Benefit Summary Name Platinum No Ded/3000 Moop Platinum No Ded/3000 Moop Limited Cost Sharing Platinum No Ded/3000 Moop Zero Cost Sharing Platinum 500 Ded/3000 Moop Platinum 500 Ded/3000 Moop Limited Cost Sharing Platinum 500 Ded/3000 Moop Zero Cost Sharing Platinum 500 Ded/4500 Moop Platinum 500 Ded/4500 Moop Limited Cost Sharing Platinum 500 Ded/4500 Moop Zero Cost Sharing Platinum 500 Ded/1000 Moop Platinum 500 Ded/1000 Moop Limited Cost Sharing Platinum 500 Ded/1000 Moop Zero Cost Sharing Gold 1500 Ded/5200 Moop Gold 1500 Ded/5200 Moop Limited Cost Sharing Gold 1500 Ded/5200 Moop Zero Cost Sharing Gold 2500 Ded/7150 Moop Gold 2500 Ded/7150 Moop Limited Cost Sharing Gold 2500 Ded/7150 Moop Zero Cost Sharing Gold 1000 Ded/3500 Moop Gold 1000 Ded/3500 Moop Limited Cost Sharing Gold 1000 Ded/3500 Moop Zero Cost Sharing Gold HSA 2000 Ded/2000 Moop Gold HSA 2000 Ded/2000 Moop Limited Cost Sharing Gold HSA 2000 Ded/2000 Moop Zero Cost Sharing Gold HSA Standardized Plan Gold Standardized Plan Zero Cost Sharing Gold Standardized Plan Limited Cost Sharing Silver 3500 Ded/7150 Moop Silver 3500 Ded/7150 Moop 73% Silver 3500 Ded/7150 Moop 87% Silver 3500 Ded/7150 Moop 94% Silver 3500 Ded/7150 Moop Limited Cost Sharing Non-Select OnExchange Non-Select OffExchange 1711101 1711102 1711103 1711104 1711105 1711106 1711107 1711108 1711109 1711110 1711111 1711112 1711201 1711202 1711203 1711204 1711205 1711206 1711207 1711208 1711209 1711210 1711211 1711212 1711301 1711302 1711303 1711304 1711305 1731101 1731104 1731107 1731110 1731201 1731204 1731207 1731210 1731301 - Select On- Select OffExchange Exchange 1712101 1712102 1712103 1712104 1712105 1712106 1712107 1712108 1712109 1712110 1712111 1712112 1712201 1712202 1712203 1712204 1712205 1712206 1712207 1712208 1712209 1712210 1712211 1712212 1712213 1712215 1712214 1712301 1712302 1712303 1712304 1712305 1732101 1732104 1732107 1732110 1732201 1732204 1732207 1732210 1732213 1732301 - Benefit Summary Name Silver 3500 Ded/7150 Moop Zero Cost Sharing Silver 4250 Ded/7150 Moop Silver 4250 Ded/7150 Moop 73% Silver 4250 Ded/7150 Moop 87% Silver 4250 Ded/7150 Moop 94% Silver 4250 Ded/7150 Moop Limited Cost Sharing Silver 4250 Ded/7150 Moop Zero Cost Sharing Silver 5000 Ded/7150 Moop Silver 5000 Ded/7150 Moop 73% Silver 5000 Ded/7150 Moop 87% Silver 5000 Ded/7150 Moop 94% Silver 5000 Ded/7150 Moop Limited Cost Sharing Silver 5000 Ded/7150 Moop Zero Cost Sharing Silver 2500 Ded/6500 Moop (30 Copay) Silver 2500 Ded/6500 Moop (30 Copay) 73% Silver 2500 Ded/6500 Moop (30 Copay) 87% Silver 2500 Ded/6500 Moop (30 Copay) 94% Silver 2500 Ded/6500 Moop (30 Copay) Limited Cost Sharing Silver 2500 Ded/6500 Moop (30 Copay) Zero Cost Sharing Silver 2000 Ded/6000 Moop Silver 2000 Ded/6000 Moop 73% Silver 2000 Ded/6000 Moop 87% Silver 2000 Ded/6000 Moop 94% Silver 2000 Ded/6000 Moop Limited Cost Sharing Silver 2000 Ded/6000 Moop Zero Cost Sharing Silver HSA 4000 Ded/4000 Moop Silver HSA 4000 Ded/4000 Moop 73% Silver HSA 4000 Ded/4000 Moop 87% Silver HSA 4000 Ded/4000 Moop 94% Silver HSA 4000 Ded/4000 Moop Limited Cost Sharing Silver HSA 4000 Ded/4000 Moop Zero Cost Sharing Silver 3500 Ded/6850 Moop Non-Select OnExchange Non-Select OffExchange 1711306 1711307 1711308 1711309 1711310 1711311 1711312 1711313 1711314 1711315 1711316 1711317 1711318 1711319 1711320 1711321 1711322 1711323 1711324 1711325 1711326 1711327 1711328 1711329 1711330 1711331 1711332 1711333 1711334 1711335 1711336 1711337 1731307 1731313 1731319 1731325 1731331 1731337 Select On- Select OffExchange Exchange 1712306 1712307 1712308 1712309 1712310 1712311 1712312 1712313 1712314 1712315 1712316 1712317 1712318 1712319 1712320 1712321 1712322 1712323 1712324 1712325 1712326 1712327 1712328 1712329 1712330 1712331 1712332 1712333 1712334 1712335 1712336 1712337 1732307 1732313 1732319 1732325 1732331 1732337 Benefit Summary Name Silver 3500 Ded/6850 Moop 73% Silver 3500 Ded/6850 Moop 87% Silver 3500 Ded/6850 Moop 94% Silver 3500 Ded/6850 Moop Limited Cost Sharing Silver 3500 Ded/6850 Moop Zero Cost Sharing Silver Standardized Silver Standardized Zero Cost Sharing Silver Standardized Limited Cost Sharing Silver Standardized 73% Silver Standardized 87% Silver Standardized 94% Bronze 4000 Ded/7150 Moop Bronze 4000 Ded/7150 Moop Limited Cost Sharing Bronze 4000 Ded/7150 Moop Zero Cost Sharing Bronze HSA 6550 Ded/6550 Moop Bronze HSA 6550 Ded/6550 Moop Limited Cost Sharing Bronze HSA 6550 Ded/6550 Moop Zero Cost Sharing Bronze Standardized Bronze Standardized Zero Cost Sharing Bronze Standardized Limited Cost Sharing Catastrophic 7150/7150 MOOP Non-Select OnExchange Non-Select OffExchange 1711338 1711339 1711340 1711341 1711342 1711401 1711402 1711403 1711404 1711405 1711406 1711001 1731401 1731404 1731001 Select On- Select OffExchange Exchange 1712338 1712339 1712340 1712341 1712342 1712343 1712348 1712347 1712344 1712345 1712346 1712401 1712402 1712403 1712404 1712405 1712406 1712407 1712409 1712408 1712001 1732343 1732401 1732404 1732407 1732001 Benefit Summary Name Individual Conversion Plan Individual $15 Co-Payment Plan Individual $15 Co-payment Plan with Rx Individual $500 Deductible Individual $500 Deductible with Rx Individual $1000 Deductible Individual $1,000 Deductible with Rx $1300 High Deductible - 0% - Plan A $1300 High Deductible - 0% w/ Rx Plan A $1300 High Deductible- 20% Plan B $1300 High Deductible - 20% w/ Rx - Plan B $2500 High Deductible - 0% - Plan C $2500 High Deductible - 0% w/ Rx - Plan C $2500 High Deductible - 20% - Plan D $2500 High Deductible - 20% w/ Rx - Plan D $5250 High Deductible - 0% - Plan E $5250 High Deductible - 0% w/ Rx - Plan E Individual Extended Plan Individual $2,000 Deductible Benefit Arch Plan Individual $2,000 Deductible Benefit Arch Plan with Rx Individual $3,000 Deductible Benefit Arch Plan Individual $3,000 Deductible Benefit Arch Plan with Rx Individual $20 Co-payment plan Individual $20 Co-payment Plan with Rx Individual $30 Co-payment Plan Individual $30 Co-payment Plan with Rx Individual $40 Co-payment plan Individual $40 Co-payment Plan with Rx Plan Number 1751501 1751502 1751503 1751504 1751505 1751506 1751507 1751508 1751509 1751510 1751511 1751512 1751513 1751514 1751515 1751516 1751517 1751518 1751519 1751520 1751521 1751522 1751523 1751524 1751525 1751526 1751527 1751528
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