Obamacare 2022 Rates for Maricopa County

Obamacare > Rates > Arizona > Maricopa County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Maricopa County, AZ.

The health insurance rates listed below are for calendar year 2022.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 122 Plans and 2022 Rates for Maricopa County, Arizona

Below, you’ll find a summary of the 122 plans for Maricopa County, Arizona and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Oscar Health Plan, Inc.

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755

Toc - Plan #1 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$250.04
$283.79
$319.54
$446.56
$678.59 		$441.32
$475.07
$510.82
$637.84 		$632.60
$666.35
$702.10
$829.12 		$823.88
$857.63
$893.38
$1,020.40 		$191.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500.08
$567.58
$639.08
$893.12
$1,357.18 		$691.36
$758.86
$830.36
$1,084.40 		$882.64
$950.14
$1,021.64
$1,275.68 		$1,073.92
$1,141.42
$1,212.92
$1,466.96 		$191.28
Toc - Plan #2 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$245.74
$278.90
$314.04
$438.87
$666.90 		$433.72
$466.88
$502.02
$626.85 		$621.70
$654.86
$690.00
$814.83 		$809.68
$842.84
$877.98
$1,002.81 		$187.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$491.48
$557.80
$628.08
$877.74
$1,333.80 		$679.46
$745.78
$816.06
$1,065.72 		$867.44
$933.76
$1,004.04
$1,253.70 		$1,055.42
$1,121.74
$1,192.02
$1,441.68 		$187.98
Toc - Plan #3 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $0 Ded+PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286.54
$325.21
$366.18
$511.73
$777.63 		$505.73
$544.40
$585.37
$730.92 		$724.92
$763.59
$804.56
$950.11 		$944.11
$982.78
$1,023.75
$1,169.30 		$219.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.08
$650.42
$732.36
$1,023.46
$1,555.26 		$792.27
$869.61
$951.55
$1,242.65 		$1,011.46
$1,088.80
$1,170.74
$1,461.84 		$1,230.65
$1,307.99
$1,389.93
$1,681.03 		$219.19
Toc - Plan #4 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$307.41
$348.90
$392.85
$549.01
$834.28 		$542.57
$584.06
$628.01
$784.17 		$777.73
$819.22
$863.17
$1,019.33 		$1,012.89
$1,054.38
$1,098.33
$1,254.49 		$235.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.82
$697.80
$785.70
$1,098.02
$1,668.56 		$849.98
$932.96
$1,020.86
$1,333.18 		$1,085.14
$1,168.12
$1,256.02
$1,568.34 		$1,320.30
$1,403.28
$1,491.18
$1,803.50 		$235.16
Toc - Plan #5 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.25
$340.77
$383.71
$536.23
$814.85 		$529.93
$570.45
$613.39
$765.91 		$759.61
$800.13
$843.07
$995.59 		$989.29
$1,029.81
$1,072.75
$1,225.27 		$229.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.50
$681.54
$767.42
$1,072.46
$1,629.70 		$830.18
$911.22
$997.10
$1,302.14 		$1,059.86
$1,140.90
$1,226.78
$1,531.82 		$1,289.54
$1,370.58
$1,456.46
$1,761.50 		$229.68
Toc - Plan #6 Oscar Health Plan, Inc.
Catastrophic

(HMO) Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$206.09
$233.90
$263.37
$368.06
$559.31 		$363.74
$391.55
$421.02
$525.71 		$521.39
$549.20
$578.67
$683.36 		$679.04
$706.85
$736.32
$841.01 		$157.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$412.18
$467.80
$526.74
$736.12
$1,118.62 		$569.83
$625.45
$684.39
$893.77 		$727.48
$783.10
$842.04
$1,051.42 		$885.13
$940.75
$999.69
$1,209.07 		$157.65
Toc - Plan #7 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $0 Ded+Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286.51
$325.18
$366.15
$511.69
$777.56 		$505.68
$544.35
$585.32
$730.86 		$724.85
$763.52
$804.49
$950.03 		$944.02
$982.69
$1,023.66
$1,169.20 		$219.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.02
$650.36
$732.30
$1,023.38
$1,555.12 		$792.19
$869.53
$951.47
$1,242.55 		$1,011.36
$1,088.70
$1,170.64
$1,461.72 		$1,230.53
$1,307.87
$1,389.81
$1,680.89 		$219.17
Toc - Plan #8 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.40
$429.48
$483.59
$675.81
$1,026.96 		$667.87
$718.95
$773.06
$965.28 		$957.34
$1,008.42
$1,062.53
$1,254.75 		$1,246.81
$1,297.89
$1,352.00
$1,544.22 		$289.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.80
$858.96
$967.18
$1,351.62
$2,053.92 		$1,046.27
$1,148.43
$1,256.65
$1,641.09 		$1,335.74
$1,437.90
$1,546.12
$1,930.56 		$1,625.21
$1,727.37
$1,835.59
$2,220.03 		$289.47
Toc - Plan #9 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,200 $14,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$265.91
$301.80
$339.82
$474.90
$721.66 		$469.32
$505.21
$543.23
$678.31 		$672.73
$708.62
$746.64
$881.72 		$876.14
$912.03
$950.05
$1,085.13 		$203.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531.82
$603.60
$679.64
$949.80
$1,443.32 		$735.23
$807.01
$883.05
$1,153.21 		$938.64
$1,010.42
$1,086.46
$1,356.62 		$1,142.05
$1,213.83
$1,289.87
$1,560.03 		$203.41
Toc - Plan #10 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.13
$340.64
$383.55
$536.02
$814.53 		$529.72
$570.23
$613.14
$765.61 		$759.31
$799.82
$842.73
$995.20 		$988.90
$1,029.41
$1,072.32
$1,224.79 		$229.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.26
$681.28
$767.10
$1,072.04
$1,629.06 		$829.85
$910.87
$996.69
$1,301.63 		$1,059.44
$1,140.46
$1,226.28
$1,531.22 		$1,289.03
$1,370.05
$1,455.87
$1,760.81 		$229.59
Toc - Plan #11 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323.55
$367.22
$413.48
$577.84
$878.08 		$571.06
$614.73
$660.99
$825.35 		$818.57
$862.24
$908.50
$1,072.86 		$1,066.08
$1,109.75
$1,156.01
$1,320.37 		$247.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.10
$734.44
$826.96
$1,155.68
$1,756.16 		$894.61
$981.95
$1,074.47
$1,403.19 		$1,142.12
$1,229.46
$1,321.98
$1,650.70 		$1,389.63
$1,476.97
$1,569.49
$1,898.21 		$247.51
Toc - Plan #12 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$258.46
$293.34
$330.30
$461.59
$701.43 		$456.17
$491.05
$528.01
$659.30 		$653.88
$688.76
$725.72
$857.01 		$851.59
$886.47
$923.43
$1,054.72 		$197.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$516.92
$586.68
$660.60
$923.18
$1,402.86 		$714.63
$784.39
$858.31
$1,120.89 		$912.34
$982.10
$1,056.02
$1,318.60 		$1,110.05
$1,179.81
$1,253.73
$1,516.31 		$197.71
Toc - Plan #13 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.15
$312.28
$351.63
$491.40
$746.73 		$485.63
$522.76
$562.11
$701.88 		$696.11
$733.24
$772.59
$912.36 		$906.59
$943.72
$983.07
$1,122.84 		$210.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.30
$624.56
$703.26
$982.80
$1,493.46 		$760.78
$835.04
$913.74
$1,193.28 		$971.26
$1,045.52
$1,124.22
$1,403.76 		$1,181.74
$1,256.00
$1,334.70
$1,614.24 		$210.48
Toc - Plan #14 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $3000 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276.17
$313.44
$352.93
$493.22
$749.50 		$487.43
$524.70
$564.19
$704.48 		$698.69
$735.96
$775.45
$915.74 		$909.95
$947.22
$986.71
$1,127.00 		$211.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.34
$626.88
$705.86
$986.44
$1,499.00 		$763.60
$838.14
$917.12
$1,197.70 		$974.86
$1,049.40
$1,128.38
$1,408.96 		$1,186.12
$1,260.66
$1,339.64
$1,620.22 		$211.26
Toc - Plan #15 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$259.08
$294.05
$331.10
$462.71
$703.13 		$457.27
$492.24
$529.29
$660.90 		$655.46
$690.43
$727.48
$859.09 		$853.65
$888.62
$925.67
$1,057.28 		$198.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518.16
$588.10
$662.20
$925.42
$1,406.26 		$716.35
$786.29
$860.39
$1,123.61 		$914.54
$984.48
$1,058.58
$1,321.80 		$1,112.73
$1,182.67
$1,256.77
$1,519.99 		$198.19
Toc - Plan #16 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,375 $16,750 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$296.51
$336.53
$378.93
$529.55
$804.71 		$523.33
$563.35
$605.75
$756.37 		$750.15
$790.17
$832.57
$983.19 		$976.97
$1,016.99
$1,059.39
$1,210.01 		$226.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$593.02
$673.06
$757.86
$1,059.10
$1,609.42 		$819.84
$899.88
$984.68
$1,285.92 		$1,046.66
$1,126.70
$1,211.50
$1,512.74 		$1,273.48
$1,353.52
$1,438.32
$1,739.56 		$226.82
Toc - Plan #17 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318.99
$362.04
$407.65
$569.69
$865.70 		$563.01
$606.06
$651.67
$813.71 		$807.03
$850.08
$895.69
$1,057.73 		$1,051.05
$1,094.10
$1,139.71
$1,301.75 		$244.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.98
$724.08
$815.30
$1,139.38
$1,731.40 		$882.00
$968.10
$1,059.32
$1,383.40 		$1,126.02
$1,212.12
$1,303.34
$1,627.42 		$1,370.04
$1,456.14
$1,547.36
$1,871.44 		$244.02
Toc - Plan #18 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic- Low Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$307.87
$349.42
$393.44
$549.84
$835.53 		$543.38
$584.93
$628.95
$785.35 		$778.89
$820.44
$864.46
$1,020.86 		$1,014.40
$1,055.95
$1,099.97
$1,256.37 		$235.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.74
$698.84
$786.88
$1,099.68
$1,671.06 		$851.25
$934.35
$1,022.39
$1,335.19 		$1,086.76
$1,169.86
$1,257.90
$1,570.70 		$1,322.27
$1,405.37
$1,493.41
$1,806.21 		$235.51
Toc - Plan #19 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.45
$360.29
$405.68
$566.94
$861.52 		$560.29
$603.13
$648.52
$809.78 		$803.13
$845.97
$891.36
$1,052.62 		$1,045.97
$1,088.81
$1,134.20
$1,295.46 		$242.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.90
$720.58
$811.36
$1,133.88
$1,723.04 		$877.74
$963.42
$1,054.20
$1,376.72 		$1,120.58
$1,206.26
$1,297.04
$1,619.56 		$1,363.42
$1,449.10
$1,539.88
$1,862.40 		$242.84
Toc - Plan #20 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.73
$359.47
$404.76
$565.66
$859.57 		$559.02
$601.76
$647.05
$807.95 		$801.31
$844.05
$889.34
$1,050.24 		$1,043.60
$1,086.34
$1,131.63
$1,292.53 		$242.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.46
$718.94
$809.52
$1,131.32
$1,719.14 		$875.75
$961.23
$1,051.81
$1,373.61 		$1,118.04
$1,203.52
$1,294.10
$1,615.90 		$1,360.33
$1,445.81
$1,536.39
$1,858.19 		$242.29
Toc - Plan #21 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.64
$355.97
$400.82
$560.14
$851.19 		$553.57
$595.90
$640.75
$800.07 		$793.50
$835.83
$880.68
$1,040.00 		$1,033.43
$1,075.76
$1,120.61
$1,279.93 		$239.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.28
$711.94
$801.64
$1,120.28
$1,702.38 		$867.21
$951.87
$1,041.57
$1,360.21 		$1,107.14
$1,191.80
$1,281.50
$1,600.14 		$1,347.07
$1,431.73
$1,521.43
$1,840.07 		$239.93
Toc - Plan #22 Oscar Health Plan, Inc.
Gold

(HMO) Gold Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.35
$466.87
$525.69
$734.65
$1,116.37 		$726.02
$781.54
$840.36
$1,049.32 		$1,040.69
$1,096.21
$1,155.03
$1,363.99 		$1,355.36
$1,410.88
$1,469.70
$1,678.66 		$314.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.70
$933.74
$1,051.38
$1,469.30
$2,232.74 		$1,137.37
$1,248.41
$1,366.05
$1,783.97 		$1,452.04
$1,563.08
$1,680.72
$2,098.64 		$1,766.71
$1,877.75
$1,995.39
$2,413.31 		$314.67
Toc - Plan #23 Oscar Health Plan, Inc.
Gold

(HMO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392.00
$444.91
$500.97
$700.10
$1,063.87 		$691.87
$744.78
$800.84
$999.97 		$991.74
$1,044.65
$1,100.71
$1,299.84 		$1,291.61
$1,344.52
$1,400.58
$1,599.71 		$299.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.00
$889.82
$1,001.94
$1,400.20
$2,127.74 		$1,083.87
$1,189.69
$1,301.81
$1,700.07 		$1,383.74
$1,489.56
$1,601.68
$1,999.94 		$1,683.61
$1,789.43
$1,901.55
$2,299.81 		$299.87
Toc - Plan #24 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $5000 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$274.99
$312.11
$351.43
$491.12
$746.31 		$485.35
$522.47
$561.79
$701.48 		$695.71
$732.83
$772.15
$911.84 		$906.07
$943.19
$982.51
$1,122.20 		$210.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.98
$624.22
$702.86
$982.24
$1,492.62 		$760.34
$834.58
$913.22
$1,192.60 		$970.70
$1,044.94
$1,123.58
$1,402.96 		$1,181.06
$1,255.30
$1,333.94
$1,613.32 		$210.36
Toc - Plan #25 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.09
$320.16
$360.50
$503.80
$765.57 		$497.88
$535.95
$576.29
$719.59 		$713.67
$751.74
$792.08
$935.38 		$929.46
$967.53
$1,007.87
$1,151.17 		$215.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.18
$640.32
$721.00
$1,007.60
$1,531.14 		$779.97
$856.11
$936.79
$1,223.39 		$995.76
$1,071.90
$1,152.58
$1,439.18 		$1,211.55
$1,287.69
$1,368.37
$1,654.97 		$215.79
Toc - Plan #26 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $1000 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.52
$320.64
$361.04
$504.55
$766.72 		$498.64
$536.76
$577.16
$720.67 		$714.76
$752.88
$793.28
$936.79 		$930.88
$969.00
$1,009.40
$1,152.91 		$216.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.04
$641.28
$722.08
$1,009.10
$1,533.44 		$781.16
$857.40
$938.20
$1,225.22 		$997.28
$1,073.52
$1,154.32
$1,441.34 		$1,213.40
$1,289.64
$1,370.44
$1,657.46 		$216.12
Toc - Plan #27 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.64
$321.92
$362.48
$506.57
$769.78 		$500.62
$538.90
$579.46
$723.55 		$717.60
$755.88
$796.44
$940.53 		$934.58
$972.86
$1,013.42
$1,157.51 		$216.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.28
$643.84
$724.96
$1,013.14
$1,539.56 		$784.26
$860.82
$941.94
$1,230.12 		$1,001.24
$1,077.80
$1,158.92
$1,447.10 		$1,218.22
$1,294.78
$1,375.90
$1,664.08 		$216.98
Toc - Plan #28 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- High Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.49
$341.05
$384.02
$536.66
$815.51 		$530.36
$570.92
$613.89
$766.53 		$760.23
$800.79
$843.76
$996.40 		$990.10
$1,030.66
$1,073.63
$1,226.27 		$229.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.98
$682.10
$768.04
$1,073.32
$1,631.02 		$830.85
$911.97
$997.91
$1,303.19 		$1,060.72
$1,141.84
$1,227.78
$1,533.06 		$1,290.59
$1,371.71
$1,457.65
$1,762.93 		$229.87
Toc - Plan #29 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.45
$344.40
$387.79
$541.94
$823.52 		$535.58
$576.53
$619.92
$774.07 		$767.71
$808.66
$852.05
$1,006.20 		$999.84
$1,040.79
$1,084.18
$1,238.33 		$232.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.90
$688.80
$775.58
$1,083.88
$1,647.04 		$839.03
$920.93
$1,007.71
$1,316.01 		$1,071.16
$1,153.06
$1,239.84
$1,548.14 		$1,303.29
$1,385.19
$1,471.97
$1,780.27 		$232.13

ADVERTISEMENT

Banner Health and Aetna Health Plan Inc.

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915 | TTY: 1-855-586-6960
Toc - Plan #30 Banner Health and Aetna Health Plan Inc.
Expanded Bronze

(HMO) Banner|Aetna Bronze: Low-Cost 98point6 Virtual Care & MinuteClinic, CVS Store Discounts, Phoenix

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$299.03
$339.40
$382.17
$534.08
$811.58 		$527.79
$568.16
$610.93
$762.84 		$756.55
$796.92
$839.69
$991.60 		$985.31
$1,025.68
$1,068.45
$1,220.36 		$228.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.06
$678.80
$764.34
$1,068.16
$1,623.16 		$826.82
$907.56
$993.10
$1,296.92 		$1,055.58
$1,136.32
$1,221.86
$1,525.68 		$1,284.34
$1,365.08
$1,450.62
$1,754.44 		$228.76
Toc - Plan #31 Banner Health and Aetna Health Plan Inc.
Bronze

(HMO) Banner|Aetna Bronze: Free 98point6 Virtual Care & MinuteClinic, CVS Store Discounts, Phoenix

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$252.05
$286.08
$322.12
$450.16
$684.06 		$444.87
$478.90
$514.94
$642.98 		$637.69
$671.72
$707.76
$835.80 		$830.51
$864.54
$900.58
$1,028.62 		$192.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.10
$572.16
$644.24
$900.32
$1,368.12 		$696.92
$764.98
$837.06
$1,093.14 		$889.74
$957.80
$1,029.88
$1,285.96 		$1,082.56
$1,150.62
$1,222.70
$1,478.78 		$192.82
Toc - Plan #32 Banner Health and Aetna Health Plan Inc.
Gold

(HMO) Banner|Aetna Gold: Free 98point6 Virtual Care & MinuteClinic, CVS Store Discounts, Phoenix

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.70
$458.20
$515.93
$721.01
$1,095.64 		$712.53
$767.03
$824.76
$1,029.84 		$1,021.36
$1,075.86
$1,133.59
$1,338.67 		$1,330.19
$1,384.69
$1,442.42
$1,647.50 		$308.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.40
$916.40
$1,031.86
$1,442.02
$2,191.28 		$1,116.23
$1,225.23
$1,340.69
$1,750.85 		$1,425.06
$1,534.06
$1,649.52
$2,059.68 		$1,733.89
$1,842.89
$1,958.35
$2,368.51 		$308.83
Toc - Plan #33 Banner Health and Aetna Health Plan Inc.
Silver

(HMO) Banner|Aetna Silver 1: Free 98point6 Virtual Care & MinuteClinic, CVS Store Discounts, Phoenix

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$356.87
$405.05
$456.09
$637.38
$968.56 		$629.88
$678.06
$729.10
$910.39 		$902.89
$951.07
$1,002.11
$1,183.40 		$1,175.90
$1,224.08
$1,275.12
$1,456.41 		$273.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.74
$810.10
$912.18
$1,274.76
$1,937.12 		$986.75
$1,083.11
$1,185.19
$1,547.77 		$1,259.76
$1,356.12
$1,458.20
$1,820.78 		$1,532.77
$1,629.13
$1,731.21
$2,093.79 		$273.01
Toc - Plan #34 Banner Health and Aetna Health Plan Inc.
Silver

