IA

TIER 1

2

Premier 200

$20

$50

Plus 250A

$72

$112

Premier 400

$0

$20

Plus 450B

$27

$59

3

4

C

Please note the figures quoted herein are subject to the Final Bid Approval by CMS.

6

TIER 1

2

3

4

5

Premier 200

$35

$60

$70

$95

$110

Premier Plus 250A

$98 $119 $114

$139

$165

Premier 400

$0

$25

$60

$75

Plus 450B

$41

$60

Plus 450C Plus 450D Plus 450E

$35

6

$56 $82 $108

Please note the figures quoted herein are subject to the Final Bid Approval by CMS.

11

TIER 1

2

3

Advantage Plus 250A

$122

Advantage Plus 450F

$51

4

C

Please note the figures quoted herein are subject to the Final Bid Approval by CMS.

5