Individual Nongrandfathered Health Plan 87718WA2190001

Plan Information

Plan Name: Regence Cascade Gold Individual and Family Network

HIOS Plan ID: 87718WA2190001

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Inside the Exchange

Metal Level: Gold

Plan Type: Standardized Non-Public Option Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 334.11 373.87 362.18 345.47 351.82 346.81 334.11 373.87 362.18 345.47 351.82 346.81

15 363.81 407.11 394.37 376.18 383.09 377.64 363.81 407.11 394.37 376.18 383.09 377.64

16 375.17 419.81 406.68 387.92 395.05 389.42 375.17 419.81 406.68 387.92 395.05 389.42

17 386.52 432.52 418.99 399.67 407.01 401.21 386.52 432.52 418.99 399.67 407.01 401.21

18 398.75 446.20 432.25 412.31 419.89 413.91 398.75 446.20 432.25 412.31 419.89 413.91

19 410.98 459.89 445.50 424.96 432.76 426.60 410.98 459.89 445.50 424.96 432.76 426.60

20 423.65 474.06 459.23 438.05 446.10 439.75 423.65 474.06 459.23 438.05 446.10 439.75

21 436.75 488.72 473.44 451.60 459.90 453.35 502.26 562.03 544.45 519.34 528.88 521.35

22 436.75 488.72 473.44 451.60 459.90 453.35 502.26 562.03 544.45 519.34 528.88 521.35

23 436.75 488.72 473.44 451.60 459.90 453.35 502.26 562.03 544.45 519.34 528.88 521.35

24 436.75 488.72 473.44 451.60 459.90 453.35 502.26 562.03 544.45 519.34 528.88 521.35

25 438.50 490.68 475.33 453.41 461.74 455.16 504.27 564.28 546.63 521.42 531.00 523.43

26 447.23 500.45 484.80 462.44 470.94 464.23 514.32 575.52 557.52 531.80 541.58 533.86

27 457.71 512.18 496.16 473.28 481.97 475.11 526.37 589.01 570.59 544.27 554.27 546.37

28 474.75 531.24 514.63 490.89 499.91 492.79 545.96 610.93 591.82 564.52 574.90 566.71

29 488.72 546.88 529.78 505.34 514.63 507.29 562.03 628.91 609.24 581.14 591.82 583.39

30 495.71 554.70 537.35 512.57 521.98 514.55 570.07 637.91 617.95 589.45 600.28 591.73

31 506.19 566.43 548.71 523.40 533.02 525.43 582.12 651.39 631.02 601.91 612.97 604.24

32 516.68 578.16 560.08 534.24 544.06 536.31 594.18 664.88 644.09 614.38 625.67 616.76

33 523.23 585.49 567.18 541.02 550.96 543.11 601.71 673.31 652.25 622.17 633.60 624.58

34 530.21 593.31 574.75 548.24 558.32 550.36 609.75 682.31 660.97 630.48 642.06 632.92

35 533.71 597.22 578.54 551.85 562.00 553.99 613.76 686.80 665.32 634.63 646.29 637.09

36 537.20 601.13 582.33 555.47 565.67 557.62 617.78 691.30 669.68 638.79 650.53 641.26

37 540.70 605.04 586.12 559.08 569.35 561.24 621.80 695.80 674.03 642.94 654.76 645.43

38 544.19 608.95 589.90 562.69 573.03 564.87 625.82 700.29 678.39 647.10 658.99 649.60

39 551.18 616.77 597.48 569.92 580.39 572.12 633.86 709.28 687.10 655.41 667.45 657.94

40 558.17 624.59 605.05 577.14 587.75 579.38 641.89 718.28 695.81 663.72 675.91 666.28

41 568.65 636.32 616.41 587.98 598.79 590.26 653.95 731.77 708.88 676.18 688.60 678.80

42 578.69 647.56 627.30 598.37 609.36 600.68 665.50 744.69 721.40 688.12 700.77 690.79

43 592.67 663.20 642.45 612.82 624.08 615.19 681.57 762.68 738.82 704.74 717.69 707.47

44 610.14 682.75 661.39 630.88 642.48 633.33 701.66 785.16 760.60 725.52 738.85 728.32

45 630.67 705.72 683.64 652.11 664.09 654.63 725.27 811.57 786.19 749.93 763.71 752.83

46 655.13 733.08 710.16 677.40 689.85 680.02 753.39 843.05 816.68 779.01 793.32 782.02

47 682.64 763.87 739.98 705.85 718.82 708.58 785.04 878.46 850.98 811.73 826.64 814.87

48 714.09 799.06 774.07 738.37 751.93 741.22 821.20 918.92 890.18 849.12 864.72 852.40

49 745.10 833.76 807.68 770.43 784.59 773.41 856.86 958.83 928.84 885.99 902.27 889.42

50 780.04 872.86 845.56 806.56 821.38 809.68 897.04 1003.79 972.39 927.54 944.58 931.13

51 814.54 911.47 882.96 842.23 857.71 845.49 936.72 1048.19 1015.40 968.57 986.37 972.31

52 852.54 953.99 924.15 881.52 897.72 884.93 980.42 1097.09 1062.77 1013.75 1032.38 1017.67

53 890.97 997.00 965.81 921.26 938.19 924.83 1024.62 1146.54 1110.68 1059.45 1078.92 1063.55

54 932.46 1043.42 1010.79 964.16 981.88 967.89 1072.33 1199.94 1162.41 1108.79 1129.16 1113.08

55 973.95 1089.85 1055.76 1007.07 1025.57 1010.96 1120.05 1253.33 1214.13 1158.13 1179.41 1162.61

56 1018.94 1140.19 1104.53 1053.58 1072.94 1057.66 1171.78 1311.22 1270.21 1211.62 1233.88 1216.31

57 1064.36 1191.02 1153.77 1100.55 1120.77 1104.81 1224.01 1369.67 1326.83 1265.63 1288.89 1270.53

58 1112.84 1245.27 1206.32 1150.68 1171.82 1155.13 1279.76 1432.06 1387.27 1323.28 1347.59 1328.40

59 1136.86 1272.15 1232.36 1175.51 1197.11 1180.06 1307.39 1462.97 1417.21 1351.84 1376.68 1357.07

60 1185.34 1326.39 1284.91 1225.64 1248.16 1230.38 1363.14 1525.35 1477.64 1409.49 1435.39 1414.94

61 1227.27 1373.31 1330.36 1268.99 1292.31 1273.90 1411.36 1579.31 1529.91 1459.34 1486.16 1464.99

62 1254.78 1404.10 1360.18 1297.45 1321.29 1302.46 1443.00 1614.72 1564.21 1492.06 1519.48 1497.83

63 1289.29 1442.71 1397.59 1333.12 1357.62 1338.28 1482.68 1659.12 1607.22 1533.09 1561.26 1539.02

64 and over 1310.25 1466.16 1420.31 1354.80 1379.69 1360.04 1506.78 1686.09 1633.35 1558.02 1586.64 1564.05

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 1 of 12

Individual Nongrandfathered Health Plan 87718WA2190002

Plan Information

Plan Name: Regence Cascade Silver Individual and Family Network

HIOS Plan ID: 87718WA2190002

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Inside the Exchange

Metal Level: Silver

Plan Type: Standardized Non-Public Option Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 284.53 318.39 308.43 294.20 299.61 295.34 284.53 318.39 308.43 294.20 299.61 295.34

15 309.82 346.69 335.84 320.35 326.24 321.59 309.82 346.69 335.84 320.35 326.24 321.59

16 319.49 357.51 346.32 330.35 336.42 331.63 319.49 357.51 346.32 330.35 336.42 331.63

17 329.16 368.33 356.81 340.35 346.60 341.67 329.16 368.33 356.81 340.35 346.60 341.67

18 339.57 379.98 368.10 351.12 357.57 352.48 339.57 379.98 368.10 351.12 357.57 352.48

19 349.99 391.63 379.38 361.89 368.54 363.29 349.99 391.63 379.38 361.89 368.54 363.29

20 360.77 403.70 391.08 373.04 379.89 374.48 360.77 403.70 391.08 373.04 379.89 374.48

21 371.93 416.19 403.17 384.58 391.64 386.06 427.72 478.62 463.65 442.26 450.39 443.97

22 371.93 416.19 403.17 384.58 391.64 386.06 427.72 478.62 463.65 442.26 450.39 443.97

23 371.93 416.19 403.17 384.58 391.64 386.06 427.72 478.62 463.65 442.26 450.39 443.97

24 371.93 416.19 403.17 384.58 391.64 386.06 427.72 478.62 463.65 442.26 450.39 443.97

25 373.42 417.85 404.78 386.11 393.21 387.61 429.43 480.53 465.50 444.03 452.19 445.75

26 380.86 426.18 412.85 393.81 401.04 395.33 437.98 490.10 474.78 452.88 461.20 454.63

27 389.78 436.17 422.52 403.04 410.44 404.59 448.25 501.59 485.90 463.49 472.01 465.28

28 404.29 452.40 438.25 418.03 425.72 419.65 464.93 520.26 503.99 480.74 489.57 482.60

29 416.19 465.72 451.15 430.34 438.25 432.00 478.62 535.57 518.82 494.89 503.98 496.81

30 422.14 472.38 457.60 436.49 444.51 438.18 485.46 543.23 526.24 501.97 511.19 503.91

31 431.07 482.36 467.28 445.72 453.91 447.45 495.73 554.72 537.37 512.58 522.00 514.56

32 439.99 492.35 476.95 454.95 463.31 456.71 505.99 566.21 548.50 523.20 532.81 525.22

33 445.57 498.60 483.00 460.72 469.19 462.50 512.41 573.38 555.45 529.83 539.57 531.88

34 451.52 505.25 489.45 466.87 475.45 468.68 519.25 581.04 562.87 536.91 546.77 538.98

35 454.50 508.58 492.68 469.95 478.59 471.77 522.67 584.87 566.58 540.44 550.37 542.53

36 457.47 511.91 495.90 473.03 481.72 474.86 526.09 588.70 570.29 543.98 553.98 546.09

37 460.45 515.24 499.13 476.10 484.85 477.95 529.52 592.53 574.00 547.52 557.58 549.64

38 463.42 518.57 502.35 479.18 487.99 481.03 532.94 596.36 577.71 551.06 561.18 553.19

39 469.38 525.23 508.80 485.33 494.25 487.21 539.78 604.02 585.12 558.13 568.39 560.29

40 475.33 531.89 515.25 491.49 500.52 493.39 546.63 611.67 592.54 565.21 575.60 567.40

41 484.25 541.88 524.93 500.72 509.92 502.65 556.89 623.16 603.67 575.83 586.41 578.05

42 492.81 551.45 534.20 509.56 518.93 511.53 566.73 634.17 614.33 586.00 596.76 588.26

43 504.71 564.77 547.10 521.87 531.46 523.89 580.42 649.48 629.17 600.15 611.18 602.47

44 519.59 581.42 563.23 537.25 547.12 539.33 597.52 668.63 647.72 617.84 629.19 620.23

45 537.07 600.98 582.18 555.33 565.53 557.48 617.63 691.12 669.51 638.63 650.36 641.10

46 557.90 624.28 604.76 576.86 587.46 579.10 641.58 717.93 695.47 663.39 675.58 665.96

47 581.33 650.50 630.16 601.09 612.14 603.42 668.53 748.08 724.68 691.26 703.96 693.93

48 608.11 680.47 659.19 628.78 640.34 631.21 699.32 782.54 758.06 723.10 736.39 725.90

49 634.51 710.02 687.81 656.09 668.14 658.62 729.69 816.52 790.98 754.50 768.36 757.42

50 664.27 743.31 720.07 686.85 699.47 689.51 763.91 854.81 828.08 789.88 804.39 792.94

51 693.65 776.19 751.92 717.23 730.41 720.01 797.70 892.62 864.70 824.82 839.97 828.01

52 726.01 812.40 786.99 750.69 764.49 753.60 834.91 934.26 905.04 863.30 879.16 866.63

53 758.74 849.03 822.47 784.53 798.95 787.57 872.55 976.38 945.84 902.21 918.79 905.70

54 794.07 888.56 860.77 821.07 836.16 824.25 913.18 1021.85 989.89 944.23 961.58 947.88

55 829.40 928.10 899.07 857.60 873.36 860.92 953.81 1067.32 1033.93 986.24 1004.37 990.06

56 867.71 970.97 940.60 897.21 913.70 900.69 997.87 1116.62 1081.69 1031.80 1050.76 1035.79

57 906.39 1014.25 982.53 937.21 954.43 940.84 1042.35 1166.39 1129.91 1077.79 1097.60 1081.96

58 947.68 1060.45 1027.28 979.90 997.90 983.69 1089.83 1219.52 1181.37 1126.88 1147.59 1131.24

59 968.13 1083.34 1049.46 1001.05 1019.44 1004.92 1113.35 1245.84 1206.88 1151.21 1172.36 1155.66

60 1009.42 1129.54 1094.21 1043.74 1062.92 1047.78 1160.83 1298.97 1258.34 1200.30 1222.35 1204.94

61 1045.12 1169.49 1132.91 1080.66 1100.51 1084.84 1201.89 1344.92 1302.85 1242.76 1265.59 1247.56

62 1068.55 1195.71 1158.31 1104.89 1125.19 1109.16 1228.84 1375.07 1332.06 1270.62 1293.97 1275.53

63 1097.94 1228.59 1190.16 1135.27 1156.13 1139.66 1262.63 1412.88 1368.69 1305.56 1329.55 1310.61

64 and over 1115.79 1248.57 1209.51 1153.73 1174.92 1158.18 1283.16 1435.85 1390.94 1326.78 1351.17 1331.91

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 2 of 12

Individual Nongrandfathered Health Plan 87718WA2170001

Plan Information

Plan Name: Silver 3000 Exchange EPO Individual and Family Network

HIOS Plan ID: 87718WA2170001

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Inside the Exchange

Metal Level: Silver

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 274.35 307.00 297.40 283.68 288.89 284.78 274.35 307.00 297.40 283.68 288.89 284.78

15 298.74 334.29 323.83 308.90 314.57 310.09 298.74 334.29 323.83 308.90 314.57 310.09

16 308.06 344.72 333.94 318.54 324.39 319.77 308.06 344.72 333.94 318.54 324.39 319.77

17 317.39 355.16 344.05 328.18 334.21 329.45 317.39 355.16 344.05 328.18 334.21 329.45

18 327.43 366.39 354.93 338.56 344.78 339.87 327.43 366.39 354.93 338.56 344.78 339.87

19 337.47 377.63 365.82 348.94 355.36 350.29 337.47 377.63 365.82 348.94 355.36 350.29

20 347.87 389.27 377.09 359.70 366.31 361.09 347.87 389.27 377.09 359.70 366.31 361.09

21 358.63 401.31 388.75 370.82 377.64 372.26 412.42 461.50 447.07 426.45 434.28 428.10

22 358.63 401.31 388.75 370.82 377.64 372.26 412.42 461.50 447.07 426.45 434.28 428.10

23 358.63 401.31 388.75 370.82 377.64 372.26 412.42 461.50 447.07 426.45 434.28 428.10

24 358.63 401.31 388.75 370.82 377.64 372.26 412.42 461.50 447.07 426.45 434.28 428.10

25 360.06 402.91 390.31 372.31 379.15 373.75 414.07 463.35 448.86 428.15 436.02 429.81

26 367.24 410.94 398.09 379.72 386.70 381.19 422.32 472.58 457.80 436.68 444.71 438.37

27 375.84 420.57 407.42 388.62 395.76 390.13 432.22 483.66 468.53 446.92 455.13 448.65

28 389.83 436.22 422.58 403.09 410.49 404.64 448.31 501.65 485.96 463.55 472.07 465.34

29 401.31 449.06 435.02 414.95 422.58 416.56 461.50 516.42 500.27 477.19 485.96 479.04

30 407.05 455.48 441.24 420.88 428.62 422.51 468.10 523.81 507.42 484.02 492.91 485.89

31 415.65 465.11 450.57 429.78 437.68 431.45 478.00 534.88 518.15 494.25 503.33 496.16

32 424.26 474.75 459.90 438.68 446.75 440.38 487.90 545.96 528.88 504.49 513.76 506.44

33 429.64 480.77 465.73 444.25 452.41 445.97 494.08 552.88 535.59 510.88 520.27 512.86

34 435.38 487.19 471.95 450.18 458.45 451.92 500.68 560.26 542.74 517.71 527.22 519.71

35 438.25 490.40 475.06 453.15 461.47 454.90 503.98 563.96 546.32 521.12 530.69 523.13

36 441.11 493.61 478.17 456.11 464.49 457.88 507.28 567.65 549.89 524.53 534.17 526.56

37 443.98 496.82 481.28 459.08 467.52 460.86 510.58 571.34 553.47 527.94 537.64 529.98

38 446.85 500.03 484.39 462.05 470.54 463.83 513.88 575.03 557.05 531.35 541.12 533.41

39 452.59 506.45 490.61 467.98 476.58 469.79 520.48 582.42 564.20 538.18 548.07 540.26

40 458.33 512.87 496.83 473.91 482.62 475.75 527.08 589.80 571.35 545.00 555.01 547.11

41 466.94 522.50 506.16 482.81 491.68 484.68 536.98 600.88 582.08 555.23 565.44 557.38

42 475.18 531.73 515.10 491.34 500.37 493.24 546.46 611.49 592.37 565.04 575.42 567.23

43 486.66 544.57 527.54 503.21 512.45 505.15 559.66 626.26 606.67 578.69 589.32 580.93

44 501.01 560.63 543.09 518.04 527.56 520.04 576.16 644.72 624.55 595.75 606.69 598.05

45 517.86 579.49 561.36 535.47 545.31 537.54 595.54 666.41 645.57 615.79 627.10 618.17

46 537.95 601.96 583.13 556.24 566.46 558.39 618.64 692.25 670.60 639.67 651.42 642.14

47 560.54 627.24 607.62 579.60 590.25 581.84 644.62 721.33 698.77 666.54 678.78 669.12

48 586.36 656.14 635.61 606.30 617.44 608.64 674.31 754.56 730.96 697.24 710.05 699.94

49 611.82 684.63 663.22 632.62 644.25 635.07 703.60 787.32 762.70 727.52 740.89 730.33

50 640.51 716.73 694.32 662.29 674.46 664.85 736.59 824.24 798.46 761.63 775.63 764.58

51 668.84 748.44 725.03 691.59 704.29 694.26 769.17 860.70 833.78 795.32 809.94 798.40

52 700.05 783.35 758.85 723.85 737.15 726.65 805.05 900.85 872.68 832.42 847.72 835.64

53 731.61 818.67 793.06 756.48 770.38 759.41 841.35 941.47 912.02 869.95 885.94 873.32

54 765.68 856.79 829.99 791.71 806.26 794.77 880.53 985.31 954.49 910.46 927.19 913.99

55 799.74 894.91 866.92 826.94 842.13 830.14 919.71 1029.15 996.96 950.98 968.45 954.66

56 836.68 936.25 906.97 865.13 881.03 868.48 962.19 1076.69 1043.01 994.90 1013.18 998.75

57 873.98 977.99 947.40 903.70 920.30 907.19 1005.08 1124.68 1089.51 1039.25 1058.35 1043.27

58 913.79 1022.53 990.55 944.86 962.22 948.51 1050.86 1175.91 1139.13 1086.59 1106.55 1090.79

59 933.51 1044.60 1011.93 965.25 982.99 968.99 1073.54 1201.29 1163.72 1110.04 1130.44 1114.34

60 973.32 1089.15 1055.08 1006.41 1024.91 1010.31 1119.32 1252.52 1213.34 1157.38 1178.64 1161.85

61 1007.75 1127.67 1092.40 1042.01 1061.16 1046.04 1158.91 1296.82 1256.26 1198.32 1220.34 1202.95

62 1030.34 1152.95 1116.89 1065.38 1084.95 1069.50 1184.90 1325.90 1284.43 1225.18 1247.70 1229.92

63 1058.68 1184.66 1147.60 1094.67 1114.79 1098.91 1217.48 1362.36 1319.75 1258.87 1282.00 1263.74

64 and over 1075.89 1203.92 1166.25 1112.46 1132.91 1116.77 1237.26 1384.50 1341.20 1279.34 1302.84 1284.29

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 3 of 12

Individual Nongrandfathered Health Plan 87718WA2150003

Plan Information

Plan Name: Silver 3000 EPO Individual and Family Network

HIOS Plan ID: 87718WA2150003

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Outside the Exchange

Metal Level: Silver

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 242.89 271.79 263.29 251.15 255.76 252.12 242.89 271.79 263.29 251.15 255.76 252.12

15 264.48 295.95 286.69 273.47 278.49 274.53 264.48 295.95 286.69 273.47 278.49 274.53

16 272.73 305.19 295.64 282.01 287.19 283.10 272.73 305.19 295.64 282.01 287.19 283.10

17 280.99 314.43 304.59 290.54 295.88 291.67 280.99 314.43 304.59 290.54 295.88 291.67

18 289.88 324.37 314.23 299.73 305.24 300.89 289.88 324.37 314.23 299.73 305.24 300.89

19 298.77 334.32 323.86 308.93 314.60 310.12 298.77 334.32 323.86 308.93 314.60 310.12

20 307.98 344.62 333.84 318.45 324.30 319.68 307.98 344.62 333.84 318.45 324.30 319.68

21 317.50 355.28 344.17 328.30 334.33 329.57 365.13 408.57 395.80 377.54 384.48 379.00

22 317.50 355.28 344.17 328.30 334.33 329.57 365.13 408.57 395.80 377.54 384.48 379.00

23 317.50 355.28 344.17 328.30 334.33 329.57 365.13 408.57 395.80 377.54 384.48 379.00

24 317.50 355.28 344.17 328.30 334.33 329.57 365.13 408.57 395.80 377.54 384.48 379.00

25 318.77 356.70 345.55 329.61 335.66 330.88 366.59 410.21 397.38 379.05 386.01 380.52

26 325.12 363.81 352.43 336.17 342.35 337.47 373.89 418.38 405.29 386.60 393.70 388.10

27 332.74 372.34 360.69 344.05 350.38 345.38 382.65 428.19 414.79 395.66 402.93 397.19

28 345.12 386.19 374.11 356.86 363.41 358.24 396.89 444.12 430.23 410.39 417.93 411.97

29 355.28 397.56 385.13 367.36 374.11 368.78 408.57 457.20 442.90 422.47 430.23 424.10

30 360.36 403.25 390.63 372.61 379.46 374.06 414.42 463.73 449.23 428.51 436.38 430.16

31 367.98 411.77 398.89 380.49 387.49 381.97 423.18 473.54 458.73 437.57 445.61 439.26

32 375.60 420.30 407.15 388.37 395.51 389.88 431.94 483.34 468.23 446.63 454.84 448.36

33 380.37 425.63 412.32 393.30 400.52 394.82 437.42 489.47 474.16 452.29 460.60 454.04

34 385.45 431.31 417.82 398.55 405.87 400.09 443.26 496.01 480.50 458.33 466.75 460.11

35 387.99 434.16 420.58 401.18 408.55 402.73 446.18 499.28 483.66 461.35 469.83 463.14

36 390.53 437.00 423.33 403.80 411.22 405.36 449.10 502.55 486.83 464.37 472.91 466.17

37 393.07 439.84 426.08 406.43 413.90 408.00 452.02 505.82 489.99 467.39 475.98 469.20

38 395.61 442.68 428.84 409.06 416.57 410.64 454.95 509.08 493.16 470.41 479.06 472.23

39 400.69 448.37 434.34 414.31 421.92 415.91 460.79 515.62 499.49 476.45 485.21 478.30

40 405.77 454.05 439.85 419.56 427.27 421.18 466.63 522.16 505.83 482.50 491.36 484.36

41 413.39 462.58 448.11 427.44 435.29 429.09 475.39 531.96 515.33 491.56 500.59 493.46

42 420.69 470.75 456.03 434.99 442.98 436.67 483.79 541.36 524.43 500.24 509.43 502.17

43 430.85 482.12 467.04 445.50 453.68 447.22 495.47 554.44 537.09 512.32 521.73 514.30

44 443.55 496.33 480.81 458.63 467.06 460.40 510.08 570.78 552.93 527.42 537.11 529.46

45 458.47 513.03 496.98 474.06 482.77 475.89 527.24 589.98 571.53 545.17 555.18 547.28

46 476.25 532.92 516.26 492.44 501.49 494.35 547.69 612.86 593.69 566.31 576.71 568.50

47 496.25 555.31 537.94 513.13 522.55 515.11 570.69 638.60 618.63 590.09 600.94 592.38

48 519.11 580.89 562.72 536.76 546.63 538.84 596.98 668.02 647.13 617.28 628.62 619.66

49 541.66 606.11 587.15 560.07 570.36 562.24 622.90 697.03 675.23 644.08 655.92 646.57

50 567.06 634.53 614.69 586.33 597.11 588.60 652.11 729.71 706.89 674.29 686.68 676.89

51 592.14 662.60 641.88 612.27 623.52 614.64 680.96 761.99 738.16 704.11 717.05 706.83

52 619.76 693.51 671.82 640.83 652.61 643.31 712.72 797.54 772.59 736.96 750.50 739.81

53 647.70 724.78 702.11 669.72 682.03 672.31 744.86 833.49 807.42 770.18 784.33 773.16

54 677.86 758.53 734.80 700.91 713.79 703.62 779.54 872.31 845.02 806.05 820.86 809.16

55 708.03 792.28 767.50 732.10 745.55 734.93 814.23 911.12 882.62 841.91 857.38 845.17

56 740.73 828.87 802.95 765.91 779.99 768.88 851.84 953.21 923.39 880.80 896.98 884.21

57 773.75 865.82 838.74 800.05 814.76 803.15 889.81 995.70 964.55 920.06 936.97 923.62

58 808.99 905.26 876.95 836.50 851.87 839.73 930.34 1041.05 1008.49 961.97 979.65 965.69

59 826.45 924.80 895.87 854.55 870.25 857.86 950.42 1063.52 1030.26 982.73 1000.79 986.54

60 861.70 964.24 934.08 890.99 907.36 894.44 990.95 1108.87 1074.19 1024.64 1043.47 1028.61

61 892.18 998.34 967.12 922.51 939.46 926.08 1026.00 1148.10 1112.19 1060.89 1080.38 1064.99

62 912.18 1020.73 988.80 943.19 960.52 946.84 1049.00 1173.84 1137.12 1084.67 1104.60 1088.87

63 937.26 1048.79 1015.99 969.13 986.93 972.88 1077.85 1206.11 1168.39 1114.50 1134.97 1118.81

64 and over 952.50 1065.84 1032.51 984.89 1002.98 988.70 1095.38 1225.71 1187.39 1132.62 1153.43 1137.00

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 4 of 12

Individual Nongrandfathered Health Plan 87718WA2150004

Plan Information

Plan Name: Silver HDHP 3000 EPO Individual and Family Network

HIOS Plan ID: 87718WA2150004

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Outside the Exchange

Metal Level: Silver

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 242.11 270.92 262.44 250.34 254.94 251.31 242.11 270.92 262.44 250.34 254.94 251.31

15 263.63 295.00 285.77 272.59 277.60 273.65 263.63 295.00 285.77 272.59 277.60 273.65

16 271.86 304.21 294.69 281.10 286.26 282.19 271.86 304.21 294.69 281.10 286.26 282.19

17 280.08 313.41 303.61 289.61 294.93 290.73 280.08 313.41 303.61 289.61 294.93 290.73

18 288.95 323.33 313.22 298.77 304.26 299.93 288.95 323.33 313.22 298.77 304.26 299.93

19 297.81 333.25 322.82 307.93 313.59 309.12 297.81 333.25 322.82 307.93 313.59 309.12

20 306.99 343.52 332.77 317.42 323.26 318.65 306.99 343.52 332.77 317.42 323.26 318.65

21 316.48 354.14 343.06 327.24 333.25 328.51 363.95 407.26 394.52 376.33 383.24 377.78

22 316.48 354.14 343.06 327.24 333.25 328.51 363.95 407.26 394.52 376.33 383.24 377.78

23 316.48 354.14 343.06 327.24 333.25 328.51 363.95 407.26 394.52 376.33 383.24 377.78

24 316.48 354.14 343.06 327.24 333.25 328.51 363.95 407.26 394.52 376.33 383.24 377.78

25 317.75 355.56 344.44 328.55 334.59 329.82 365.41 408.89 396.10 377.83 384.77 379.29

26 324.08 362.64 351.30 335.09 341.25 336.39 372.69 417.04 403.99 385.36 392.44 386.85

27 331.67 371.14 359.53 342.95 349.25 344.27 381.42 426.81 413.46 394.39 401.64 395.92

28 344.01 384.95 372.91 355.71 362.25 357.09 395.62 442.69 428.85 409.07 416.58 410.65

29 354.14 396.28 383.89 366.18 372.91 367.60 407.26 455.73 441.47 421.11 428.85 422.74

30 359.20 401.95 389.38 371.42 378.24 372.85 413.09 462.24 447.78 427.13 434.98 428.78

31 366.80 410.45 397.61 379.27 386.24 380.74 421.82 472.02 457.25 436.16 444.18 437.85

32 374.40 418.95 405.85 387.13 394.24 388.62 430.56 481.79 466.72 445.19 453.37 446.92

33 379.14 424.26 410.99 392.03 399.24 393.55 436.01 487.90 472.64 450.84 459.12 452.58

34 384.21 429.93 416.48 397.27 404.57 398.81 441.84 494.42 478.95 456.86 465.26 458.63

35 386.74 432.76 419.22 399.89 407.24 401.43 444.75 497.67 482.11 459.87 468.32 461.65

36 389.27 435.59 421.97 402.51 409.90 404.06 447.66 500.93 485.26 462.88 471.39 464.67

37 391.80 438.43 424.71 405.12 412.57 406.69 450.57 504.19 488.42 465.89 474.45 467.69

38 394.33 441.26 427.46 407.74 415.23 409.32 453.48 507.45 491.58 468.90 477.52 470.72

39 399.40 446.93 432.95 412.98 420.57 414.57 459.31 513.97 497.89 474.92 483.65 476.76

40 404.46 452.59 438.44 418.21 425.90 419.83 465.13 520.48 504.20 480.95 489.78 482.81

41 412.06 461.09 446.67 426.07 433.90 427.72 473.87 530.26 513.67 489.98 498.98 491.87

42 419.34 469.24 454.56 433.59 441.56 435.27 482.24 539.62 522.74 498.63 507.79 500.56

43 429.46 480.57 465.54 444.07 452.22 445.78 493.88 552.65 535.37 510.67 520.06 512.65

44 442.12 494.74 479.26 457.15 465.56 458.92 508.44 568.95 551.15 525.73 535.39 527.76

45 457.00 511.38 495.38 472.54 481.22 474.36 525.55 588.09 569.69 543.42 553.40 545.52

46 474.72 531.21 514.60 490.86 499.88 492.76 545.93 610.89 591.79 564.49 574.86 566.67

47 494.66 553.52 536.21 511.48 520.88 513.46 568.86 636.55 616.64 588.20 599.01 590.47

48 517.44 579.02 560.91 535.04 544.87 537.11 595.06 665.87 645.05 615.29 626.60 617.67

49 539.91 604.16 585.27 558.27 568.53 560.43 620.90 694.79 673.06 642.01 653.81 644.50

50 565.23 632.50 612.71 584.45 595.19 586.71 650.02 727.37 704.62 672.12 684.47 674.72

51 590.24 660.47 639.81 610.30 621.52 612.66 678.77 759.54 735.79 701.85 714.75 704.56

52 617.77 691.28 669.66 638.77 650.51 641.24 710.43 794.98 770.11 734.59 748.09 737.43

53 645.62 722.45 699.85 667.57 679.84 670.15 742.46 830.82 804.83 767.71 781.81 770.68

54 675.68 756.09 732.44 698.66 711.50 701.36 777.04 869.50 842.31 803.46 818.22 806.56

55 705.75 789.73 765.03 729.75 743.16 732.57 811.61 908.19 879.79 839.21 854.63 842.45

56 738.35 826.21 800.37 763.45 777.48 766.41 849.10 950.14 920.42 877.97 894.10 881.37

57 771.26 863.04 836.05 797.48 812.14 800.57 886.95 992.50 961.45 917.11 933.96 920.66

58 806.39 902.35 874.13 833.81 849.13 837.03 927.35 1037.70 1005.25 958.88 976.50 962.59

59 823.80 921.83 893.00 851.81 867.46 855.10 947.37 1060.10 1026.95 979.58 997.58 983.37

60 858.93 961.14 931.08 888.13 904.45 891.57 987.77 1105.31 1070.74 1021.35 1040.12 1025.30

61 889.31 995.14 964.01 919.55 936.44 923.10 1022.71 1144.41 1108.61 1057.48 1076.91 1061.57

62 909.25 1017.45 985.62 940.16 957.44 943.80 1045.63 1170.06 1133.47 1081.19 1101.05 1085.37

63 934.25 1045.42 1012.73 966.01 983.76 969.75 1074.39 1202.24 1164.63 1110.92 1131.33 1115.21

64 and over 949.44 1062.42 1029.18 981.72 999.75 985.52 1091.85 1221.78 1183.56 1128.98 1149.72 1133.34

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 5 of 12

Individual Nongrandfathered Health Plan 87718WA2190003

Plan Information

Plan Name: Regence Cascade Bronze Individual and Family Network

HIOS Plan ID: 87718WA2190003

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Inside the Exchange

Metal Level: Bronze

Plan Type: Standardized Non-Public Option Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 194.94 218.13 211.31 201.57 205.27 202.34 194.94 218.13 211.31 201.57 205.27 202.34

15 212.27 237.52 230.10 219.48 223.52 220.33 212.27 237.52 230.10 219.48 223.52 220.33

16 218.89 244.94 237.28 226.33 230.49 227.21 218.89 244.94 237.28 226.33 230.49 227.21

17 225.52 252.35 244.46 233.18 237.47 234.09 225.52 252.35 244.46 233.18 237.47 234.09

18 232.65 260.34 252.19 240.56 244.98 241.49 232.65 260.34 252.19 240.56 244.98 241.49

19 239.79 268.32 259.93 247.94 252.49 248.90 239.79 268.32 259.93 247.94 252.49 248.90

20 247.18 276.59 267.94 255.58 260.28 256.57 247.18 276.59 267.94 255.58 260.28 256.57

21 254.82 285.14 276.22 263.48 268.33 264.50 293.04 327.92 317.66 303.01 308.57 304.18

22 254.82 285.14 276.22 263.48 268.33 264.50 293.04 327.92 317.66 303.01 308.57 304.18

23 254.82 285.14 276.22 263.48 268.33 264.50 293.04 327.92 317.66 303.01 308.57 304.18

24 254.82 285.14 276.22 263.48 268.33 264.50 293.04 327.92 317.66 303.01 308.57 304.18

25 255.84 286.28 277.33 264.54 269.40 265.56 294.22 329.23 318.93 304.22 309.81 305.40

26 260.94 291.99 282.85 269.81 274.77 270.85 300.08 335.79 325.28 310.28 315.98 311.48

27 267.05 298.83 289.48 276.13 281.21 277.20 307.11 343.66 332.91 317.55 323.39 318.78

28 276.99 309.95 300.26 286.41 291.67 287.51 318.54 356.44 345.29 329.37 335.42 330.64

29 285.14 319.08 309.10 294.84 300.26 295.98 327.92 366.94 355.46 339.06 345.29 340.38

30 289.22 323.64 313.52 299.05 304.55 300.21 332.60 372.18 360.54 343.91 350.23 345.24

31 295.34 330.48 320.14 305.38 310.99 306.56 339.64 380.05 368.17 351.18 357.64 352.54

32 301.45 337.32 326.77 311.70 317.43 312.91 346.67 387.92 375.79 358.46 365.04 359.84

33 305.27 341.60 330.92 315.65 321.45 316.87 351.07 392.84 380.56 363.00 369.67 364.41

34 309.35 346.16 335.34 319.87 325.75 321.11 355.75 398.09 385.64 367.85 374.61 369.27

35 311.39 348.45 337.55 321.98 327.89 323.22 358.10 400.71 388.18 370.27 377.08 371.71

36 313.43 350.73 339.76 324.09 330.04 325.34 360.44 403.34 390.72 372.70 379.55 374.14

37 315.47 353.01 341.97 326.19 332.19 327.45 362.79 405.96 393.26 375.12 382.01 376.57

38 317.51 355.29 344.18 328.30 334.33 329.57 365.13 408.58 395.80 377.55 384.48 379.01

39 321.58 359.85 348.60 332.52 338.63 333.80 369.82 413.83 400.89 382.39 389.42 383.87

40 325.66 364.41 353.02 336.73 342.92 338.04 374.51 419.08 405.97 387.24 394.36 388.74

41 331.78 371.26 359.64 343.06 349.36 344.38 381.54 426.95 413.59 394.51 401.76 396.04

42 337.64 377.82 366.00 349.12 355.53 350.47 388.28 434.49 420.90 401.48 408.86 403.04

43 345.79 386.94 374.84 357.55 364.12 358.93 397.66 444.98 431.06 411.18 418.74 412.77

44 355.98 398.35 385.89 368.09 374.85 369.51 409.38 458.10 443.77 423.30 431.08 424.94

45 367.96 411.75 398.87 380.47 387.46 381.94 423.15 473.51 458.70 437.54 445.58 439.23

46 382.23 427.72 414.34 395.23 402.49 396.75 439.56 491.87 476.49 454.51 462.86 456.27

47 398.28 445.68 431.74 411.83 419.39 413.42 458.03 512.53 496.50 473.60 482.30 475.43

48 416.63 466.21 451.63 430.80 438.71 432.46 479.13 536.14 519.37 495.42 504.52 497.33

49 434.72 486.45 471.24 449.50 457.76 451.24 499.93 559.42 541.93 516.93 526.43 518.93

50 455.11 509.27 493.34 470.58 479.23 472.40 523.37 585.66 567.34 541.17 551.11 543.26

51 475.24 531.79 515.16 491.40 500.43 493.30 546.53 611.56 592.43 565.11 575.49 567.29

52 497.41 556.60 539.19 514.32 523.77 516.31 572.02 640.09 620.07 591.47 602.34 593.76

53 519.83 581.69 563.50 537.51 547.38 539.59 597.81 668.95 648.02 618.13 629.49 620.52

54 544.04 608.78 589.74 562.54 572.87 564.71 625.65 700.10 678.20 646.92 658.81 649.42

55 568.25 635.87 615.98 587.57 598.37 589.84 653.49 731.25 708.38 675.70 688.12 678.32

56 594.50 665.24 644.43 614.71 626.00 617.09 683.67 765.03 741.10 706.91 719.90 709.65

57 621.00 694.89 673.16 642.11 653.91 644.59 714.15 799.13 774.13 738.43 752.00 741.28

58 649.28 726.55 703.82 671.36 683.69 673.95 746.67 835.53 809.39 772.06 786.25 775.05

59 663.30 742.23 719.01 685.85 698.45 688.50 762.79 853.56 826.87 788.73 803.22 791.78

60 691.58 773.88 749.67 715.10 728.24 717.86 795.32 889.96 862.13 822.36 837.47 825.54

61 716.04 801.25 776.19 740.39 753.99 743.25 823.45 921.44 892.62 851.45 867.09 854.74

62 732.10 819.22 793.59 756.99 770.90 759.92 841.91 942.10 912.63 870.54 886.53 873.91

63 752.23 841.74 815.42 777.80 792.10 780.81 865.06 968.01 937.73 894.48 910.91 897.94

64 and over 764.46 855.42 828.66 790.44 804.98 793.50 879.12 983.75 952.98 909.02 925.71 912.54

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 6 of 12

Individual Nongrandfathered Health Plan 87718WA2150005

Plan Information

Plan Name: Bronze HDHP 5700 EPO Individual and Family Network

HIOS Plan ID: 87718WA2150005

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Outside the Exchange

Metal Level: Bronze

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 192.99 215.95 209.20 199.55 203.21 200.32 192.99 215.95 209.20 199.55 203.21 200.32

15 210.14 235.15 227.79 217.29 221.28 218.13 210.14 235.15 227.79 217.29 221.28 218.13

16 216.70 242.49 234.90 224.07 228.19 224.93 216.70 242.49 234.90 224.07 228.19 224.93

17 223.26 249.83 242.01 230.85 235.09 231.74 223.26 249.83 242.01 230.85 235.09 231.74

18 230.32 257.73 249.67 238.15 242.53 239.07 230.32 257.73 249.67 238.15 242.53 239.07

19 237.39 265.64 257.33 245.46 249.97 246.41 237.39 265.64 257.33 245.46 249.97 246.41

20 244.70 273.82 265.26 253.02 257.67 254.00 244.70 273.82 265.26 253.02 257.67 254.00

21 252.27 282.29 273.46 260.85 265.64 261.86 290.11 324.63 314.48 299.97 305.49 301.13

22 252.27 282.29 273.46 260.85 265.64 261.86 290.11 324.63 314.48 299.97 305.49 301.13

23 252.27 282.29 273.46 260.85 265.64 261.86 290.11 324.63 314.48 299.97 305.49 301.13

24 252.27 282.29 273.46 260.85 265.64 261.86 290.11 324.63 314.48 299.97 305.49 301.13

25 253.28 283.42 274.55 261.89 266.70 262.90 291.27 325.93 315.74 301.17 306.71 302.34

26 258.32 289.07 280.02 267.11 272.02 268.14 297.07 332.42 322.03 307.17 312.82 308.36

27 264.38 295.84 286.59 273.37 278.39 274.43 304.04 340.22 329.57 314.37 320.15 315.59

28 274.22 306.85 297.25 283.54 288.75 284.64 315.35 352.88 341.84 326.07 332.06 327.33

29 282.29 315.88 306.00 291.89 297.25 293.02 324.63 363.27 351.90 335.67 341.84 336.97

30 286.33 320.40 310.38 296.06 301.50 297.21 329.28 368.46 356.93 340.47 346.73 341.79

31 292.38 327.17 316.94 302.32 307.88 303.49 336.24 376.25 364.48 347.67 354.06 349.02

32 298.44 333.95 323.50 308.58 314.25 309.78 343.20 384.04 372.03 354.87 361.39 356.24

33 302.22 338.18 327.61 312.49 318.24 313.70 347.55 388.91 376.75 359.37 365.97 360.76

34 306.26 342.70 331.98 316.67 322.49 317.89 352.19 394.11 381.78 364.17 370.86 365.58

35 308.27 344.96 334.17 318.76 324.61 319.99 354.52 396.70 384.29 366.57 373.30 367.99

36 310.29 347.22 336.36 320.84 326.74 322.08 356.84 399.30 386.81 368.97 375.75 370.40

37 312.31 349.48 338.54 322.93 328.86 324.18 359.16 401.90 389.33 371.37 378.19 372.80

38 314.33 351.73 340.73 325.02 330.99 326.27 361.48 404.49 391.84 373.77 380.64 375.21

39 318.36 356.25 345.11 329.19 335.24 330.46 366.12 409.69 396.87 378.57 385.52 380.03

40 322.40 360.77 349.48 333.36 339.49 334.65 370.76 414.88 401.91 383.37 390.41 384.85

41 328.46 367.54 356.05 339.62 345.86 340.94 377.72 422.67 409.45 390.57 397.74 392.08

42 334.26 374.03 362.34 345.62 351.97 346.96 384.40 430.14 416.69 397.47 404.77 399.00

43 342.33 383.07 371.09 353.97 360.47 355.34 393.68 440.53 426.75 407.07 414.54 408.64

44 352.42 394.36 382.02 364.40 371.10 365.81 405.28 453.51 439.33 419.06 426.76 420.69

45 364.28 407.63 394.88 376.66 383.58 378.12 418.92 468.77 454.11 433.16 441.12 434.84

46 378.41 423.44 410.19 391.27 398.46 392.78 435.17 486.95 471.72 449.96 458.23 451.70

47 394.30 441.22 427.42 407.70 415.20 409.28 453.44 507.40 491.53 468.86 477.48 470.67

48 412.46 461.54 447.11 426.49 434.32 428.13 474.33 530.78 514.17 490.46 499.47 492.36

49 430.37 481.59 466.52 445.01 453.18 446.73 494.93 553.83 536.50 511.76 521.16 513.74

50 450.55 504.17 488.40 465.87 474.43 467.68 518.14 579.80 561.66 535.75 545.60 537.83

51 470.48 526.47 510.00 486.48 495.42 488.36 541.06 605.44 586.50 559.45 569.73 561.62

52 492.43 551.03 533.80 509.17 518.53 511.14 566.30 633.68 613.86 585.55 596.31 587.81

53 514.63 575.87 557.86 532.13 541.91 534.19 591.83 662.25 641.54 611.95 623.19 614.31

54 538.60 602.69 583.84 556.91 567.14 559.06 619.39 693.09 671.41 640.45 652.21 642.92

55 562.56 629.51 609.82 581.69 592.38 583.94 646.95 723.93 701.29 668.94 681.23 671.53

56 588.55 658.58 637.98 608.56 619.74 610.91 676.83 757.37 733.68 699.84 712.70 702.55

57 614.78 687.94 666.42 635.68 647.37 638.14 707.00 791.13 766.39 731.04 744.47 733.87

58 642.78 719.28 696.78 664.64 676.85 667.21 739.20 827.17 801.29 764.33 778.38 767.29

59 656.66 734.80 711.82 678.99 691.46 681.61 755.16 845.02 818.59 780.83 795.18 783.85

60 684.66 766.14 742.17 707.94 720.95 710.68 787.36 881.06 853.50 814.13 829.09 817.28

61 708.88 793.24 768.42 732.98 746.45 735.82 815.21 912.22 883.69 842.93 858.42 846.19

62 724.77 811.02 785.65 749.41 763.18 752.31 833.49 932.67 903.50 861.83 877.66 865.16

63 744.70 833.32 807.26 770.02 784.17 773.00 856.41 958.32 928.34 885.52 901.80 888.95

64 and over 756.81 846.87 820.38 782.54 796.92 785.57 870.33 973.89 943.44 899.91 916.46 903.39

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 7 of 12

Individual Nongrandfathered Health Plan 87718WA2170002

Plan Information

Plan Name: Bronze HDHP 5700 Exchange EPO Individual and Family Network

HIOS Plan ID: 87718WA2170002

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Inside the Exchange

Metal Level: Bronze

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 192.21 215.08 208.35 198.74 202.39 199.51 192.21 215.08 208.35 198.74 202.39 199.51

15 209.29 234.20 226.87 216.41 220.38 217.24 209.29 234.20 226.87 216.41 220.38 217.24

16 215.82 241.51 233.95 223.16 227.26 224.03 215.82 241.51 233.95 223.16 227.26 224.03

17 222.36 248.82 241.03 229.92 234.14 230.81 222.36 248.82 241.03 229.92 234.14 230.81

18 229.39 256.69 248.66 237.19 241.55 238.11 229.39 256.69 248.66 237.19 241.55 238.11

19 236.43 264.56 256.29 244.46 248.96 245.41 236.43 264.56 256.29 244.46 248.96 245.41

20 243.71 272.71 264.18 252.00 256.63 252.97 243.71 272.71 264.18 252.00 256.63 252.97

21 251.25 281.15 272.36 259.79 264.57 260.80 288.94 323.32 313.21 298.76 304.25 299.92

22 251.25 281.15 272.36 259.79 264.57 260.80 288.94 323.32 313.21 298.76 304.25 299.92

23 251.25 281.15 272.36 259.79 264.57 260.80 288.94 323.32 313.21 298.76 304.25 299.92

24 251.25 281.15 272.36 259.79 264.57 260.80 288.94 323.32 313.21 298.76 304.25 299.92

25 252.26 282.27 273.44 260.83 265.62 261.84 290.09 324.61 314.46 299.96 305.47 301.12

26 257.28 287.90 278.89 266.03 270.92 267.06 295.87 331.08 320.73 305.93 311.55 307.12

27 263.31 294.64 285.43 272.26 277.27 273.32 302.81 338.84 328.24 313.10 318.86 314.31

28 273.11 305.61 296.05 282.39 287.58 283.49 314.08 351.45 340.46 324.75 330.72 326.01

29 281.15 314.61 304.77 290.71 296.05 291.83 323.32 361.80 350.48 334.31 340.46 335.61

30 285.17 319.10 309.12 294.86 300.28 296.01 327.94 366.97 355.49 339.09 345.33 340.41

31 291.20 325.85 315.66 301.10 306.63 302.26 334.88 374.73 363.01 346.26 352.63 347.60

32 297.23 332.60 322.20 307.33 312.98 308.52 341.81 382.49 370.53 353.43 359.93 354.80

33 301.00 336.82 326.28 311.23 316.95 312.44 346.15 387.34 375.22 357.92 364.49 359.30

34 305.02 341.31 330.64 315.39 321.18 316.61 350.77 392.51 380.23 362.70 369.36 364.10

35 307.03 343.56 332.82 317.47 323.30 318.69 353.08 395.10 382.74 365.09 371.79 366.50

36 309.04 345.81 335.00 319.54 325.42 320.78 355.39 397.68 385.25 367.48 374.23 368.90

37 311.05 348.06 337.18 321.62 327.53 322.87 357.70 400.27 387.75 369.87 376.66 371.30

38 313.06 350.31 339.35 323.70 329.65 324.95 360.02 402.86 390.26 372.26 379.10 373.70

39 317.08 354.81 343.71 327.86 333.88 329.13 364.64 408.03 395.27 377.04 383.96 378.50

40 321.10 359.31 348.07 332.01 338.12 333.30 369.26 413.20 400.28 381.82 388.83 383.29

41 327.13 366.06 354.61 338.25 344.47 339.56 376.20 420.96 407.80 388.99 396.14 390.49

42 332.91 372.52 360.87 344.23 350.55 345.56 382.84 428.40 415.00 395.86 403.13 397.39

43 340.95 381.52 369.59 352.54 359.02 353.90 392.09 438.75 425.02 405.42 412.87 406.99

44 351.00 392.76 380.48 362.93 369.60 364.33 403.65 451.68 437.55 417.37 425.04 418.98

45 362.81 405.98 393.28 375.14 382.03 376.59 417.23 466.88 452.27 431.41 439.34 433.08

46 376.88 421.72 408.53 389.69 396.85 391.20 433.41 484.98 469.81 448.14 456.38 449.88

47 392.70 439.44 425.69 406.06 413.52 407.63 451.61 505.35 489.54 466.96 475.54 468.77

48 410.79 459.68 445.30 424.76 432.57 426.40 472.41 528.63 512.10 488.47 497.45 490.36

49 428.63 479.64 464.64 443.21 451.35 444.92 492.93 551.59 534.33 509.69 519.05 511.66

50 448.73 502.13 486.43 463.99 472.52 465.78 516.04 577.45 559.39 533.59 543.39 535.65

51 468.58 524.34 507.94 484.51 493.42 486.39 538.87 602.99 584.13 557.19 567.43 559.35

52 490.44 548.80 531.64 507.11 516.43 509.08 564.01 631.12 611.38 583.18 593.90 585.44

53 512.55 573.54 555.60 529.98 539.72 532.03 589.43 659.57 638.94 609.47 620.67 611.83

54 536.42 600.25 581.48 554.66 564.85 556.80 616.88 690.29 668.70 637.86 649.58 640.32

55 560.29 626.96 607.35 579.34 589.98 581.58 644.33 721.01 698.45 666.24 678.48 668.82

56 586.17 655.92 635.40 606.10 617.23 608.44 674.09 754.31 730.71 697.01 709.82 699.71

57 612.30 685.16 663.73 633.11 644.75 635.56 704.14 787.93 763.29 728.08 741.46 730.90

58 640.19 716.37 693.96 661.95 674.11 664.51 736.21 823.82 798.05 761.24 775.23 764.19

59 654.00 731.83 708.94 676.24 688.67 678.86 752.10 841.60 815.28 777.68 791.97 780.68

60 681.89 763.04 739.17 705.08 718.03 707.80 784.18 877.49 850.05 810.84 825.74 813.98

61 706.01 790.03 765.32 730.02 743.43 732.84 811.91 908.53 880.12 839.52 854.95 842.77

62 721.84 807.74 782.48 746.38 760.10 749.27 830.12 928.90 899.85 858.34 874.11 861.66

63 741.69 829.95 803.99 766.91 781.00 769.87 852.94 954.44 924.59 881.94 898.15 885.36

64 and over 753.75 843.45 817.07 779.37 793.70 782.39 866.81 969.96 939.62 896.28 912.75 899.75

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 8 of 12

Individual Nongrandfathered Health Plan 87718WA2150001

Plan Information

Plan Name: Bronze Essential 7500 EPO Individual and Family Network

HIOS Plan ID: 87718WA2150001

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Outside the Exchange

Metal Level: Bronze

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 187.13 209.40 202.85 193.50 197.05 194.25 187.13 209.40 202.85 193.50 197.05 194.25

15 203.77 228.02 220.89 210.70 214.57 211.51 203.77 228.02 220.89 210.70 214.57 211.51

16 210.13 235.13 227.78 217.27 221.27 218.11 210.13 235.13 227.78 217.27 221.27 218.11

17 216.49 242.25 234.67 223.85 227.96 224.72 216.49 242.25 234.67 223.85 227.96 224.72

18 223.34 249.92 242.10 230.93 235.17 231.82 223.34 249.92 242.10 230.93 235.17 231.82

19 230.19 257.58 249.52 238.01 242.39 238.93 230.19 257.58 249.52 238.01 242.39 238.93

20 237.28 265.52 257.21 245.35 249.86 246.30 237.28 265.52 257.21 245.35 249.86 246.30

21 244.62 273.73 265.17 252.94 257.58 253.92 281.31 314.79 304.94 290.88 296.22 292.00

22 244.62 273.73 265.17 252.94 257.58 253.92 281.31 314.79 304.94 290.88 296.22 292.00

23 244.62 273.73 265.17 252.94 257.58 253.92 281.31 314.79 304.94 290.88 296.22 292.00

24 244.62 273.73 265.17 252.94 257.58 253.92 281.31 314.79 304.94 290.88 296.22 292.00

25 245.60 274.82 266.23 253.95 258.62 254.93 282.44 316.05 306.16 292.04 297.41 293.17

26 250.49 280.30 271.53 259.01 263.77 260.01 288.06 322.34 312.26 297.86 303.33 299.01

27 256.36 286.87 277.90 265.08 269.95 266.10 294.82 329.90 319.58 304.84 310.44 306.02

28 265.90 297.54 288.24 274.94 279.99 276.01 305.79 342.18 331.47 316.18 321.99 317.41

29 273.73 306.30 296.72 283.04 288.24 284.13 314.79 352.25 341.23 325.49 331.47 326.75

30 277.64 310.68 300.97 287.08 292.36 288.19 319.29 357.29 346.11 330.15 336.21 331.42

31 283.51 317.25 307.33 293.15 298.54 294.29 326.04 364.84 353.43 337.13 343.32 338.43

32 289.39 323.82 313.69 299.22 304.72 300.38 332.79 372.40 360.75 344.11 350.43 345.44

33 293.05 327.93 317.67 303.02 308.59 304.19 337.01 377.12 365.32 348.47 354.87 349.82

34 296.97 332.31 321.91 307.07 312.71 308.25 341.51 382.15 370.20 353.13 359.61 354.49

35 298.93 334.50 324.04 309.09 314.77 310.28 343.76 384.67 372.64 355.45 361.98 356.83

36 300.88 336.69 326.16 311.11 316.83 312.32 346.01 387.19 375.08 357.78 364.35 359.16

37 302.84 338.88 328.28 313.14 318.89 314.35 348.27 389.71 377.52 360.11 366.72 361.50

38 304.80 341.07 330.40 315.16 320.95 316.38 350.52 392.23 379.96 362.43 369.09 363.84

39 308.71 345.45 334.64 319.21 325.07 320.44 355.02 397.26 384.84 367.09 373.83 368.51

40 312.62 349.83 338.88 323.25 329.19 324.50 359.52 402.30 389.72 371.74 378.57 373.18

41 318.50 356.40 345.25 329.32 335.38 330.60 366.27 409.86 397.04 378.72 385.68 380.19

42 324.12 362.69 351.35 335.14 341.30 336.44 372.74 417.10 404.05 385.41 392.49 386.90

43 331.95 371.45 359.83 343.24 349.54 344.56 381.74 427.17 413.81 394.72 401.97 396.25

44 341.73 382.40 370.44 353.35 359.85 354.72 392.99 439.76 426.01 406.36 413.82 407.93

45 353.23 395.27 382.90 365.24 371.95 366.65 406.22 454.56 440.34 420.03 427.75 421.65

46 366.93 410.59 397.75 379.41 386.38 380.87 421.97 472.18 457.41 436.32 444.33 438.00

47 382.34 427.84 414.46 395.34 402.61 396.87 439.69 492.02 476.63 454.64 463.00 456.40

48 399.95 447.55 433.55 413.55 421.15 415.15 459.95 514.68 498.58 475.58 484.32 477.42

49 417.32 466.98 452.38 431.51 439.44 433.18 479.92 537.03 520.23 496.24 505.36 498.16

50 436.89 488.88 473.59 451.75 460.05 453.49 502.43 562.21 544.63 519.51 529.05 521.52

51 456.22 510.51 494.54 471.73 480.40 473.55 524.65 587.08 568.72 542.49 552.46 544.59

52 477.50 534.32 517.61 493.73 502.81 495.64 549.12 614.47 595.25 567.79 578.23 569.99

53 499.02 558.41 540.94 515.99 525.47 517.99 573.88 642.17 622.08 593.39 604.29 595.69

54 522.26 584.41 566.13 540.02 549.94 542.11 600.60 672.08 651.05 621.02 632.44 623.43

55 545.50 610.42 591.32 564.05 574.41 566.23 627.33 701.98 680.02 648.66 660.58 651.17

56 570.70 638.61 618.64 590.10 600.95 592.39 656.30 734.40 711.43 678.62 691.09 681.24

57 596.14 667.08 646.21 616.41 627.73 618.79 685.56 767.14 743.15 708.87 721.89 711.61

58 623.29 697.46 675.65 644.48 656.33 646.98 716.79 802.08 777.00 741.16 754.78 744.02

59 636.75 712.52 690.23 658.40 670.49 660.94 732.26 819.40 793.77 757.15 771.07 760.08

60 663.90 742.90 719.67 686.47 699.09 689.13 763.48 854.34 827.62 789.44 803.95 792.50

61 687.38 769.18 745.12 710.75 723.81 713.50 790.49 884.56 856.89 817.37 832.39 820.53

62 702.79 786.43 761.83 726.69 740.04 729.50 808.21 904.39 876.10 835.69 851.05 838.92

63 722.12 808.05 782.78 746.67 760.39 749.56 830.44 929.26 900.19 858.67 874.45 861.99

64 and over 733.86 821.19 795.50 758.81 772.74 761.75 843.93 944.37 914.82 872.63 888.66 876.00

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 9 of 12

Individual Nongrandfathered Health Plan 87718WA2170004

Plan Information

Plan Name: Bronze Essential 7500 Exchange EPO Individual and Family Network

HIOS Plan ID: 87718WA2170004

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Inside the Exchange

Metal Level: Bronze

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 185.96 208.09 201.58 192.29 195.82 193.03 185.96 208.09 201.58 192.29 195.82 193.03

15 202.49 226.59 219.50 209.38 213.23 210.19 202.49 226.59 219.50 209.38 213.23 210.19

16 208.81 233.66 226.35 215.91 219.88 216.75 208.81 233.66 226.35 215.91 219.88 216.75

17 215.13 240.74 233.21 222.45 226.54 223.31 215.13 240.74 233.21 222.45 226.54 223.31

18 221.94 248.35 240.58 229.49 233.70 230.37 221.94 248.35 240.58 229.49 233.70 230.37

19 228.75 255.97 247.96 236.53 240.87 237.44 228.75 255.97 247.96 236.53 240.87 237.44

20 235.80 263.86 255.60 243.81 248.29 244.76 235.80 263.86 255.60 243.81 248.29 244.76

21 243.09 272.02 263.51 251.36 255.97 252.33 279.55 312.82 303.04 289.06 294.37 290.18

22 243.09 272.02 263.51 251.36 255.97 252.33 279.55 312.82 303.04 289.06 294.37 290.18

23 243.09 272.02 263.51 251.36 255.97 252.33 279.55 312.82 303.04 289.06 294.37 290.18

24 243.09 272.02 263.51 251.36 255.97 252.33 279.55 312.82 303.04 289.06 294.37 290.18

25 244.06 273.11 264.56 252.36 257.00 253.34 280.67 314.07 304.25 290.21 295.55 291.34

26 248.92 278.55 269.83 257.39 262.12 258.38 286.26 320.33 310.31 296.00 301.43 297.14

27 254.76 285.07 276.16 263.42 268.26 264.44 292.97 327.84 317.58 302.93 308.50 304.11

28 264.24 295.68 286.43 273.22 278.24 274.28 303.87 340.04 329.40 314.21 319.98 315.42

29 272.02 304.39 294.87 281.27 286.43 282.35 312.82 350.05 339.10 323.46 329.40 324.71

30 275.91 308.74 299.08 285.29 290.53 286.39 317.29 355.05 343.95 328.08 334.11 329.35

31 281.74 315.27 305.41 291.32 296.67 292.45 324.00 362.56 351.22 335.02 341.17 336.31

32 287.58 321.80 311.73 297.35 302.82 298.50 330.71 370.07 358.49 341.96 348.24 343.28

33 291.22 325.88 315.68 301.12 306.66 302.29 334.91 374.76 363.04 346.29 352.66 347.63

34 295.11 330.23 319.90 305.15 310.75 306.33 339.38 379.76 367.89 350.92 357.36 352.27

35 297.06 332.41 322.01 307.16 312.80 308.34 341.61 382.27 370.31 353.23 359.72 354.60

36 299.00 334.58 324.12 309.17 314.85 310.36 343.85 384.77 372.73 355.54 362.07 356.92

37 300.95 336.76 326.22 311.18 316.90 312.38 346.09 387.27 375.16 357.85 364.43 359.24

38 302.89 338.93 328.33 313.19 318.94 314.40 348.32 389.77 377.58 360.17 366.78 361.56

39 306.78 343.29 332.55 317.21 323.04 318.44 352.80 394.78 382.43 364.79 371.49 366.20

40 310.67 347.64 336.77 321.23 327.13 322.47 357.27 399.78 387.28 369.42 376.20 370.85

41 316.50 354.17 343.09 327.26 333.28 328.53 363.98 407.29 394.55 376.35 383.27 377.81

42 322.09 360.42 349.15 333.05 339.17 334.33 370.41 414.49 401.52 383.00 390.04 384.48

43 329.87 369.13 357.58 341.09 347.36 342.41 379.35 424.50 411.22 392.25 399.46 393.77

44 339.60 380.01 368.12 351.14 357.60 352.50 390.54 437.01 423.34 403.81 411.23 405.38

45 351.02 392.79 380.51 362.96 369.63 364.36 403.68 451.71 437.58 417.40 425.07 419.01

46 364.64 408.03 395.26 377.03 383.96 378.49 419.33 469.23 454.55 433.59 441.55 435.26

47 379.95 425.16 411.87 392.87 400.09 394.39 436.94 488.94 473.65 451.80 460.10 453.55

48 397.45 444.75 430.84 410.97 418.52 412.56 457.07 511.46 495.46 472.61 481.29 474.44

49 414.71 464.06 449.55 428.81 436.69 430.47 476.92 533.67 516.98 493.13 502.19 495.04

50 434.16 485.82 470.63 448.92 457.17 450.66 499.28 558.70 541.22 516.26 525.74 518.26

51 453.36 507.31 491.45 468.78 477.39 470.59 521.37 583.41 565.16 539.09 549.00 541.18

52 474.51 530.98 514.37 490.65 499.66 492.54 545.69 610.63 591.53 564.24 574.61 566.42

53 495.90 554.92 537.56 512.76 522.19 514.75 570.29 638.15 618.19 589.68 600.51 591.96

54 519.00 580.76 562.59 536.64 546.50 538.72 596.85 667.87 646.98 617.14 628.48 619.53

55 542.09 606.60 587.63 560.52 570.82 562.69 623.40 697.59 675.77 644.60 656.44 647.09

56 567.13 634.62 614.77 586.41 597.19 588.68 652.20 729.81 706.98 674.37 686.76 676.98

57 592.41 662.91 642.17 612.55 623.81 614.92 681.27 762.34 738.50 704.44 717.38 707.16

58 619.39 693.10 671.42 640.45 652.22 642.93 712.30 797.07 772.14 736.52 750.05 739.37

59 632.76 708.06 685.92 654.28 666.30 656.81 727.68 814.27 788.80 752.42 766.24 755.33

60 659.75 738.26 715.16 682.18 694.71 684.82 758.71 848.99 822.44 784.50 798.92 787.54

61 683.08 764.37 740.46 706.31 719.29 709.04 785.55 879.03 851.53 812.25 827.18 815.40

62 698.40 781.51 757.06 722.14 735.41 724.94 803.16 898.73 870.62 830.46 845.72 833.68

63 717.60 803.00 777.88 742.00 755.63 744.87 825.24 923.45 894.56 853.30 868.98 856.60

64 and over 729.27 816.05 790.53 754.07 767.91 756.98 838.65 938.46 909.11 867.17 883.11 870.53

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 10 of 12

Individual Nongrandfathered Health Plan 87718WA2150007

Plan Information

Plan Name: Bronze Care on Demand 8000 EPO Individual and Family Network

HIOS Plan ID: 87718WA2150007

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Outside the Exchange

Metal Level: Bronze

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 177.78 198.93 192.71 183.82 187.20 184.53 177.78 198.93 192.71 183.82 187.20 184.53

15 193.58 216.62 209.84 200.16 203.84 200.94 193.58 216.62 209.84 200.16 203.84 200.94

16 199.62 223.38 216.39 206.41 210.20 207.21 199.62 223.38 216.39 206.41 210.20 207.21

17 205.67 230.14 222.94 212.66 216.57 213.48 205.67 230.14 222.94 212.66 216.57 213.48

18 212.17 237.42 229.99 219.39 223.42 220.23 212.17 237.42 229.99 219.39 223.42 220.23

19 218.68 244.70 237.05 226.11 230.27 226.99 218.68 244.70 237.05 226.11 230.27 226.99

20 225.42 252.24 244.35 233.08 237.37 233.98 225.42 252.24 244.35 233.08 237.37 233.98

21 232.39 260.04 251.91 240.29 244.71 241.22 267.25 299.05 289.70 276.33 281.41 277.40

22 232.39 260.04 251.91 240.29 244.71 241.22 267.25 299.05 289.70 276.33 281.41 277.40

23 232.39 260.04 251.91 240.29 244.71 241.22 267.25 299.05 289.70 276.33 281.41 277.40

24 232.39 260.04 251.91 240.29 244.71 241.22 267.25 299.05 289.70 276.33 281.41 277.40

25 233.32 261.08 252.92 241.25 245.69 242.19 268.32 300.25 290.86 277.44 282.54 278.51

26 237.97 266.29 257.96 246.06 250.58 247.01 273.66 306.23 296.65 282.97 288.17 284.06

27 243.54 272.53 264.00 251.83 256.45 252.80 280.08 313.41 303.60 289.60 294.92 290.72

28 252.61 282.67 273.83 261.20 266.00 262.21 290.50 325.07 314.90 300.38 305.90 301.54

29 260.04 290.99 281.89 268.89 273.83 269.93 299.05 334.64 324.17 309.22 314.90 310.42

30 263.76 295.15 285.92 272.73 277.74 273.79 303.33 339.42 328.81 313.64 319.40 314.85

31 269.34 301.39 291.96 278.50 283.62 279.57 309.74 346.60 335.76 320.27 326.16 321.51

32 274.92 307.63 298.01 284.26 289.49 285.36 316.15 353.78 342.71 326.90 332.91 328.17

33 278.40 311.53 301.79 287.87 293.16 288.98 320.16 358.26 347.06 331.05 337.13 332.33

34 282.12 315.69 305.82 291.71 297.07 292.84 324.44 363.05 351.69 335.47 341.63 336.77

35 283.98 317.77 307.83 293.64 299.03 294.77 326.58 365.44 354.01 337.68 343.89 338.99

36 285.84 319.85 309.85 295.56 300.99 296.70 328.72 367.83 356.33 339.89 346.14 341.21

37 287.70 321.93 311.87 297.48 302.95 298.63 330.85 370.23 358.65 342.10 348.39 343.43

38 289.56 324.02 313.88 299.40 304.90 300.56 332.99 372.62 360.96 344.31 350.64 345.65

39 293.28 328.18 317.91 303.25 308.82 304.42 337.27 377.40 365.60 348.73 355.14 350.08

40 296.99 332.34 321.94 307.09 312.74 308.28 341.54 382.19 370.23 353.16 359.65 354.52

41 302.57 338.58 327.99 312.86 318.61 314.07 347.96 389.36 377.19 359.79 366.40 361.18

42 307.92 344.56 333.78 318.39 324.24 319.62 354.10 396.24 383.85 366.14 372.87 367.56

43 315.35 352.88 341.84 326.08 332.07 327.34 362.66 405.81 393.12 374.99 381.88 376.44

44 324.65 363.28 351.92 335.69 341.86 336.99 373.35 417.77 404.71 386.04 393.13 387.53

45 335.57 375.50 363.76 346.98 353.36 348.32 385.91 431.83 418.32 399.03 406.36 400.57

46 348.59 390.07 377.87 360.44 367.06 361.83 400.87 448.58 434.55 414.50 422.12 416.11

47 363.23 406.45 393.74 375.58 382.48 377.03 417.71 467.42 452.80 431.91 439.85 433.58

48 379.96 425.17 411.87 392.88 400.10 394.40 436.95 488.95 473.66 451.81 460.11 453.56

49 396.46 443.64 429.76 409.94 417.47 411.52 455.93 510.18 494.22 471.43 480.09 473.25

50 415.05 464.44 449.91 429.16 437.05 430.82 477.31 534.11 517.40 493.53 502.60 495.44

51 433.41 484.98 469.81 448.14 456.38 449.88 498.42 557.73 540.29 515.36 524.83 517.36

52 453.63 507.61 491.73 469.05 477.67 470.86 521.67 583.75 565.49 539.41 549.32 541.49

53 474.08 530.49 513.90 490.19 499.20 492.09 545.19 610.06 590.98 563.72 574.08 565.90

54 496.15 555.19 537.83 513.02 522.45 515.01 570.58 638.47 618.50 589.98 600.82 592.26

55 518.23 579.90 561.76 535.85 545.70 537.92 595.96 666.88 646.03 616.23 627.55 618.61

56 542.17 606.68 587.71 560.60 570.90 562.77 623.49 697.69 675.86 644.69 656.54 647.18

57 566.33 633.73 613.91 585.59 596.35 587.86 651.28 728.79 705.99 673.43 685.80 676.03

58 592.13 662.59 641.87 612.26 623.51 614.63 680.95 761.98 738.15 704.10 717.04 706.83

59 604.91 676.90 655.72 625.48 636.97 627.90 695.65 778.43 754.08 719.30 732.52 722.08

60 630.71 705.76 683.69 652.15 664.13 654.67 725.31 811.62 786.24 749.97 763.75 752.87

61 653.02 730.72 707.87 675.22 687.63 677.83 750.97 840.33 814.05 776.50 790.77 779.51

62 667.66 747.11 723.74 690.36 703.04 693.03 767.80 859.17 832.30 793.91 808.50 796.98

63 686.02 767.65 743.64 709.34 722.37 712.08 788.92 882.80 855.19 815.74 830.73 818.90

64 and over 697.17 780.12 755.73 720.87 734.12 723.66 801.75 897.15 869.09 828.99 844.23 832.20

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 11 of 12

Individual Nongrandfathered Health Plan 87718WA2170003

Plan Information

Plan Name: Bronze Care on Demand 8000 Exchange EPO Individual and Family Network

HIOS Plan ID: 87718WA2170003

Effective Date: 1/1/2021

Market Type: Individual

Exchange Status: Inside the Exchange

Metal Level: Bronze

Plan Type: Non-Standardized Plan

Plan Geographic Availability

Area

Number

Available

in area?

1 Yes

2 Yes

3 Yes

4 N/A

5 Yes

6 Yes

7 N/A

8 Yes

9 N/A

Plan Rates

Age

Band Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9

0-14 177.00 198.06 191.87 183.02 186.38 183.72 177.00 198.06 191.87 183.02 186.38 183.72

15 192.73 215.67 208.92 199.28 202.95 200.05 192.73 215.67 208.92 199.28 202.95 200.05

16 198.75 222.40 215.44 205.50 209.28 206.30 198.75 222.40 215.44 205.50 209.28 206.30

17 204.76 229.13 221.96 211.72 215.61 212.54 204.76 229.13 221.96 211.72 215.61 212.54

18 211.24 236.38 228.99 218.42 222.44 219.27 211.24 236.38 228.99 218.42 222.44 219.27

19 217.72 243.63 236.01 225.12 229.26 225.99 217.72 243.63 236.01 225.12 229.26 225.99

20 224.43 251.14 243.28 232.06 236.32 232.96 224.43 251.14 243.28 232.06 236.32 232.96

21 231.37 258.90 250.81 239.24 243.63 240.16 266.08 297.74 288.43 275.12 280.18 276.19

22 231.37 258.90 250.81 239.24 243.63 240.16 266.08 297.74 288.43 275.12 280.18 276.19

23 231.37 258.90 250.81 239.24 243.63 240.16 266.08 297.74 288.43 275.12 280.18 276.19

24 231.37 258.90 250.81 239.24 243.63 240.16 266.08 297.74 288.43 275.12 280.18 276.19

25 232.30 259.94 251.81 240.19 244.61 241.12 267.14 298.93 289.58 276.22 281.30 277.29

26 236.92 265.12 256.82 244.98 249.48 245.93 272.46 304.88 295.35 281.72 286.90 282.81

27 242.48 271.33 262.84 250.72 255.33 251.69 278.85 312.03 302.27 288.33 293.63 289.44

28 251.50 281.43 272.63 260.05 264.83 261.06 289.22 323.64 313.52 299.06 304.55 300.21

29 258.90 289.71 280.65 267.71 272.62 268.74 297.74 333.17 322.75 307.86 313.52 309.05

30 262.60 293.85 284.66 271.53 276.52 272.58 302.00 337.93 327.36 312.26 318.00 313.47

31 268.16 300.07 290.68 277.28 282.37 278.35 308.38 345.08 334.29 318.87 324.73 320.10

32 273.71 306.28 296.70 283.02 288.22 284.11 314.77 352.22 341.21 325.47 331.45 326.73

33 277.18 310.17 300.46 286.61 291.87 287.71 318.76 356.69 345.53 329.60 335.65 330.87

34 280.88 314.31 304.48 290.43 295.77 291.56 323.02 361.45 350.15 334.00 340.14 335.29

35 282.73 316.38 306.48 292.35 297.72 293.48 325.14 363.84 352.46 336.20 342.38 337.50

36 284.59 318.45 308.49 294.26 299.67 295.40 327.27 366.22 354.76 338.40 344.62 339.71

37 286.44 320.52 310.50 296.17 301.62 297.32 329.40 368.60 357.07 340.60 346.86 341.92

38 288.29 322.59 312.50 298.09 303.57 299.24 331.53 370.98 359.38 342.80 349.10 344.13

39 291.99 326.74 316.52 301.92 307.46 303.08 335.79 375.75 363.99 347.20 353.58 348.55

40 295.69 330.88 320.53 305.74 311.36 306.93 340.04 380.51 368.61 351.61 358.07 352.97

41 301.24 337.09 326.55 311.49 317.21 312.69 346.43 387.66 375.53 358.21 364.79 359.59

42 306.57 343.05 332.32 316.99 322.81 318.21 352.55 394.50 382.16 364.54 371.24 365.95

43 313.97 351.33 340.34 324.64 330.61 325.90 361.06 404.03 391.39 373.34 380.20 374.78

44 323.22 361.69 350.37 334.21 340.35 335.51 371.71 415.94 402.93 384.35 391.41 385.83

45 334.10 373.86 362.16 345.46 351.81 346.79 384.21 429.93 416.49 397.28 404.58 398.81

46 347.06 388.35 376.21 358.85 365.45 360.24 399.11 446.61 432.64 412.68 420.27 414.28

47 361.63 404.67 392.01 373.93 380.80 375.37 415.88 465.37 450.81 430.02 437.92 431.68

48 378.29 423.31 410.07 391.15 398.34 392.66 435.03 486.80 471.58 449.82 458.09 451.56

49 394.72 441.69 427.87 408.14 415.64 409.72 453.92 507.94 492.05 469.36 477.98 471.17

50 413.23 462.40 447.94 427.28 435.13 428.93 475.21 531.76 515.13 491.37 500.40 493.27

51 431.51 482.85 467.75 446.18 454.37 447.90 496.23 555.28 537.91 513.10 522.53 515.09

52 451.63 505.38 489.57 466.99 475.57 468.80 519.38 581.19 563.01 537.04 546.91 539.12

53 471.99 528.16 511.64 488.04 497.01 489.93 542.79 607.39 588.39 561.25 571.56 563.42

54 493.97 552.76 535.47 510.77 520.16 512.75 568.07 635.67 615.79 587.39 598.18 589.66

55 515.96 577.35 559.30 533.50 543.30 535.56 593.35 663.96 643.19 613.52 624.80 615.90

56 539.79 604.02 585.13 558.14 568.39 560.30 620.75 694.62 672.90 641.86 653.65 644.34

57 563.85 630.95 611.21 583.02 593.73 585.27 648.43 725.59 702.89 670.47 682.79 673.07

58 589.53 659.68 639.05 609.57 620.78 611.93 677.96 758.64 734.91 701.01 713.89 703.72

59 602.26 673.92 652.85 622.73 634.18 625.14 692.59 775.01 750.77 716.14 729.30 718.91

60 627.94 702.66 680.68 649.29 661.22 651.80 722.13 808.06 782.79 746.68 760.40 749.57

61 650.15 727.52 704.76 672.25 684.61 674.86 747.67 836.65 810.48 773.09 787.30 776.08

62 664.73 743.83 720.56 687.33 699.96 689.99 764.43 855.40 828.65 790.43 804.95 793.48

63 683.00 764.28 740.38 706.23 719.20 708.96 785.45 878.92 851.43 812.16 827.08 815.30

64 and over 694.11 776.70 752.42 717.71 730.89 720.48 798.23 893.22 865.28 825.36 840.53 828.56

Non-Smoker Rates Smoker Rates

Mason, Pierce, Thurston

Yakima

Island, San Juan, Skagit, Snohomish, Whatcom

Regence BlueShield

RATE SCHEDULE

Counties where this plan is available

King

Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, Wahkiakum

Klickitat, Skamania

Page 12 of 12