(HMO) Banner|Aetna Silver 2: Free 98point6 Virtual Care & MinuteClinic, CVS Store Discounts, Phoenix

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304.71
$345.84
$389.42
$544.21
$826.98 		$537.81
$578.94
$622.52
$777.31 		$770.91
$812.04
$855.62
$1,010.41 		$1,004.01
$1,045.14
$1,088.72
$1,243.51 		$233.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.42
$691.68
$778.84
$1,088.42
$1,653.96 		$842.52
$924.78
$1,011.94
$1,321.52 		$1,075.62
$1,157.88
$1,245.04
$1,554.62 		$1,308.72
$1,390.98
$1,478.14
$1,787.72 		$233.10

ADVERTISEMENT

Medica

Local: 1-877-347-0267 | Toll Free: 1-877-347-0267 | TTY: 1-800-676-3777
Toc - Plan #35 Medica
Gold

(HMO) Medica Pinnacle Gold Copay ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$1,250 $3,750 Annual Deductible
$8,450 $16,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.08
$457.49
$515.13
$719.89
$1,093.95 		$711.43
$765.84
$823.48
$1,028.24 		$1,019.78
$1,074.19
$1,131.83
$1,336.59 		$1,328.13
$1,382.54
$1,440.18
$1,644.94 		$308.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.16
$914.98
$1,030.26
$1,439.78
$2,187.90 		$1,114.51
$1,223.33
$1,338.61
$1,748.13 		$1,422.86
$1,531.68
$1,646.96
$2,056.48 		$1,731.21
$1,840.03
$1,955.31
$2,364.83 		$308.35
Toc - Plan #36 Medica
Silver

(HMO) Medica Pinnacle Silver Copay ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.39
$355.69
$400.51
$559.71
$850.53 		$553.13
$595.43
$640.25
$799.45 		$792.87
$835.17
$879.99
$1,039.19 		$1,032.61
$1,074.91
$1,119.73
$1,278.93 		$239.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.78
$711.38
$801.02
$1,119.42
$1,701.06 		$866.52
$951.12
$1,040.76
$1,359.16 		$1,106.26
$1,190.86
$1,280.50
$1,598.90 		$1,346.00
$1,430.60
$1,520.24
$1,838.64 		$239.74
Toc - Plan #37 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Copay ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.95
$276.88
$311.77
$435.69
$662.08 		$430.57
$463.50
$498.39
$622.31 		$617.19
$650.12
$685.01
$808.93 		$803.81
$836.74
$871.63
$995.55 		$186.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$487.90
$553.76
$623.54
$871.38
$1,324.16 		$674.52
$740.38
$810.16
$1,058.00 		$861.14
$927.00
$996.78
$1,244.62 		$1,047.76
$1,113.62
$1,183.40
$1,431.24 		$186.62
Toc - Plan #38 Medica
Gold

(HMO) Medica Pinnacle Gold Share ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$700 $2,100 Annual Deductible
$8,450 $16,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.46
$473.81
$533.51
$745.58
$1,132.98 		$736.81
$793.16
$852.86
$1,064.93 		$1,056.16
$1,112.51
$1,172.21
$1,384.28 		$1,375.51
$1,431.86
$1,491.56
$1,703.63 		$319.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.92
$947.62
$1,067.02
$1,491.16
$2,265.96 		$1,154.27
$1,266.97
$1,386.37
$1,810.51 		$1,473.62
$1,586.32
$1,705.72
$2,129.86 		$1,792.97
$1,905.67
$2,025.07
$2,449.21 		$319.35
Toc - Plan #39 Medica
Silver

(HMO) Medica Pinnacle Silver Share ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$2,700 $8,100 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.43
$369.36
$415.90
$581.22
$883.22 		$574.38
$618.31
$664.85
$830.17 		$823.33
$867.26
$913.80
$1,079.12 		$1,072.28
$1,116.21
$1,162.75
$1,328.07 		$248.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.86
$738.72
$831.80
$1,162.44
$1,766.44 		$899.81
$987.67
$1,080.75
$1,411.39 		$1,148.76
$1,236.62
$1,329.70
$1,660.34 		$1,397.71
$1,485.57
$1,578.65
$1,909.29 		$248.95
Toc - Plan #40 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Share Plus ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$2,500 $7,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$262.86
$298.34
$335.93
$469.46
$713.39 		$463.95
$499.43
$537.02
$670.55 		$665.04
$700.52
$738.11
$871.64 		$866.13
$901.61
$939.20
$1,072.73 		$201.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.72
$596.68
$671.86
$938.92
$1,426.78 		$726.81
$797.77
$872.95
$1,140.01 		$927.90
$998.86
$1,074.04
$1,341.10 		$1,128.99
$1,199.95
$1,275.13
$1,542.19 		$201.09
Toc - Plan #41 Medica
Bronze

