| Plans & Benefits Template | To use this template, please review the user guide and instructions. | ||||||||||||||||||||||||||||||||||||||
| HIOS Issuer ID* | You will need to save the latest version of the add-in file (PlansBenefitsAddIn.xlam) on your machine. | ||||||||||||||||||||||||||||||||||||||
| Issuer State* | To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro. | ||||||||||||||||||||||||||||||||||||||
| Market Coverage* | To create additional Benefits Package worksheets, use the Create New Benefits Package macro. | ||||||||||||||||||||||||||||||||||||||
| Dental Only Plan* | To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro. | ||||||||||||||||||||||||||||||||||||||
| Plan Identifiers | Plan Attributes | Stand Alone Dental Only | Plan Dates | Geographic Coverage | |||||||||||||||||||||||||||||||||||
| HIOS Plan ID* (Standard Component) |
Plan Marketing Name* | HIOS Product ID* | HPID | Network ID* | Service Area ID* | Formulary ID* | New/Existing Plan?* | Plan Type* | Level of Coverage* | Unique Plan Design?* | Is this a QHP Offered on the Exchange? * | If Off Exchange, is it the Same or Substantially the Same as a Certified Exchange QHP? | If the Same or Substantially the Same as a Certified Exchange QHP, Provide HIOS Plan ID (14-digit Standard Component) for the Certified Exchange QHP | Multi-State Plan* | Notice Required for Pregnancy* | Is a Referral Required for Specialist?* | Specialist(s) Requiring a Referral | Plan Level Exclusions | Limited Cost Sharing Plan Variation - Est Advanced Payment (Optional) | Do You Want a Zero Cost Sharing Plan Variation Created for this Plan?* (Y/N) |
Does this plan allow Child-Only Enrollments?* (Y/N) |
Is this a Child-Only plan? (Y/N) |
If No, enter corresponding plan ID for Child-Only plan | Tobacco Related Wellness Program Offered* | Disease Management Programs Offered | Composite vs. Individual Member Rating (SHOP Plans Only) | Out of Network Coverage | Does the QHP Issuer Operate a Medicaid Health Plan with Substantially the Same Provider Network and Service Area (Y/N)? | EHB as a Percent Premium | EHB Apportionment for Pediatric Dental | Guaranteed vs. Estimated Rate | Plan Effective Date* | Plan Expiration Date | Plan vs. Benefit Year | Out of Country Coverage* | Out of Country Coverage Description | Out of Service Area Coverage* | Out of Service Area Coverage Description | National Network* |
| Benefit Information | General Information | Deductible and Out of Pocket Exceptions | |||||||||||||||||||||||||||||||||||||
| Benefits | EHB (Autopopulated) | EHB (Issuer) | State-Required Benefit | Is this Benefit Covered? | Quantitative Limit on Service | Limit Quantity | Limit Unit | Quantitative Limit Units Apply see EHB Benchmark | Exclusions | Benefit Explanation | EHB Variance Reason | Subject to Deductible (Tier 1) | Subject to Deductible (Tier 2) |
Excluded from In Network MOOP | Excluded from Out of Network MOOP | ||||||||||||||||||||||||
| Primary Care Visit to Treat an Injury or Illness | |||||||||||||||||||||||||||||||||||||||
| Specialist Visit | |||||||||||||||||||||||||||||||||||||||
| Other Practitioner Office Visit (Nurse, Physician Assistant) | |||||||||||||||||||||||||||||||||||||||
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | |||||||||||||||||||||||||||||||||||||||
| Outpatient Surgery Physician/Surgical Services | |||||||||||||||||||||||||||||||||||||||
| Hospice Services | |||||||||||||||||||||||||||||||||||||||
| Non-Emergency Care When Traveling Outside the U.S. | |||||||||||||||||||||||||||||||||||||||
| Routine Dental Services (Adult) | |||||||||||||||||||||||||||||||||||||||
| Infertility Treatment | |||||||||||||||||||||||||||||||||||||||
| Long-Term/Custodial Nursing Home Care | |||||||||||||||||||||||||||||||||||||||
| Private-Duty Nursing | |||||||||||||||||||||||||||||||||||||||
| Routine Eye Exam (Adult) | |||||||||||||||||||||||||||||||||||||||
| Urgent Care Centers or Facilities | |||||||||||||||||||||||||||||||||||||||
| Home Health Care Services | |||||||||||||||||||||||||||||||||||||||
| Emergency Room Services | |||||||||||||||||||||||||||||||||||||||
| Emergency Transportation/Ambulance | |||||||||||||||||||||||||||||||||||||||
| Inpatient Hospital Services (e.g., Hospital Stay) | |||||||||||||||||||||||||||||||||||||||
| Inpatient Physician and Surgical Services | |||||||||||||||||||||||||||||||||||||||
| Bariatric Surgery | |||||||||||||||||||||||||||||||||||||||
