.35 314.39 297.65 322.30
33 268.00 276.85 262.11 283.82 308.21 318.38 301.42 326.39
34 271.58 280.55 265.61 287.61 312.32 322.63 305.45 330.75
35 273.37 282.39 267.36 289.50 314.38 324.75 307.46 332.93
36 275.16 284.24 269.11 291.40 316.44 326.88 309.48 335.11
37 276.95 286.09 270.86 293.29 318.50 329.01 311.49 337.29
38 278.74 287.94 272.61 295.19 320.55 331.13 313.50 339.47
39 282.32 291.64 276.11 298.98 324.67 335.38 317.53 343.83
40 285.90 295.34 279.61 302.77 328.79 339.64 321.55 348.18
41 291.27 300.88 284.86 308.46 334.96 346.01 327.59 354.72
42 296.42 306.20 289.89 313.90 340.88 352.13 333.38 360.99
43 303.57 313.59 296.90 321.49 349.11 360.63 341.43 369.71
44 312.52 322.84 305.65 330.96 359.40 371.26 351.49 380.61
45 323.04 333.70 315.93 342.10 371.49 383.75 363.32 393.41
46 335.57 346.64 328.18 355.36 385.90 398.63 377.41 408.67
47 349.66 361.20 341.97 370.29 402.11 415.38 393.26 425.83
48 365.77 377.84 357.72 387.35 420.63 434.51 411.38 445.45
49 381.65 394.24 373.25 404.17 438.90 453.38 429.24 464.79
50 399.55 412.73 390.76 423.12 459.48 474.64 449.37 486.59
51 417.22 430.99 408.04 441.84 479.80 495.64 469.25 508.11
52 436.68 451.09 427.07 462.45 502.18 518.76 491.14 531.81
53 456.37 471.43 446.33 483.29 524.82 542.14 513.28 555.79
54 477.62 493.38 467.11 505.80 549.26 567.39 537.18 581.67
55 498.87 515.34 487.90 528.31 573.70 592.64 561.08 607.55
56 521.92 539.14 510.43 552.71 600.20 620.01 587.00 635.61
57 545.18 563.17 533.19 577.35 626.96 647.65 613.17 663.95
58 570.01 588.82 557.47 603.64 655.52 677.15 641.09 694.19
59 582.32 601.53 569.51 616.67 669.66 691.76 654.93 709.17
60 607.15 627.18 593.79 642.97 698.22 721.26 682.86 739.42
61 628.63 649.37 614.80 665.71 722.92 746.78 707.01 765.57
62 642.72 663.93 628.58 680.64 739.13 763.52 722.87 782.74
63 660.39 682.18 645.86 699.36 759.45 784.51 742.74 804.26
64 671.13 693.27 656.37 710.73 771.80 797.27 754.82 817.34
65 and over 671.13 693.27 656.37 710.73 771.80 797.27 754.82 817.34
Spokane
Benton, Franklin, Walla Walla, Yakima
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Kitsap, Pierce, Skagit, Snohomish, Thurston
N/A
Page 26 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780003
Plan Information
Plan Name: Bronze Essential 7150 EPO RealValue
HIOS Plan ID: 53732WA0780003
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Bronze
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 Yes
5 Yes
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 151.76 156.77 148.42 160.71 151.76 156.77 148.42 160.71
21 238.99 246.88 233.73 253.09 274.84 283.91 268.79 291.05
22 238.99 246.88 233.73 253.09 274.84 283.91 268.79 291.05
23 238.99 246.88 233.73 253.09 274.84 283.91 268.79 291.05
24 238.99 246.88 233.73 253.09 274.84 283.91 268.79 291.05
25 239.95 247.86 234.67 254.10 275.94 285.04 269.87 292.22
26 244.73 252.80 239.34 259.16 281.43 290.72 275.24 298.04
27 250.46 258.73 244.95 265.24 288.03 297.54 281.69 305.02
28 259.78 268.35 254.07 275.11 298.75 308.61 292.18 316.38
29 267.43 276.25 261.55 283.21 307.54 317.69 300.78 325.69
30 271.25 280.21 265.29 287.26 311.94 322.24 305.08 330.35
31 276.99 286.13 270.90 293.33 318.54 329.05 311.53 337.33
32 282.73 292.06 276.51 299.41 325.13 335.86 317.98 344.32
33 286.31 295.76 280.01 303.20 329.26 340.12 322.01 348.68
34 290.13 299.71 283.75 307.25 333.65 344.66 326.31 353.34
35 292.05 301.68 285.62 309.28 335.85 346.94 328.46 355.67
36 293.96 303.66 287.49 311.30 338.05 349.21 330.61 358.00
37 295.87 305.63 289.36 313.33 340.25 351.48 332.76 360.32
38 297.78 307.61 291.23 315.35 342.45 353.75 334.91 362.65
39 301.61 311.56 294.97 319.40 346.85 358.29 339.22 367.31
40 305.43 315.51 298.71 323.45 351.24 362.83 343.52 371.97
41 311.16 321.43 304.32 329.52 357.84 369.65 349.97 378.95
42 316.66 327.11 309.70 335.34 364.16 376.18 356.15 385.65
43 324.31 335.01 317.17 343.44 372.96 385.26 364.75 394.96
44 333.87 344.89 326.52 353.57 383.95 396.62 375.50 406.60
45 345.10 356.49 337.51 365.46 396.87 409.96 388.14 420.28
46 358.49 370.32 350.60 379.64 412.26 425.86 403.19 436.58
47 373.54 385.87 365.32 395.58 429.57 443.75 420.12 454.92
48 390.75 403.64 382.15 413.80 449.36 464.19 439.48 475.87
49 407.72 421.17 398.75 431.77 468.87 484.35 458.56 496.54
50 426.84 440.92 417.45 452.02 490.86 507.06 480.06 519.82
51 445.72 460.42 435.91 472.01 512.57 529.49 501.30 542.82
52 466.51 481.90 456.25 494.03 536.48 554.19 524.68 568.14
53 487.54 503.63 476.81 516.30 560.67 579.17 548.34 593.75
54 510.24 527.08 499.02 540.35 586.78 606.14 573.87 621.40
55 532.95 550.53 521.22 564.39 612.89 633.12 599.41 649.05
56 557.56 575.96 545.30 590.46 641.20 662.36 627.09 679.03
57 582.42 601.64 569.61 616.78 669.78 691.88 655.05 709.30
58 608.95 629.04 595.55 644.87 700.29 723.40 684.88 741.61
59 622.09 642.62 608.40 658.79 715.40 739.01 699.67 757.61
60 648.62 670.02 634.35 686.89 745.91 770.53 729.50 789.92
61 671.56 693.72 656.79 711.18 772.30 797.78 755.31 817.86
62 686.62 709.28 671.51 727.13 789.61 815.67 772.24 836.20
63 705.50 728.78 689.98 747.12 811.32 838.10 793.47 859.19
64 716.97 740.63 701.19 759.27 824.52 851.72 806.37 873.15
65 and over 716.97 740.63 701.19 759.27 824.52 851.72 806.37 873.15
Spokane
Benton, Franklin, Walla Walla, Yakima
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Kitsap, Pierce, Skagit, Snohomish, Thurston
N/A
Page 27 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780004
Plan Information
Plan Name: Silver HDHP 3000 EPO RealValue
HIOS Plan ID: 53732WA0780004
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 Yes
5 Yes
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 166.05 171.53 162.40 175.85 166.05 171.53 162.40 175.85
21 261.50 270.13 255.75 276.93 300.73 310.65 294.11 318.47
22 261.50 270.13 255.75 276.93 300.73 310.65 294.11 318.47
23 261.50 270.13 255.75 276.93 300.73 310.65 294.11 318.47
24 261.50 270.13 255.75 276.93 300.73 310.65 294.11 318.47
25 262.55 271.21 256.77 278.04 301.93 311.89 295.29 319.74
26 267.78 276.61 261.88 283.57 307.94 318.10 301.17 326.11
27 274.05 283.10 268.02 290.22 315.16 325.56 308.23 333.75
28 284.25 293.63 278.00 301.02 326.89 337.68 319.70 346.17
29 292.62 302.27 286.18 309.88 336.51 347.62 329.11 356.37
30 296.80 306.60 290.27 314.31 341.32 352.59 333.81 361.46
31 303.08 313.08 296.41 320.96 348.54 360.04 340.87 369.10
32 309.35 319.56 302.55 327.61 355.76 367.50 347.93 376.75
33 313.28 323.62 306.38 331.76 360.27 372.16 352.34 381.52
34 317.46 327.94 310.48 336.19 365.08 377.13 357.05 386.62
35 319.55 330.10 312.52 338.41 367.49 379.61 359.40 389.17
36 321.65 332.26 314.57 340.62 369.89 382.10 361.75 391.72
37 323.74 334.42 316.61 342.84 372.30 384.58 364.11 394.26
38 325.83 336.58 318.66 345.05 374.70 387.07 366.46 396.81
39 330.01 340.90 322.75 349.48 379.51 392.04 371.17 401.91
40 334.20 345.23 326.84 353.91 384.33 397.01 375.87 407.00
41 340.47 351.71 332.98 360.56 391.54 404.46 382.93 414.65
42 346.49 357.92 338.86 366.93 398.46 411.61 389.69 421.97
43 354.86 366.57 347.05 375.79 408.08 421.55 399.11 432.16
44 365.32 377.37 357.28 386.87 420.11 433.98 410.87 444.90
45 377.61 390.07 369.30 399.88 434.25 448.58 424.69 459.87
46 392.25 405.19 383.62 415.39 451.09 465.97 441.16 477.70
47 408.72 422.21 399.73 432.84 470.03 485.54 459.69 497.77
48 427.55 441.66 418.15 452.78 491.69 507.91 480.87 520.69
49 446.12 460.84 436.30 472.44 513.04 529.97 501.75 543.31
50 467.04 482.45 456.76 494.59 537.09 554.82 525.28 568.78
51 487.70 503.79 476.97 516.47 560.85 579.36 548.51 593.94
52 510.45 527.29 499.22 540.56 587.02 606.39 574.10 621.65
53 533.46 551.06 521.72 564.93 613.48 633.72 599.98 649.67
54 558.30 576.73 546.02 591.24 642.05 663.24 627.92 679.93
55 583.15 602.39 570.32 617.55 670.62 692.75 655.86 710.18
56 610.08 630.21 596.66 646.07 701.59 724.74 686.16 742.99
57 637.28 658.31 623.26 674.87 732.87 757.05 716.74 776.11
58 666.30 688.29 651.64 705.61 766.25 791.53 749.39 811.46
59 680.68 703.15 665.71 720.84 782.79 808.62 765.57 828.97
60 709.71 733.13 694.10 751.58 816.17 843.10 798.21 864.32
61 734.82 759.06 718.65 778.17 845.04 872.92 826.45 894.89
62 751.29 776.08 734.76 795.62 863.98 892.49 844.98 914.96
63 771.95 797.42 754.97 817.49 887.74 917.04 868.21 940.12
64 784.50 810.39 767.24 830.79 902.18 931.95 882.33 955.40
65 and over 784.50 810.39 767.24 830.79 902.18 931.95 882.33 955.40
Spokane
Benton, Franklin, Walla Walla, Yakima
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Kitsap, Pierce, Skagit, Snohomish, Thurston
N/A
Page 28 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780002
Plan Information
Plan Name: Silver Essential 3500 EPO RealValue
HIOS Plan ID: 53732WA0780002
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 Yes
5 Yes
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 174.67 180.43 170.83 184.97 174.67 180.43 170.83 184.97
21 275.07 284.15 269.02 291.30 316.33 326.77 309.37 334.99
22 275.07 284.15 269.02 291.30 316.33 326.77 309.37 334.99
23 275.07 284.15 269.02 291.30 316.33 326.77 309.37 334.99
24 275.07 284.15 269.02 291.30 316.33 326.77 309.37 334.99
25 276.17 285.28 270.09 292.46 317.60 328.08 310.61 336.33
26 281.67 290.97 275.47 298.29 323.92 334.61 316.80 343.03
27 288.27 297.79 281.93 305.28 331.51 342.45 324.22 351.07
28 299.00 308.87 292.42 316.64 343.85 355.20 336.29 364.14
29 307.80 317.96 301.03 325.96 353.97 365.65 346.19 374.86
30 312.20 322.51 305.34 330.62 359.04 370.88 351.14 380.22
31 318.81 329.33 311.79 337.62 366.63 378.73 358.56 388.26
32 325.41 336.15 318.25 344.61 374.22 386.57 365.99 396.30
33 329.53 340.41 322.28 348.98 378.96 391.47 370.63 401.32
34 333.93 344.95 326.59 353.64 384.03 396.70 375.58 406.68
35 336.14 347.23 328.74 355.97 386.56 399.31 378.05 409.36
36 338.34 349.50 330.89 358.30 389.09 401.93 380.53 412.04
37 340.54 351.77 333.04 360.63 391.62 404.54 383.00 414.72
38 342.74 354.05 335.20 362.96 394.15 407.15 385.48 417.40
39 347.14 358.59 339.50 367.62 399.21 412.38 390.43 422.76
40 351.54 363.14 343.81 372.28 404.27 417.61 395.38 428.12
41 358.14 369.96 350.26 379.27 411.86 425.45 402.80 436.16
42 364.47 376.50 356.45 385.97 419.14 432.97 409.92 443.87
43 373.27 385.59 365.06 395.29 429.26 443.43 419.82 454.59
44 384.27 396.95 375.82 406.94 441.91 456.50 432.19 467.99
45 397.20 410.31 388.46 420.64 456.78 471.86 446.73 483.73
46 412.61 426.22 403.53 436.95 474.50 490.15 464.06 502.49
47 429.93 444.12 420.48 455.30 494.42 510.74 483.55 523.60
48 449.74 464.58 439.85 476.27 517.20 534.27 505.82 547.72
49 469.27 484.76 458.95 496.96 539.66 557.47 527.79 571.50
50 491.28 507.49 480.47 520.26 564.97 583.61 552.54 598.30
51 513.01 529.93 501.72 543.27 589.96 609.42 576.98 624.76
52 536.94 554.66 525.12 568.62 617.48 637.85 603.89 653.91
53 561.14 579.66 548.80 594.25 645.31 666.61 631.12 683.39
54 587.27 606.65 574.35 621.92 675.37 697.65 660.51 715.21
55 613.41 633.65 599.91 649.60 705.42 728.70 689.90 747.04
56 641.74 662.92 627.62 679.60 738.00 762.35 721.76 781.54
57 670.35 692.47 655.60 709.90 770.90 796.34 753.94 816.38
58 700.88 724.01 685.46 742.23 806.01 832.61 788.28 853.56
59 716.01 739.64 700.26 758.25 823.41 850.58 805.29 871.99
60 746.54 771.18 730.12 790.59 858.52 886.85 839.63 909.17
61 772.95 798.45 755.94 818.55 888.89 918.22 869.33 941.33
62 790.28 816.36 772.89 836.90 908.82 938.81 888.82 962.44
63 812.01 838.80 794.14 859.92 933.81 964.62 913.26 988.90
64 825.21 852.44 807.06 873.90 948.99 980.31 928.11 1004.97
65 and over 825.21 852.44 807.06 873.90 948.99 980.31 928.11 1004.97
Spokane
Benton, Franklin, Walla Walla, Yakima
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Kitsap, Pierce, Skagit, Snohomish, Thurston
N/A
Page 29 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0780001
Plan Information
Plan Name: Gold Essential 1200 EPO RealValue
HIOS Plan ID: 53732WA0780001
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Gold
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 Yes
5 Yes
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 217.81 224.99 213.01 230.66 217.81 224.99 213.01 230.66
21 343.00 354.32 335.45 363.24 394.45 407.47 385.77 417.72
22 343.00 354.32 335.45 363.24 394.45 407.47 385.77 417.72
23 343.00 354.32 335.45 363.24 394.45 407.47 385.77 417.72
24 343.00 354.32 335.45 363.24 394.45 407.47 385.77 417.72
25 344.37 355.74 336.80 364.69 396.03 409.10 387.32 419.39
26 351.23 362.82 343.50 371.95 403.92 417.25 395.03 427.75
27 359.46 371.33 351.56 380.67 413.38 427.03 404.29 437.77
28 372.84 385.14 364.64 394.84 428.77 442.92 419.33 454.06
29 383.82 396.48 375.37 406.46 441.39 455.96 431.68 467.43
30 389.31 402.15 380.74 412.27 447.70 462.47 437.85 474.12
31 397.54 410.66 388.79 420.99 457.17 472.25 447.11 484.14
32 405.77 419.16 396.84 429.71 466.63 482.03 456.37 494.17
33 410.91 424.47 401.87 435.16 472.55 488.15 462.15 500.43
34 416.40 430.14 407.24 440.97 478.86 494.66 468.33 507.12
35 419.15 432.98 409.92 443.88 482.02 497.92 471.41 510.46
36 421.89 435.81 412.61 446.78 485.17 501.18 474.50 513.80
37 424.63 438.65 415.29 449.69 488.33 504.44 477.59 517.14
38 427.38 441.48 417.98 452.59 491.48 507.70 480.67 520.48
39 432.87 447.15 423.34 458.41 497.80 514.22 486.84 527.17
40 438.35 452.82 428.71 464.22 504.11 520.74 493.02 533.85
41 446.59 461.32 436.76 472.93 513.57 530.52 502.28 543.87
42 454.48 469.47 444.48 481.29 522.65 539.89 511.15 553.48
43 465.45 480.81 455.21 492.91 535.27 552.93 523.49 566.85
44 479.17 494.98 468.63 507.44 551.05 569.23 538.92 583.56
45 495.29 511.64 484.40 524.51 569.59 588.38 557.05 603.19
46 514.50 531.48 503.18 544.86 591.68 611.20 578.66 626.58
47 536.11 553.80 524.31 567.74 616.53 636.87 602.96 652.90
48 560.81 579.31 548.47 593.89 644.93 666.21 630.74 682.98
49 585.16 604.47 572.28 619.68 672.93 695.14 658.13 712.63
50 612.60 632.81 599.12 648.74 704.49 727.74 688.99 746.05
51 639.70 660.80 625.62 677.44 735.65 759.93 719.46 779.05
52 669.54 691.63 654.81 709.04 769.97 795.38 753.03 815.39
53 699.72 722.81 684.33 741.00 804.68 831.23 786.98 852.15
54 732.31 756.47 716.19 775.51 842.15 869.94 823.62 891.84
55 764.89 790.13 748.06 810.02 879.62 908.65 860.27 931.52
56 800.22 826.63 782.61 847.43 920.25 950.62 900.01 974.55
57 835.89 863.48 817.50 885.21 961.27 993.00 940.13 1017.99
58 873.96 902.80 854.74 925.53 1005.06 1038.23 982.95 1064.36
59 892.83 922.29 873.19 945.51 1026.75 1060.64 1004.16 1087.33
60 930.90 961.62 910.42 985.83 1070.54 1105.87 1046.99 1133.70
61 963.83 995.64 942.63 1020.70 1108.40 1144.98 1084.02 1173.80
62 985.44 1017.96 963.76 1043.58 1133.25 1170.65 1108.32 1200.12
63 1012.54 1045.95 990.26 1072.28 1164.42 1202.84 1138.80 1233.12
64 1029.00 1062.96 1006.35 1089.71 1183.35 1222.40 1157.31 1253.16
65 and over 1029.00 1062.96 1006.35 1089.71 1183.35 1222.40 1157.31 1253.16
Spokane
Benton, Franklin, Walla Walla, Yakima
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Kitsap, Pierce, Skagit, Snohomish, Thurston
N/A
Page 30 of 31
2017 Individual Nongrandfathered Health Plan 53732WA0020005
Plan Information
Plan Name: Silver HDHP 2500 RealValue
HIOS Plan ID: 53732WA0020005
Effective Date: 1/1/2017
Market Type: Individual
Exchange Status: In the exchange
Metal Level: Silver
Plan Geographic Availability
Area Number Available in area?
1 Yes
2 Yes
3 No
4 Yes
5 Yes
Plan Rates
Age
Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 1 Area 2 Area 3 Area 4 Area 5
0-20 169.59 175.19 165.86 179.60 169.59 175.19 165.86 179.60
21 267.07 275.88 261.19 282.83 307.13 317.27 300.37 325.25
22 267.07 275.88 261.19 282.83 307.13 317.27 300.37 325.25
23 267.07 275.88 261.19 282.83 307.13 317.27 300.37 325.25
24 267.07 275.88 261.19 282.83 307.13 317.27 300.37 325.25
25 268.14 276.99 262.24 283.96 308.36 318.53 301.58 326.55
26 273.48 282.50 267.46 289.61 314.50 324.88 307.58 333.06
27 279.89 289.13 273.73 296.40 321.87 332.49 314.79 340.86
28 290.31 299.89 283.92 307.43 333.85 344.87 326.51 353.55
29 298.85 308.71 292.28 316.48 343.68 355.02 336.12 363.96
30 303.12 313.13 296.46 321.01 348.59 360.10 340.92 369.16
31 309.53 319.75 302.72 327.80 355.96 367.71 348.13 376.97
32 315.94 326.37 308.99 334.58 363.34 375.33 355.34 384.77
33 319.95 330.51 312.91 338.83 367.94 380.08 359.85 389.65
34 324.22 334.92 317.09 343.35 372.86 385.16 364.65 394.85
35 326.36 337.13 319.18 345.61 375.31 387.70 367.06 397.46
36 328.50 339.34 321.27 347.88 377.77 390.24 369.46 400.06
37 330.63 341.54 323.36 350.14 380.23 392.78 371.86 402.66
38 332.77 343.75 325.45 352.40 382.68 395.31 374.27 405.26
39 337.04 348.16 329.63 356.93 387.60 400.39 379.07 410.47
40 341.32 352.58 333.81 361.45 392.51 405.47 383.88 415.67
41 347.73 359.20 340.08 368.24 399.88 413.08 391.09 423.48
42 353.87 365.55 346.08 374.75 406.95 420.38 398.00 430.96
43 362.41 374.37 354.44 383.80 416.78 430.53 407.61 441.37
44 373.10 385.41 364.89 395.11 429.06 443.22 419.62 454.38
45 385.65 398.38 377.16 408.40 443.50 458.13 433.74 469.66
46 400.61 413.82 391.79 424.24 460.70 475.90 450.56 487.88
47 417.43 431.21 408.25 442.06 480.04 495.89 469.48 508.37
48 436.66 451.07 427.05 462.42 502.16 518.73 491.11 531.79
49 455.62 470.66 445.60 482.50 523.96 541.26 512.44 554.88
50 476.99 492.73 466.49 505.13 548.54 566.64 536.47 580.90
51 498.09 514.52 487.13 527.47 572.80 591.70 560.20 606.59
52 521.32 538.52 509.85 552.08 599.52 619.30 586.33 634.89
53 544.82 562.80 532.84 576.97 626.55 647.22 612.76 663.51
54 570.19 589.01 557.65 603.84 655.72 677.36 641.30 694.41
55 595.57 615.22 582.46 630.70 684.90 707.50 669.83 725.31
56 623.07 643.64 609.37 659.84 716.54 740.18 700.77 758.81
57 650.85 672.33 636.53 689.25 748.48 773.18 732.01 792.64
58 680.49 702.95 665.52 720.64 782.57 808.39 765.35 828.74
59 695.18 718.12 679.89 736.20 799.46 825.84 781.87 846.63
60 724.83 748.75 708.88 767.59 833.55 861.06 815.21 882.73
61 750.47 775.23 733.96 794.74 863.04 891.52 844.05 913.96
62 767.29 792.61 750.41 812.56 882.39 911.50 862.97 934.45
63 788.39 814.41 771.05 834.91 906.65 936.57 886.70 960.14
64 801.21 827.64 783.57 848.48 921.39 951.80 901.11 975.75
65 and over 801.21 827.64 783.57 848.48 921.39 951.80 901.11 975.75
Spokane
Benton, Franklin, Walla Walla, Yakima
Non-Smoker Rates Smoker Rates
BridgeSpan Health Company
RATE SCHEDULE
Counties where this plan is available
King
Kitsap, Pierce, Skagit, Snohomish, Thurston
N/A
Page 31 of 31