(HMO) Medica Pinnacle Bronze Value ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$229.27
$260.22
$293.01
$409.47
$622.23 		$404.66
$435.61
$468.40
$584.86 		$580.05
$611.00
$643.79
$760.25 		$755.44
$786.39
$819.18
$935.64 		$175.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$458.54
$520.44
$586.02
$818.94
$1,244.46 		$633.93
$695.83
$761.41
$994.33 		$809.32
$871.22
$936.80
$1,169.72 		$984.71
$1,046.61
$1,112.19
$1,345.11 		$175.39
Toc - Plan #42 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Copay $0 Primary Care ($0 Virtual Care + Online Wellness)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$255.71
$290.23
$326.80
$456.70
$694.00 		$451.33
$485.85
$522.42
$652.32 		$646.95
$681.47
$718.04
$847.94 		$842.57
$877.09
$913.66
$1,043.56 		$195.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$511.42
$580.46
$653.60
$913.40
$1,388.00 		$707.04
$776.08
$849.22
$1,109.02 		$902.66
$971.70
$1,044.84
$1,304.64 		$1,098.28
$1,167.32
$1,240.46
$1,500.26 		$195.62

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-482-9045 | Toll Free: 1-877-482-9045 | TTY: 1-877-482-9045
Toc - Plan #43 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$2,600 $5,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$355.68
$403.69
$454.56
$635.24
$965.31 		$627.77
$675.78
$726.65
$907.33 		$899.86
$947.87
$998.74
$1,179.42 		$1,171.95
$1,219.96
$1,270.83
$1,451.51 		$272.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.36
$807.38
$909.12
$1,270.48
$1,930.62 		$983.45
$1,079.47
$1,181.21
$1,542.57 		$1,255.54
$1,351.56
$1,453.30
$1,814.66 		$1,527.63
$1,623.65
$1,725.39
$2,086.75 		$272.09
Toc - Plan #44 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ Saver ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$268.61
$304.88
$343.29
$479.74
$729.02 		$474.10
$510.37
$548.78
$685.23 		$679.59
$715.86
$754.27
$890.72 		$885.08
$921.35
$959.76
$1,096.21 		$205.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.22
$609.76
$686.58
$959.48
$1,458.04 		$742.71
$815.25
$892.07
$1,164.97 		$948.20
$1,020.74
$1,097.56
$1,370.46 		$1,153.69
$1,226.23
$1,303.05
$1,575.95 		$205.49
Toc - Plan #45 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$265.01
$300.79
$338.69
$473.32
$719.25 		$467.75
$503.53
$541.43
$676.06 		$670.49
$706.27
$744.17
$878.80 		$873.23
$909.01
$946.91
$1,081.54 		$202.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.02
$601.58
$677.38
$946.64
$1,438.50 		$732.76
$804.32
$880.12
$1,149.38 		$935.50
$1,007.06
$1,082.86
$1,352.12 		$1,138.24
$1,209.80
$1,285.60
$1,554.86 		$202.74
Toc - Plan #46 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$7,950 $15,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269.29
$305.64
$344.15
$480.95
$730.85 		$475.30
$511.65
$550.16
$686.96 		$681.31
$717.66
$756.17
$892.97 		$887.32
$923.67
$962.18
$1,098.98 		$206.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538.58
$611.28
$688.30
$961.90
$1,461.70 		$744.59
$817.29
$894.31
$1,167.91 		$950.60
$1,023.30
$1,100.32
$1,373.92 		$1,156.61
$1,229.31
$1,306.33
$1,579.93 		$206.01
Toc - Plan #47 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ ($3 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$228.57
$259.43
$292.11
$408.23
$620.34 		$403.43
$434.29
$466.97
$583.09 		$578.29
$609.15
$641.83
$757.95 		$753.15
$784.01
$816.69
$932.81 		$174.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$457.14
$518.86
$584.22
$816.46
$1,240.68 		$632.00
$693.72
$759.08
$991.32 		$806.86
$868.58
$933.94
$1,166.18 		$981.72
$1,043.44
$1,108.80
$1,341.04 		$174.86
Toc - Plan #48 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$229.92
$260.96
$293.84
$410.64
$624.00 		$405.81
$436.85
$469.73
$586.53 		$581.70
$612.74
$645.62
$762.42 		$757.59
$788.63
$821.51
$938.31 		$175.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$459.84
$521.92
$587.68
$821.28
$1,248.00 		$635.73
$697.81
$763.57
$997.17 		$811.62
$873.70
$939.46
$1,173.06 		$987.51
$1,049.59
$1,115.35
$1,348.95 		$175.89
Toc - Plan #49 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ Saver ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$229.92
$260.96
$293.84
$410.64
$624.00 		$405.81
$436.85
$469.73
$586.53 		$581.70
$612.74
$645.62
$762.42 		$757.59
$788.63
$821.51
$938.31 		$175.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$459.84
$521.92
$587.68
$821.28
$1,248.00 		$635.73
$697.81
$763.57
$997.17 		$811.62
$873.70
$939.46
$1,173.06 		$987.51
$1,049.59
$1,115.35
$1,348.95 		$175.89
Toc - Plan #50 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.08
$409.82
$461.46
$644.88
$979.96 		$637.30
$686.04
$737.68
$921.10 		$913.52
$962.26
$1,013.90
$1,197.32 		$1,189.74
$1,238.48
$1,290.12
$1,473.54 		$276.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.16
$819.64
$922.92
$1,289.76
$1,959.92 		$998.38
$1,095.86
$1,199.14
$1,565.98 		$1,274.60
$1,372.08
$1,475.36
$1,842.20 		$1,550.82
$1,648.30
$1,751.58
$2,118.42 		$276.22
Toc - Plan #51 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.08
$420.04
$472.96
$660.96
$1,004.39 		$653.19
$703.15
$756.07
$944.07 		$936.30
$986.26
$1,039.18
$1,227.18 		$1,219.41
$1,269.37
$1,322.29
$1,510.29 		$283.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.16
$840.08
$945.92
$1,321.92
$2,008.78 		$1,023.27
$1,123.19
$1,229.03
$1,605.03 		$1,306.38
$1,406.30
$1,512.14
$1,888.14 		$1,589.49
$1,689.41
$1,795.25
$2,171.25 		$283.11
Toc - Plan #52 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$266.81
$302.83
$340.99
$476.53
$724.13 		$470.92
$506.94
$545.10
$680.64 		$675.03
$711.05
$749.21
$884.75 		$879.14
$915.16
$953.32
$1,088.86 		$204.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$533.62
$605.66
$681.98
$953.06
$1,448.26 		$737.73
$809.77
$886.09
$1,157.17 		$941.84
$1,013.88
$1,090.20
$1,361.28 		$1,145.95
$1,217.99
$1,294.31
$1,565.39 		$204.11
Toc - Plan #53 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ Base ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$267.04
$303.09
$341.28
$476.93
$724.74 		$471.33
$507.38
$545.57
$681.22 		$675.62
$711.67
$749.86
$885.51 		$879.91
$915.96
$954.15
$1,089.80 		$204.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.08
$606.18
$682.56
$953.86
$1,449.48 		$738.37
$810.47
$886.85
$1,158.15 		$942.66
$1,014.76
$1,091.14
$1,362.44 		$1,146.95
$1,219.05
$1,295.43
$1,566.73 		$204.29
Toc - Plan #54 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.01
$321.22
$361.69
$505.46
$768.10 		$499.51
$537.72
$578.19
$721.96 		$716.01
$754.22
$794.69
$938.46 		$932.51
$970.72
$1,011.19
$1,154.96 		$216.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$566.02
$642.44
$723.38
$1,010.92
$1,536.20 		$782.52
$858.94
$939.88
$1,227.42 		$999.02
$1,075.44
$1,156.38
$1,443.92 		$1,215.52
$1,291.94
$1,372.88
$1,660.42 		$216.50
Toc - Plan #55 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ (HSA)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$227.22
$257.89
$290.39
$405.81
$616.67 		$401.04
$431.71
$464.21
$579.63 		$574.86
$605.53
$638.03
$753.45 		$748.68
$779.35
$811.85
$927.27 		$173.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$454.44
$515.78
$580.78
$811.62
$1,233.34 		$628.26
$689.60
$754.60
$985.44 		$802.08
$863.42
$928.42
$1,159.26 		$975.90
$1,037.24
$1,102.24
$1,333.08 		$173.82
Toc - Plan #56 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$224.97
$255.34
$287.51
$401.80
$610.57 		$397.07
$427.44
$459.61
$573.90 		$569.17
$599.54
$631.71
$746.00 		$741.27
$771.64
$803.81
$918.10 		$172.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$449.94
$510.68
$575.02
$803.60
$1,221.14 		$622.04
$682.78
$747.12
$975.70 		$794.14
$854.88
$919.22
$1,147.80 		$966.24
$1,026.98
$1,091.32
$1,319.90 		$172.10

ADVERTISEMENT

Blue Cross Blue Shield of Arizona

Local: 1-844-341-5837 | Toll Free: 1-844-341-5837 | TTY: 1-602-864-4823
Toc - Plan #57 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue EverydayHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$438.37
$497.54
$560.23
$782.92
$1,189.72 		$773.72
$832.89
$895.58
$1,118.27 		$1,109.07
$1,168.24
$1,230.93
$1,453.62 		$1,444.42
$1,503.59
$1,566.28
$1,788.97 		$335.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.74
$995.08
$1,120.46
$1,565.84
$2,379.44 		$1,212.09
$1,330.43
$1,455.81
$1,901.19 		$1,547.44
$1,665.78
$1,791.16
$2,236.54 		$1,882.79
$2,001.13
$2,126.51
$2,571.89 		$335.35
Toc - Plan #58 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue EverydayHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$4,750 $9,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341.43
$387.52
$436.35
$609.79
$926.64 		$602.63
$648.72
$697.55
$870.99 		$863.83
$909.92
$958.75
$1,132.19 		$1,125.03
$1,171.12
$1,219.95
$1,393.39 		$261.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.86
$775.04
$872.70
$1,219.58
$1,853.28 		$944.06
$1,036.24
$1,133.90
$1,480.78 		$1,205.26
$1,297.44
$1,395.10
$1,741.98 		$1,466.46
$1,558.64
$1,656.30
$2,003.18 		$261.20
Toc - Plan #59 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue EverydayHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.51
$318.38
$358.50
$500.99
$761.31 		$495.10
$532.97
$573.09
$715.58 		$709.69
$747.56
$787.68
$930.17 		$924.28
$962.15
$1,002.27
$1,144.76 		$214.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.02
$636.76
$717.00
$1,001.98
$1,522.62 		$775.61
$851.35
$931.59
$1,216.57 		$990.20
$1,065.94
$1,146.18
$1,431.16 		$1,204.79
$1,280.53
$1,360.77
$1,645.75 		$214.59
Toc - Plan #60 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue TrueHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$6,750 $13,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348.44
$395.47
$445.30
$622.30
$945.64 		$614.99
$662.02
$711.85
$888.85 		$881.54
$928.57
$978.40
$1,155.40 		$1,148.09
$1,195.12
$1,244.95
$1,421.95 		$266.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.88
$790.94
$890.60
$1,244.60
$1,891.28 		$963.43
$1,057.49
$1,157.15
$1,511.15 		$1,229.98
$1,324.04
$1,423.70
$1,777.70 		$1,496.53
$1,590.59
$1,690.25
$2,044.25 		$266.55
Toc - Plan #61 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue AdvanceHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.63
$362.78
$408.48
$570.85
$867.46 		$564.15
$607.30
$653.00
$815.37 		$808.67
$851.82
$897.52
$1,059.89 		$1,053.19
$1,096.34
$1,142.04
$1,304.41 		$244.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.26
$725.56
$816.96
$1,141.70
$1,734.92 		$883.78
$970.08
$1,061.48
$1,386.22 		$1,128.30
$1,214.60
$1,306.00
$1,630.74 		$1,372.82
$1,459.12
$1,550.52
$1,875.26 		$244.52
Toc - Plan #62 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue Portfolio HSA Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.36
$343.17
$386.41
$540.01
$820.59 		$533.66
$574.47
$617.71
$771.31 		$764.96
$805.77
$849.01
$1,002.61 		$996.26
$1,037.07
$1,080.31
$1,233.91 		$231.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.72
$686.34
$772.82
$1,080.02
$1,641.18 		$836.02
$917.64
$1,004.12
$1,311.32 		$1,067.32
$1,148.94
$1,235.42
$1,542.62 		$1,298.62
$1,380.24
$1,466.72
$1,773.92 		$231.30
Toc - Plan #63 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue AdvanceHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$260.89
$296.11
$333.42
$465.95
$708.05 		$460.47
$495.69
$533.00
$665.53 		$660.05
$695.27
$732.58
$865.11 		$859.63
$894.85
$932.16
$1,064.69 		$199.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.78
$592.22
$666.84
$931.90
$1,416.10 		$721.36
$791.80
$866.42
$1,131.48 		$920.94
$991.38
$1,066.00
$1,331.06 		$1,120.52
$1,190.96
$1,265.58
$1,530.64 		$199.58
Toc - Plan #64 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue AdvanceHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$4,750 $9,500 Annual Deductible
$4,750 $9,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.25
$473.58
$533.25
$745.21
$1,132.42 		$736.45
$792.78
$852.45
$1,064.41 		$1,055.65
$1,111.98
$1,171.65
$1,383.61 		$1,374.85
$1,431.18
$1,490.85
$1,702.81 		$319.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.50
$947.16
$1,066.50
$1,490.42
$2,264.84 		$1,153.70
$1,266.36
$1,385.70
$1,809.62 		$1,472.90
$1,585.56
$1,704.90
$2,128.82 		$1,792.10
$1,904.76
$2,024.10
$2,448.02 		$319.20
Toc - Plan #65 Blue Cross Blue Shield of Arizona
Gold

(PPO) Blue PPO Gold - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$596.68
$677.23
$762.56
$1,065.67
$1,619.39 		$1,053.14
$1,133.69
$1,219.02
$1,522.13 		$1,509.60
$1,590.15
$1,675.48
$1,978.59 		$1,966.06
$2,046.61
$2,131.94
$2,435.05 		$456.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,193.36
$1,354.46
$1,525.12
$2,131.34
$3,238.78 		$1,649.82
$1,810.92
$1,981.58
$2,587.80 		$2,106.28
$2,267.38
$2,438.04
$3,044.26 		$2,562.74
$2,723.84
$2,894.50
$3,500.72 		$456.46
Toc - