BE READY FOR ANYTHING

Transcription

1 BE READY FOR ANYTHING Learn What You Need to Know About Your 2018 Highmark Coverage Options Benefit Period: January 1 to December 31, 2018 Plans are offered by First Priority Life Insurance Company and First Priority Health, which are subsidiaries of Highmark Blue Cross Blue Shield HEALTH INSURANCE

2 CONNECTING CARE AND COVERAGE * You want to be ready for 2018 with the right health insurance coverage in place. At Highmark, we re here to help. That s why we ve been working on new solutions that offer high-quality, easy-to-access care. This guide contains information you need to understand your health insurance options before you enroll in a 2018 plan. That means no surprises when you see your doctor, receive care at a hospital, or fill a prescription. We understand that there is a lot to consider, and that change can feel overwhelming at times. We hope you will use this guide to review details about our new 2018 plans and contact us with any questions you have. Whatever 2018 has in store for you and your family, or whatever your health demands, we want you to feel ready for anything. That s why we re offering you simplified plan options with easier access to care by: Teaming up with doctors and hospitals in your community so you don t have to travel for care Bringing care to you on your terms with virtual medicine and direct access to a Blues on Call SM health coach who is a specially trained registered nurse Important Details to Consider Before Choosing a Plan: A shorter open enrollment period only 6 weeks BlueCard is available for emergency care and urgent care Check to see if your providers are in-network Choose Highmark for Your Coverage in 2018 and You ll Have: Peace of mind from knowing your health plan is from a name trusted by generations. A network that includes top-rated, providers right in your own community. Benefits including $0 copays for preventive care, such as checkups, immunizations, and much more. Free tools and resources to help you better manage your health and get the most from your health coverage. *Plans are offered by First Priority Life Insurance Company and First Priority Health, which are subsidiaries of Highmark Blue Cross Blue Shield. We re here for you if you have questions or need help along the way: Call (TTY/TDD 711) Visit a Highmark health insurance store Visit DiscoverHighmark.com Talk to your local insurance agent We can also help you enroll through the Health Insurance Marketplace ( the Marketplace ). Or you can contact the Marketplace at: HealthCare.gov (TTY: ) 2

3 BE READY FOR ANYTHING BE ON TIME for Open Enrollment P. 4 BE WELL-INFORMED About Your Health Plan Options P. 5 BE PREPARED Before You Choose P. 12 BE KNOWLEDGEABLE with Base Plan Options & Monthly Rates by County Base Plans P. 14 Base Rates P. 27 YOUR HEALTH INSURANCE GLOSSARY P. 33 3

4 BE ON TIME for Open Enrollment SHORTER OPEN ENROLLMENT PERIOD: NOVEMBER 1 TO DECEMBER 15, 2017 Mark your calendar for this year s accelerated Open Enrollment Period. Enroll by December 15, 2017, for coverage beginning January 1, DEC Open Enrollment is the time when you can enroll in health insurance coverage. Enroll by December 15 or you won t have coverage on January 1 unless you qualify for a Special Enrollment Period. If you don t enroll in a health insurance plan for 2018, you may be charged a fee by the federal government. To avoid this fee and a lapse in coverage, sign up for a 2018 health insurance plan before Open Enrollment ends. SPECIAL ENROLLMENT PERIOD Most people will enroll during Open Enrollment. But you can also change or enroll in coverage through a Special Enrollment Period if you have a qualifying life event. Some examples are: A NEW BABY GETTING MARRIED LOSING MINIMAL ESSENTIAL COVERAGE, SUCH AS COVERAGE THROUGH AN EMPLOYER MOVING TO A NEW, PERMANENT RESIDENCE WHERE YOU CAN T HAVE ACCESS TO THE SAME HEALTH PLANS If you think a Special Enrollment Period may apply to you, you can learn more by visiting HealthCare.gov. You may be asked to submit documents to show that you re eligible for a Special Enrollment Period. 4

5 BE WELL-INFORMED About Your Health Plan Options This year s plan options are designed with you in mind. Our new 2018 plans focus on offering you high-quality care, right in your community. It s easier than ever to prepare Highmark has a variety of 2018 plan options. To bring you top-quality care, Highmark works with your local hospitals and providers. This helps to lower the rising costs of health care, and keeps your copays and other out-of-pocket costs lower. Plan options include access to Lehigh Valley Health Network facilities that provide comprehensive care to northeastern PA. Lehigh Valley is recognized for its Level 1 trauma center, children s hospital, pediatric emergency room trauma center, and intensive care unit. Along with providing access to care close to home, finding a provider is less complicated. Doctors, facilities, and other providers are either in-network or out-of-network it s that simple. HIGHMARK PLAN OPTIONS A Highmark Health Maintenance Organization (HMO) plan makes it easy to get the care you need with in-network providers. You ll have access to a network of quality doctors and hospitals based in the community. With Highmark plans, you get: $0 preventive screens and routine wellness exams $0 immunizations and vaccinations More services that can be paid with a simple copay No referrals to see a specialist See a list of in-network hospitals starting on page 8. my Priority Blue Flex HMO & my Lehigh Valley Flex Blue HMO We want you to feel ready for anything. That s why we re offering you plan options with a choice of two in-network benefit levels, or tiers. The my Priority Blue Flex HMO and my Lehigh Valley Flex Blue HMO plans include Enhanced and Standard levels of benefits. You can choose from many doctors or hospitals that participate in the HMO network. Care received from out-of-network providers is not covered under these plans, except for emergency and urgent care. Both levels offer the same high-quality care no matter which level you use. The difference is the amount you will pay for your, coinsurance, and out-of-pocket fees. Value Level of Benefits Amount You Pay In-Network (2 Value Level of Benefits) $ Enhanced $$ Standard Least out of your own pocket when you choose a network provider at the Enhanced level, than if you use a provider at the Standard level. Higher out of pocket costs for care when you select network providers from this level than from the Enhanced level. No Out-of-Network Care received from out-of-network providers is not covered, except for emergency and urgent care. 5

6 BE WELL-INFORMED About Your Health Plan Options Major Events/Catastrophic Coverage If you are under 30 or meet financial hardship requirements, the lower cost Major Events plan may be for you. It provides the protection you need in case of an emergency, serious illness, or accident. Plus, your first three visits to your primary care doctor and certain preventive services are covered at no cost. Qualified High Deductible Health Plan * Advantages Highmark also offers qualified high- plans that may be coupled with a Health Savings Account (HSA). Other than preventive care, you will pay most costs until your is met. After that, Highmark pays for most covered in-network care for the remainder of the benefit period plans are available in Bronze and Silver levels. *Highmark qualified high health plans are identified with a Q in the name. Highmark Blue Edge Dental Do you need adult dental insurance? Visit HighmarkBlueEdgeDental.com to find out more. 6

7 BE WELL-INFORMED About Your Health Plan Options IN AN EMERGENCY, YOU RE COVERED! Your health matters to us. We know medical emergencies happen and you can rest easy knowing that you re covered no matter if you are home or traveling. But there are some important things that you should know when receiving non-emergency services under most Highmark plans. * Out-of-Network Care for Emergency & Urgent Care Only Most Highmark plans include out-of-network care for emergencies and urgent care. In a medical emergency, call 911 or go immediately to the nearest emergency room. If in-patient hospital care is required, Highmark will work with the treating physician and hospital to transfer you or your family to an in-network facility once care is stable. Out-of-Area Network Coverage BlueCard coverage is available for emergency and urgent care when you are away from home. If you seek care out of the the plan network for a nonemergent condition, you may be responsible for additional costs associated with that care. REMINDER It s a good idea to check the status of the provider or facility that you are visiting before you make an appointment. If an out-of-network provider or facility is selected for non-emergency care, you may be responsible for additional costs associated with that care. *Highmark also offers PPO plans. Health care plans are subject to terms of your benefit agreement. 7

8 BE WELL-INFORMED Find a Network Hospital Clinton Tioga 28 Lycoming Union 24 Susquehanna 15 Bradford 8 Montour 9 Columbia 14 7 Northumberland Schuylkill Wyoming 16 Sullivan Lackawanna Luzerne Monroe Carbon 1,2 Northampton Lehigh 31 3 Wayne Pike my Priority Blue Flex Network Tier Enhanced Value Level of Benefits Standard Value Level of Benefits NETWORK HOSPITALS - my Priority Blue Flex HMO* # On Map County Value Level of Benefits Hospital 1 Carbon Enhanced Blue Mountain Hospital-Gnaden Campus 2 Carbon Enhanced Blue Mountain Hospital-Palmerton Campus 3 Lehigh Enhanced Lehigh Valley Hospital 4 Luzerne Enhanced Lehigh Valley Hospital-Hazleton 5 Northampton Enhanced Lehigh Valley Hospital-Muhlenberg 6 Monroe Enhanced Lehigh Valley Hospital-Pocono 7 Columbia Enhanced Berwick Hospital Center 8 Susquehanna Enhanced Endless Mountain Health System 9 Bradford Enhanced Guthrie Towanda Memorial Hospital 10 Lycoming Enhanced Jersey Shore Hospital 11 Clinton Enhanced Lock Haven Hospital 12 Lackawanna Enhanced Moses Taylor Hospital 13 Lackawanna Enhanced Regional Hospital of Scranton 14 Bradford Enhanced Robert Packer Hospital 15 Bradford Enhanced Troy Community Hospital 16 Wyoming Enhanced Tyler Memorial Hospital 17 Wayne Enhanced Wayne Memorial Hospital 18 Luzerne Enhanced Wilkes Barre General Hospital 19 Susquehanna Standard Barnes Kasson County Hospital 20 Columbia Standard Bloomsburg Hospital 21 Clinton Standard Bucktail Medical Center 22 Lycoming Standard Divine Providence Hospital 23 Northampton Standard Easton Hospital 24 Union Standard Evangelical Community Hospital 25 Lackawanna Standard Geisinger Community Medical Center 26 Luzerne Standard Geisinger Wyoming Valley Medical Center 27 Lycoming Standard Muncy Valley Hospital 28 Tioga Standard Soldiers and Sailors Memorial Hospital 29 Northampton Standard St Luke s Hospital 30 Monroe Standard St Luke's Hospital - Monroe Campus 31 Lehigh Standard St Luke s Hospital Allentown Campus 32 Northampton Standard St Luke s Hospital Anderson Campus 33 Schuylkill Standard St Luke s Miners Memorial Hospital 34 Lycoming Standard Williamsport Hospital For 2018, we re teaming up with hospitals and medical professionals in your backyard to deliver high quality care. *Network provider list as of September Please refer to the online Find a Doctor tool at HighmarkBCBS.com for a listing of network hospitals. 8

9 BE WELL-INFORMED Find a Network Hospital Clinton Tioga 28 Lycoming Union 24 Susquehanna 15 Bradford 8 Montour Sullivan 27 Northumberland 9 Columbia Schuylkill Wyoming 18 Luzerne Lackawanna Carbon 1,2 Lehigh 31 Monroe 3 Wayne Pike 6 30 Northampton MY Lehigh Valley Flex Blue HMO Network Tier Enhanced Value Level of Benefits Standard Value Level of Benefits NETWORK HOSPITALS - my Lehigh Valley Flex Blue HMO* # On Map County Value Level of Benefits Hospital 1 Carbon Enhanced Blue Mountain Hospital-Gnaden Campus 2 Carbon Enhanced Blue Mountain Hospital-Palmerton Campus 3 Lehigh Enhanced Lehigh Valley Hospital 4 Luzerne Enhanced Lehigh Valley Hospital-Hazleton 5 Northampton Enhanced Lehigh Valley Hospital-Muhlenberg 6 Monroe Enhanced Lehigh Valley Hospital-Pocono 7 Columbia Standard Berwick Hospital Center 8 Susquehanna Standard Endless Mountain Health System 9 Bradford Standard Guthrie Towanda Memorial Hospital 10 Lycoming Standard Jersey Shore Hospital 11 Clinton Standard Lock Haven Hospital 12 Lackawanna Standard Moses Taylor Hospital 13 Lackawanna Standard Regional Hospital of Scranton 14 Bradford Standard Robert Packer Hospital 15 Bradford Standard Troy Community Hospital 16 Wyoming Standard Tyler Memorial Hospital 17 Wayne Standard Wayne Memorial Hospital 18 Luzerne Standard Wilkes Barre General Hospital 19 Susquehanna Standard Barnes Kasson County Hospital 20 Columbia Standard Bloomsburg Hospital 21 Clinton Standard Bucktail Medical Center 22 Lycoming Standard Divine Providence Hospital 23 Northampton Standard Easton Hospital 24 Union Standard Evangelical Community Hospital 25 Lackawanna Standard Geisinger Community Medical Center 26 Luzerne Standard Geisinger Wyoming Valley Medical Center 27 Lycoming Standard Muncy Valley Hospital 28 Tioga Standard Soldiers and Sailors Memorial Hospital 29 Northampton Standard St Lukes Hospital 30 Monroe Standard St Luke's Hospital - Monroe Campus 31 Lehigh Standard St Luke s Hospital Allentown Campus 32 Northampton Standard St Luke s Hospital Anderson Campus 33 Schuylkill Standard St Luke s Miners Memorial Hospital 34 Lycoming Standard Williamsport Hospital *Network provider list as of September Please refer to the online Find a Doctor tool at HighmarkBCBS.com for a listing of network hospitals. 9

10 BE WELL-INFORMED Choose a Network Primary Care Provider Get More From Your Highmark Plan Choose an In-Network Primary Care Provider (PCP) Even when you re healthy, having an in-network Primary Care Provider (PCP) feels great. A PCP is the doctor, medical professional, or practice that you visit for your primary and routine health care services, such as physicals and immunizations. The Journal of Health Affairs has found that people with primary care providers enjoy lower overall health care costs and higher satisfaction with their care. A PCP Can Help You: Get the most value from your health care dollar Achieve health goals Monitor chronic health conditions Make sure you receive preventive care, like annual exams Coordinate the care you receive from other providers, such as specialists, labs, and imaging centers, to prevent gaps or overlaps in service Improve your patient experience HMO PLANS ONLY Please be aware that if you select a Highmark HMO (Health Maintenance Organization) plan and do not choose an in-network primary care provider (PCP), one will be assigned to you. How to Find Out if Your Provider Is In-Network: 3 Easy Ways Doctors, hospitals, and pharmacies in networks often change. That s why it is very important to make sure your provider and/or facility are in-network before choosing an insurance plan. That way, you ll avoid surprises and unexpected costs. If you go to an out-of-network doctor, pharmacy, hospital, or other provider, you will have to pay 100% of the cost, except in the case of emergency or urgent care. Your services may not be covered by Highmark. Find a Doctor or Rx It s quick and easy to find an in-network provider or facility. Search online by plan type to make sure your doctor, specialist, or hospital is in-network. See maps, office hours, quality ratings, member reviews, and more. Visit HighmarkBCBS.com and click Find a Doctor or Rx to get started. NEW FOR 2018 It s now easier to check which prescribed drugs are covered under your 2018 insurance plan. View Highmark s online Rx drug listing (or formulary) at HighmarkBCBS.com and click Find a Doctor or Rx. 10

11 BE WELL-INFORMED Review Your Prescription Drug List My Care Navigator Is your doctor in-network? My Care Navigator health advocates make it easy for you to find or change to an in-network doctor or facility, schedule an appointment, and transfer your medical records. Call BLUE-428 or visit MyCareNavigator.com. Highmark Member Service Already a Highmark member? You probably know the value of great customer service from our Member Service area. By calling the number on the back of your Highmark ID card, our dedicated team can help find you an in-network doctor or facility Prescription Drug List Prescription drugs are an important part of your coverage. The list of the drugs that your plan covers is called a formulary. As you choose a plan for 2018, be well-informed and avoid surprises. Be sure to check to see if your prescription drugs will be covered. Highmark plans use the Essential Formulary, which groups drugs into four levels or tiers. Each tier may include generic, brand-name, and/or specialty drugs. If your doctor prescribes a drug that is not included in the Essential Formulary, you may have to pay 100% out of pocket. It s easy to check how your prescription drugs are covered visit HighmarkEssentialFormulary.com. Essential Formulary - 4 Tiers of Drugs Tier 1 Tier 2 Tier 3 Tier 4 Low-Cost Generics Medium-Cost Generics & Low-Cost Brands High-Cost Generics & Medium/High- Cost Brands High-Cost Generics & High-Cost Brands 11

12 BE PREPARED Before You Choose Ask yourself these important questions before choosing a plan! Is my doctor in-network? Is my hospital in-network? At what tier are my prescription drugs covered and how much will they be? Can I get financial help through the Marketplace? Would I rather have lower monthly premiums or lower copays? Should I open a Health Savings Account (HSA) to manage out-of-pocket costs with a qualified high health plan? Highmark offers you the support you need to answer these questions and more. We want you to have the plan that works best for your needs so you can be ready for anything. Metal Levels and Essential Health Benefits When you are shopping for one of Highmark s Affordable Care Act (ACA) health insurance plans, it s important to know about metal levels and essential health benefits. Metal Levels Highmark s Affordable Care Act health plans are grouped in metal categories: Bronze, Silver, and Gold. These levels are based on how you and your health plan split the costs of your health care. They are simply ways to categorize plan payment levels. They do not describe the quality of care you receive. PLAN CATEGORY MONTHLY PREMIUM Essential Health Benefits All Highmark ACA plans include these essential health benefits: BRONZE SILVER GOLD Ambulatory services, such as Pediatric services, including dental Hospitalization primary care and specialist visits and vision care Laboratory services Maternity and newborn care Mental health and substance abuse services Emergency services Prescription drugs, including retail and mail order Rehabilitative and habilitative services and devices Lower Medium Higher Preventive and wellness services, and chronic disease management 12

13 BE PREPARED Before You Choose You May Qualify for Financial Help. It s Easy to Check. Most people who buy insurance through the Marketplace are pleased to learn they can get help paying for insurance. Before you enroll, you should find out if you can get this help to lower the cost of your monthly premium. To start, check the 2018 Household Income Chart below. You may qualify for one or both kinds of financial help: Advanced Premium Tax Credits (APTC), which may be applied in advance to lower what you pay each month for your premium on any Marketplace metal-level plan. Cost-Sharing Reductions (CSR)* will lower out-of-pocket costs that you may pay at the time of service for doctors visits, lab tests, drugs, and other covered services. You can only get these savings if you enroll in a Marketplace Silver metal-level plan. Eligibility for financial help can only be determined through the Marketplace at HealthCare.gov Household Persons In Family / Household Income Cost-Sharing $12,060 - $16,240 - $20,420 - $24,600 - $28,780 - $32,960 - $37,140 - $41,320 - Reductions (CSR) $30,150 $40,600 $51,050 $61,500 $71,950 $82,400 $92,850 $103,300 Advanced Premium Tax Credits (APTC) $12,060 - $48,240 $16,240 - $64,960 $20,420 - $81,680 $24,600 - $98,400 $28,780 - $115,120 $32,960 - $131,840 $37,140 - $148,560 $41,320 - $165,280 Medicaid Eligible Range ( % or less FPL) $12,060 - $16,643 $16,240 - $22,411 $20,420 - $28,180 $24,600 - $33,948 $28,780 - $39,716 $32,960 - $45,485 $37,140 - $51,253 $41,320 - $57,022 This chart is only applicable for coverage in 2018 and in the 48 contiguous states and the District of Columbia. For families/households with more than 8 persons, add $4,180 for each additional person. HHS Poverty Guidelines for 2017 (January 31, 2017). Retrieved from *American Indians and Alaska Natives who are members of federally recognized tribes are eligible for cost-sharing reductions at alternative dollar thresholds. You ll need these documents for yourself and every family member you want to enroll: Social Security numbers (or documents for legal immigrants) Birth dates Pay stubs, W-2 forms, or wage and tax statements to determine your income Policy numbers for any current health insurance Information about any health insurance you or your family could get from your job 13

14 BE KNOWLEDGEABLE With Base Plan Options by County 2018 PLAN BENEFIT GRIDS Plans are offered by First Priority Life Insurance Company and First Priority Health, which are subsidiaries of Highmark Blue Cross Blue Shield. There's a lot to know and do when it comes to picking the right plan for you and your family. If you are looking for more medical plan details, visit HighmarkBCBS-SBC.com to find each plan s Summary of Benefits and Coverage. If you do not have online access, you can get a paper copy of any Summary of Benefits free of charge by calling Highmark toll-free at (TTY/TDD 711). 14

15 Counties Plan Available In: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming my Priority Blue Major Events HMO 7350 CATASTROPHIC On Exchange Base Plan ID: 83731PA ; Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Network Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $7,350 Deductible - Aggregate (Family) 2 $14,700 Coinsurance Out of Pocket Maximum (Individual) 3 $7,350 Out of Pocket Maximum - Aggregate (Family) 3 $14,700 Office/Clinic/Urgent Care Visits Retail Clinic Visits Primary Care Provider Office Visits (Eligible For 3 Visits Prior To Deductible At Zero Cost) Specialist Office & Virtual Visits Urgent Care Center Visits Telemedicine Service Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient Hospital Outpatient Inpatient Hospital Maternity Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity Emergency Services Emergency Room Services Ambulance Therapy, Rehabilitative and Habilitative Services Physical Medicine Speech & Occupational Therapy Chiropractor Services 20 visits per benefit period Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation Outpatient Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 6 Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 Lab/Pathology 4 Skilled Nursing Facility Care 120 days per Benefit Period Prescription Drugs 8 Formulary (Drug List) - Essential Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 0% after 0% after 0% after 0% after Prescription Drug Coverage Mail (90 days supply) 0% after 0% after 0% after 0% after 15

16 Counties Plan Available In: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming my Priority Blue Flex HMO 6200BQE 9 BRONZE On Exchange Base Plan ID: 83731PA ; Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $6,200 $6,200 Deductible - Embedded (Family) 1 $12,400 $12,400 Coinsurance 1 4 Out of Pocket Maximum (Individual) 3 $6,550 Out of Pocket Maximum - Embedded (Family) 3 $13,100 Office/Clinic/Urgent Care Visits Retail Clinic Visits 1 4 Primary Care Provider Office Visits 1 4 Specialist Office & Virtual Visits 1 4 Urgent Care Center Visits 1 4 Telemedicine Service 1 Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 1 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 1 4 Hospital Outpatient 1 4 Inpatient Hospital Maternity 1 4 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 1 4 Emergency Services Emergency Room Services 1 Ambulance 1 Therapy, Rehabilitative and Habilitative Services Physical Medicine 1 4 Speech & Occupational Therapy 1 4 Chiropractor Services visits per benefit period Mental Health/Substance Abuse Inpatient 1 Inpatient Detoxification/Rehabilitation 1 Outpatient 1 Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) Lab/Pathology Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 10% after 10% after 10% after 10% after Prescription Drug Coverage Mail (90 days supply) 10% after 10% after 10% after 10% after 16

17 Counties Plan Available In: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming my Priority Blue Flex HMO 7150B BRONZE On Exchange Base Plan ID: 83731PA ; Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $7,150 $7,150 Deductible - Aggregate (Family) 2 $14,300 $14,300 Coinsurance 6 Out of Pocket Maximum (Individual) 3 $7,350 Out of Pocket Maximum - Aggregate (Family) 3 $14,700 Office/Clinic/Urgent Care Visits Retail Clinic Visits $50 copay $80 copay Primary Care Provider Office Visits $50 copay $80 copay Specialist Office & Virtual Visits $100 copay $135 copay Urgent Care Center Visits $125 copay $165 copay Telemedicine Service $20 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 6 Hospital Outpatient 6 Inpatient Hospital Maternity 6 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 6 Emergency Services Emergency Room Services Ambulance Therapy, Rehabilitative and Habilitative Services Physical Medicine 6 Speech & Occupational Therapy 6 Chiropractor Services $100 copay $135 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation Outpatient $100 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 6 6 Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $95 copay $135 copay Lab/Pathology 4 $70 copay $135 copay Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail ( 90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 17

18 Counties Plan Available In: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming my Priority Blue Flex HMO 6900S SILVER On Exchange Base Plan ID: 83731PA ; Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $6,900 $7,150 Deductible - Aggregate (Family) 2 $13,800 $14,300 Coinsurance 4 5 Out of Pocket Maximum (Individual) 3 $7,350 Out of Pocket Maximum - Aggregate (Family) 3 $14,700 Office/Clinic/Urgent Care Visits Retail Clinic Visits $50 copay $70 copay Primary Care Provider Office Visits $50 copay $70 copay Specialist Office & Virtual Visits $80 copay $100 copay Urgent Care Center Visits $100 copay $130 copay Telemedicine Service $20 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 4 5 Hospital Outpatient 4 5 Inpatient Hospital Maternity 4 5 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 4 5 Emergency Services Emergency Room Services 4 Ambulance 4 Therapy, Rehabilitative and Habilitative Services Physical Medicine 4 5 Speech & Occupational Therapy 4 5 Chiropractor Services $80 copay $100 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient 4 Inpatient Detoxification/Rehabilitation 4 Outpatient $80 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $90 copay $110 copay Lab/Pathology 4 $70 copay $100 copay Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail (90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 18

19 Counties Plan Available In: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming my Priority Blue Flex HMO 1000G GOLD On Exchange Base Plan ID: 83731PA ; Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $1,000 $2,000 Deductible - Aggregate (Family) 2 $2,000 $4,000 Coinsurance 1 Out of Pocket Maximum (Individual) 3 $6,000 Out of Pocket Maximum - Aggregate (Family) 3 $12,000 Office/Clinic/Urgent Care Visits Retail Clinic Visits $20 copay $40 copay Primary Care Provider Office Visits $20 copay $40 copay Specialist Office & Virtual Visits $60 copay $80 copay Urgent Care Center Visits $80 copay $100 copay Telemedicine Service $10 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 1 Hospital Outpatient 1 Inpatient Hospital Maternity 1 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 1 Emergency Services Emergency Room Services $250 copay (waived if admitted) Ambulance 1 Therapy, Rehabilitative and Habilitative Services Physical Medicine 1 Speech & Occupational Therapy 1 Chiropractor Services $60 copay $80 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient 1 Inpatient Detoxification/Rehabilitation 1 Outpatient $60 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 6 1 Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $60 copay $80 copay Lab/Pathology 4 $40 copay $60 copay Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail (90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 19

20 Counties Plan Available In: Carbon & Monroe my Lehigh Valley Flex Blue HMO 1000G On Exchange Base Plan ID: 83731PA ; Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $1,000 $3,000 Deductible - Aggregate (Family) 2 $2,000 $6,000 Coinsurance 2 4 Out of Pocket Maximum (Individual) 3 $6,000 Out of Pocket Maximum - Aggregate (Family) 3 $12,000 Office/Clinic/Urgent Care Visits Retail Clinic Visits $20 copay $40 copay Primary Care Provider Office Visits $20 copay $40 copay Specialist Office & Virtual Visits $60 copay $80 copay Urgent Care Center Visits $80 copay $100 copay Telemedicine Service $10 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 2 4 Hospital Outpatient 2 4 Inpatient Hospital Maternity 2 4 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 2 4 Emergency Services Emergency Room Services $250 copay (waived if admitted) Ambulance 2 Therapy, Rehabilitative and Habilitative Services Physical Medicine 2 4 Speech & Occupational Therapy 2 4 Chiropractor Services $60 copay $80 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient 2 Inpatient Detoxification/Rehabilitation 2 Outpatient $60 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $60 copay $80 copay Lab/Pathology 4 $40 copay $60 copay Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 GOLD Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail (90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 20

21 Additional Plan Options Without Financial Help The following Highmark plan options are not available on the Marketplace and may be purchased directly through Highmark without financial help in select Pennsylvania counties: my Blue Access $7,000B my Priority Blue Flex HMO 7150B my Priority Blue Flex HMO 2100S my Priority Blue Flex HMO 2750SQE my Lehigh Valley Flex Blue HMO 1850S Plans are offered by First Priority Life Insurance Company and First Priority Health, which are subsidiaries of Highmark Blue Cross Blue Shield. 21

22 Counties Plan Available In: Clinton, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming myblue Access $7,000 BRONZE Off Exchange Base Plan ID: 55957PA The chart below shows in-network costs for all categories as a member. Benefit Network Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $7,000 Deductible - Aggregate (Family) 2 $14,000 Coinsurance Out of Pocket Maximum (Individual) 3 $7,350 Out of Pocket Maximum - Aggregate (Family) 3 $14,700 Office/Clinic/Urgent Care Visits Retail Clinic Visits $60 copay Primary Care Provider Office Visits $60 copay Specialist Office & Virtual Visits $100 copay Urgent Care Center Visits Telemedicine Service $20 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient Hospital Outpatient Inpatient Hospital Maternity Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity Emergency Services Emergency Room Services Ambulance Therapy, Rehabilitative and Habilitative Services Physical Medicine Speech & Occupational Therapy Chiropractor Services $100 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation Outpatient $100 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 6 Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $100 copay Lab/Pathology 4 $60 copay Skilled Nursing Facility Care 120 days per Benefit Period Prescription Drugs 8 Formulary (Drug List) - Essential Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail (90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 22

23 Counties Plan Available In: Lycoming my Priority Blue Flex HMO 7150B BRONZE Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $7,150 $7,150 Deductible - Aggregate (Family) 2 $14,300 $14,300 Coinsurance 6 Out of Pocket Maximum (Individual) 3 $7,350 Out of Pocket Maximum - Aggregate (Family) 3 $14,700 Office/Clinic/Urgent Care Visits Retail Clinic Visits $50 copay $80 copay Primary Care Provider Office Visits $50 copay $80 copay Specialist Office & Virtual Visits $100 copay $135 copay Urgent Care Center Visits $125 copay $165 copay Telemedicine Service $20 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 6 Hospital Outpatient 6 Inpatient Hospital Maternity 6 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 6 Emergency Services Emergency Room Services Ambulance Therapy, Rehabilitative and Habilitative Services Physical Medicine 6 Speech & Occupational Therapy 6 Chiropractor Services $100 copay $135 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation Outpatient $100 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 6 6 Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $95 copay $135 copay Lab/Pathology 4 $70 copay $135 copay Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail ( 90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 23

24 Counties Plan Available In: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming my Priority Blue Flex HMO 2100S SILVER Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $2,100 $4,200 Deductible - Aggregate (Family) 2 $4,200 $8,400 Coinsurance 5 Out of Pocket Maximum (Individual) 3 $7,350 Out of Pocket Maximum - Aggregate (Family) 3 $14,700 Office/Clinic/Urgent Care Visits Retail Clinic Visits $25 copay $45 copay Primary Care Provider Office Visits $25 copay $45 copay Specialist Office & Virtual Visits $90 copay $120 copay Urgent Care Center Visits $100 copay $130 copay Telemedicine Service $20 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 5 Hospital Outpatient 5 Inpatient Hospital Maternity 5 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 5 Emergency Services Emergency Room Services $750 copay (waived if admitted) Ambulance Therapy, Rehabilitative and Habilitative Services Physical Medicine 5 Speech & Occupational Therapy 5 Chiropractor Services $90 copay $120 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation Outpatient $90 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 6 5 Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $90 copay $140 copay Lab/Pathology 4 $70 copay $120 copay Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail (90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 24

25 Counties Plan Available In: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming my Priority Blue Flex HMO 2750SQE 9 Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $2,750 $2,750 SILVER Deductible - Embedded (Family) 1 $5,500 $5,500 Coinsurance 2 4 Out of Pocket Maximum (Individual) 3 $6,000 Out of Pocket Maximum - Embedded (Family) 3 $12,000 Office/Clinic/Urgent Care Visits Retail Clinic Visits 2 4 Primary Care Provider Office Visits 2 4 Specialist Office & Virtual Visits 2 4 Urgent Care Center Visits 2 4 Telemedicine Service 2 Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 2 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 2 4 Hospital Outpatient 2 4 Inpatient Hospital Maternity 2 4 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 2 4 Emergency Services Emergency Room Services 2 Ambulance 2 Therapy, Rehabilitative and Habilitative Services Physical Medicine 2 4 Speech & Occupational Therapy 2 4 Chiropractor Services visits per benefit period Mental Health/Substance Abuse Inpatient 2 Inpatient Detoxification/Rehabilitation 2 Outpatient 2 Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) Lab/Pathology Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 20% after 20% after 20% after 20% after Prescription Drug Coverage Mail (90 days supply) 20% after 20% after 20% after 20% after 25

26 Counties Plan Available In: Carbon & Monroe my Lehigh Valley Flex Blue HMO 1850S SILVER Off Exchange Base Plan ID: 83731PA The chart below shows in-network costs for all categories as a member. Benefit Enhanced Standard Deductible/Coinsurance and Out of Pocket Costs Deductible Individual $1,850 $4,200 Deductible - Aggregate (Family) 2 $3,700 $8,400 Coinsurance 5 Out of Pocket Maximum (Individual) 3 $7,350 Out of Pocket Maximum - Aggregate (Family) 3 $14,700 Office/Clinic/Urgent Care Visits Retail Clinic Visits $25 copay $45 copay Primary Care Provider Office Visits $25 copay $45 copay Specialist Office & Virtual Visits $90 copay $120 copay Urgent Care Center Visits $100 copay $130 copay Telemedicine Service $20 copay Pediatric Dental and Vision Pediatric Vision Exam 7 Pediatric Vision Frame selection/standard eyeglass lenses 7 Pediatric Dental Exam and Cleanings 7 Pediatric Dental Basic Restorative Services 7 5 Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 5 Hospital Outpatient 5 Inpatient Hospital Maternity 5 Medical Care (including inpatient visits and consultations)/surgical Expenses and Maternity 5 Emergency Services Emergency Room Services $750 copay (waived if admitted) Ambulance Therapy, Rehabilitative and Habilitative Services Physical Medicine 5 Speech & Occupational Therapy 5 Chiropractor Services $90 copay $120 copay 20 visits per benefit period Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation Outpatient $90 copay Other Services Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 6 5 Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 5 $100 copay $130 copay Lab/Pathology 4 $80 copay $110 copay Skilled Nursing Facility Care days per Benefit Period Formulary (Drug List) - Essential Prescription Drugs 8 Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 15% ($3 min / $10 max) 25% ($20 min / $75 max) 35% ($70 min / $250 max) 50% ($150 min / $1,000 max) Prescription Drug Coverage Mail (90 days supply) 15% ($6 min / $20 max) 25% ($40 min / $150 max) 35% ($140 min / $500 max) 50% ($300 min / $2,000 max) 26

27 BE KNOWLEDGEABLE with Base Monthly Rates by County Understand How Your Monthly Premium Rate Is Calculated At Highmark, we want you to trust in the value of your health care coverage. To help you understand how we calculate the price you pay, we have included a guide to base rates on pages The base premium rate listed is the most a person* will pay for their premium each month. Find Your Rate By: The county where you live. If you re under age 21, find either the county where you live or the county where you live with your parent/guardian. The Highmark plan you wish to purchase Your age and the age of each dependent on your plan Your tobacco use and the tobacco use of each dependent on your plan If You Have More Than Three Children Under Age 21: Only include rates for you, your spouse/domestic partner, children between ages 21 26, and/or the three oldest children under age 21. Your policy will also cover your remaining children. Please include them as eligible dependents when you enroll. *If you are also enrolling family members, you will need to get the base rate for each member of your family. Add these base rates together to get the rate that covers the family members on your plan. 27

28 BASE RATES FOR YOUR COUNTY (Use the Plan ID to find your plan on the Marketplace.) Bradford, Clinton, Carbon, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne & Wyoming CATASTROPHIC BRONZE BRONZE SILVER GOLD Major Events Blue HMO 7350 my Priority Blue Flex HMO 6200BQE my Priority Blue Flex HMO 7150B my Priority Blue Flex HMO 6900S my Priority Blue Flex HMO 1000G PLAN ID 83731PA PA PA PA PA AGE No Tobacco Tobacco No Tobacco Tobacco No Tobacco Tobacco No Tobacco Tobacco No Tobacco Tobacco 0-14 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $ $ $ $ $ $ $ $1, $ $1, $ $ $ $ $ $ $ $1, $ $1, $ $ $ $ $ $ $ $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $ $1, $ $ $ $ $ $ $1, $1, $1, $1, $ $ $ $ $ $ $1, $1, $1, $1, $ $ $ $ $ $ $1, $1, $1, $1, $ $ $ $ $ $ $1, $1, $1, $1, $ $ $ $ $ $1, $1, $1, $1, $1, $ $ $ $1, $ $1, $1, $1, $1, $1, $ $ $ $1, $ $1, $1, $1, $1, $1, $ $ $ $1, $ $1, $1, $1, $1, $1, $ $ $ $1, $ $1, $1, $1, $1, $1,

29 BASE RATES FOR YOUR COUNTY (Use the Plan ID to find your plan on the Marketplace.) Carbon & Monroe GOLD my Lehigh Valley Flex Blue HMO 1000G PLAN ID 83731PA AGE No Tobacco Tobacco 0-14 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $1, $ $1, $ $1, $ $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1,