Regence BlueShield RATE SCHEDULE Plan Information Plan ......Individual Nongrandfathered Health Plan...
Transcript of Regence BlueShield RATE SCHEDULE Plan Information Plan ......Individual Nongrandfathered Health Plan...
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