| Cosmetic Surgery | |||||||||||||||||||||||||||||||||||||||
| Skilled Nursing Facility | |||||||||||||||||||||||||||||||||||||||
| Prenatal and Postnatal Care | |||||||||||||||||||||||||||||||||||||||
| Delivery and All Inpatient Services for Maternity Care | |||||||||||||||||||||||||||||||||||||||
| Mental/ Behavioral Health Outpatient Services | |||||||||||||||||||||||||||||||||||||||
| Mental/ Behavioral Health Inpatient Services | |||||||||||||||||||||||||||||||||||||||
| Substance Abuse Disorder Outpatient Services | |||||||||||||||||||||||||||||||||||||||
| Substance Abuse Disorder Inpatient Services | |||||||||||||||||||||||||||||||||||||||
| Generic Drugs | |||||||||||||||||||||||||||||||||||||||
| Preferred Brand Drugs | |||||||||||||||||||||||||||||||||||||||
| Non-Preferred Brand Drugs | |||||||||||||||||||||||||||||||||||||||
| Specialty Drugs | |||||||||||||||||||||||||||||||||||||||
| Outpatient Rehabilitation Services | |||||||||||||||||||||||||||||||||||||||
| Habilitation Services | |||||||||||||||||||||||||||||||||||||||
| Chiropractic Care | |||||||||||||||||||||||||||||||||||||||
| Durable Medical Equipment | |||||||||||||||||||||||||||||||||||||||
| Hearing Aids | |||||||||||||||||||||||||||||||||||||||
| Imaging (CT/PET Scans, MRIs) | |||||||||||||||||||||||||||||||||||||||
| Preventive Care/Screening/Immunization | |||||||||||||||||||||||||||||||||||||||
| Routine Foot Care | |||||||||||||||||||||||||||||||||||||||
| Acupuncture | |||||||||||||||||||||||||||||||||||||||
| Weight Loss Programs | |||||||||||||||||||||||||||||||||||||||
| Routine Eye Exam for Children | |||||||||||||||||||||||||||||||||||||||
| Eye Glasses for Children | |||||||||||||||||||||||||||||||||||||||
| Dental Check-Up for Children | |||||||||||||||||||||||||||||||||||||||
| Rehabilitative Speech Therapy | |||||||||||||||||||||||||||||||||||||||
| Rehabilitative Occupational and Rehabilitative Physical Therapy | |||||||||||||||||||||||||||||||||||||||
| Well Baby Visits and Care | |||||||||||||||||||||||||||||||||||||||
| Laboratory Outpatient and Professional Services | |||||||||||||||||||||||||||||||||||||||
| X-rays and Diagnostic Imaging | |||||||||||||||||||||||||||||||||||||||
| Basic Dental Care – Child | |||||||||||||||||||||||||||||||||||||||
| Orthodontia – Child | |||||||||||||||||||||||||||||||||||||||
| Major Dental Care – Child | |||||||||||||||||||||||||||||||||||||||
| Basic Dental Care – Adult | |||||||||||||||||||||||||||||||||||||||
| Orthodontia – Adult | |||||||||||||||||||||||||||||||||||||||
| Major Dental Care – Adult | |||||||||||||||||||||||||||||||||||||||
| Abortion for Which Public Funding is Prohibited | |||||||||||||||||||||||||||||||||||||||
| Transplant | |||||||||||||||||||||||||||||||||||||||
| Accidental Dental | |||||||||||||||||||||||||||||||||||||||
| Dialysis | |||||||||||||||||||||||||||||||||||||||
| Allergy Treatment | |||||||||||||||||||||||||||||||||||||||
| Chemotherapy | |||||||||||||||||||||||||||||||||||||||
| Radiation | |||||||||||||||||||||||||||||||||||||||
| Diabetes Education | |||||||||||||||||||||||||||||||||||||||
| Prosthetic Devices | |||||||||||||||||||||||||||||||||||||||
| Infusion Therapy | |||||||||||||||||||||||||||||||||||||||
| Treatment for Temporomandibular Joint Disorders | |||||||||||||||||||||||||||||||||||||||
| Nutritional Counseling | |||||||||||||||||||||||||||||||||||||||
| Reconstructive Surgery | |||||||||||||||||||||||||||||||||||||||
| Additional State-Required Benefits | |||||||||||||||||||||||||||||||||||||||
| SBC Scenario | Maximum Out of Pocket for Medical EHB Benefits | Maximum Out of Pocket for Drug EHB Benefits | Maximum Out of Pocket for Medical and Drug EHB Benefits (Total) | Medical EHB Deductible | Drug EHB Deductible | Combined Medical and Drug EHB Deductible | Primary Care Visit to Treat an Injury or Illness | Specialist Visit | Other Practitioner Office Visit (Nurse, Physician Assistant) | Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | Outpatient Surgery Physician/Surgical Services | Hospice Services | Non-Emergency Care When Traveling Outside the U.S. | Routine Dental Services (Adult) | Infertility Treatment | Long-Term/Custodial Nursing Home Care | Private-Duty Nursing | Routine Eye Exam (Adult) | Urgent Care Centers or Facilities | Home Health Care Services | Emergency Room Services | Emergency Transportation/Ambulance | Inpatient Hospital Services (e.g., Hospital Stay) | Inpatient Physician and Surgical Services | Bariatric Surgery | Cosmetic Surgery | Skilled Nursing Facility | Prenatal and Postnatal Care | Delivery and All Inpatient Services for Maternity Care | Mental/ Behavioral Health Outpatient Services | Substance Abuse Disorder Outpatient Services | Mental/ Behavioral Health Inpatient Services | Substance Abuse Disorder Inpatient Services | Generic Drugs | Preferred Brand Drugs | Non-Preferred Brand Drugs | Specialty Drugs | Outpatient Rehabilitation Services | Habilitation Services | Chiropractic Care | Durable Medical Equipment | Hearing Aids | Imaging (CT/PET Scans, MRIs) | Preventive Care/Screening/Immunization | Routine Foot Care | Acupuncture | Weight Loss Programs | Routine Eye Exam for Children | Eye Glasses for Children | Dental Check-Up for Children | Rehabilitative Speech Therapy | Rehabilitative Occupational and Rehabilitative Physical Therapy | Well Baby Visits and Care | Laboratory Outpatient and Professional Services | X-rays and Diagnostic Imaging | Basic Dental Care – Child | Orthodontia – Child | Major Dental Care – Child | Basic Dental Care – Adult | Orthodontia – Adult | Major Dental Care – Adult | Abortion for Which Public Funding is Prohibited | Transplant | Accidental Dental | Dialysis | Allergy Testing | Chemotherapy | Radiation | Diabetes Education | Prosthetic Devices | Infusion Therapy | Treatment for Temporomandibular Joint Disorders | Nutritional Counseling | Reconstructive Surgery | Additional State-Required Benefits | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Plan Cost Sharing Attributes | HSA/HRA Detail | URLs | Having a Baby | Having Diabetes | In Network | In Network (Tier 2) | Out of Network | Combined In/Out Network | In Network | In Network (Tier 2) | Out of Network | Combined In/Out Network | In Network | In Network (Tier 2) | Out of Network | Combined In/Out Network | In Network | In Network (Tier 2) |
Out of Network | Combined In/Out Network | In Network | In Network (Tier 2) | Out of Network | Combined In/Out Network | In Network | In Network (Tier 2) | Out of Network | Combined In/Out Network | Copay | Coinsurance | AV Calculator Additional Benefit Design | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Coinsurance for AV Calculator | Copay | Coinsurance | Coinsurance for AV Calculator | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | AV Calculator Additional Benefit Design | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | AV Calculator Additional Benefit Design | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | Copay | Coinsurance | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HIOS Plan ID* (Standard Component + Variant) |
Plan Marketing Name* | Level of Coverage* (Metal Level) |
CSR Variation Type* | Issuer Actuarial Value | AV Calculator Output Number* | Medical & Drug Deductibles Integrated?* | Medical & Drug Maximum Out of Pocket Integrated?* | Out of Network Coverage?* | Multiple In Network Tiers?* | 1st Tier Utilization* | 2nd Tier Utilization | HSA Eligible* | HSA/HRA Employer Contribution | HSA/HRA Employer Contribution Amount | URL for Summary of Benefits & Coverage | URL for Enrollment Payment | Plan Brochure | Deductible | Copayment | Coinsurance | Limit | Deductible | Copayment | Coinsurance | Limit | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Default Coinsurance | Individual | Per Person in Family | Family | Default Coinsurance | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Default Coinsurance | Individual | Per Person in Family | Family | Default Coinsurance | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | Default Coinsurance | Individual | Per Person in Family | Family | Default Coinsurance | Individual | Per Person in Family | Family | Individual | Per Person in Family | Family | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | Begin Primary Care Cost-Sharing After a Set Number of Visits? | Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays? | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | Maximum Number of Days for Charging an Inpatient Copay? | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | Maximum Coinsurance for Specialty Drugs | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network | In Network (Tier 1) | In Network (Tier 2) | Out of Network |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |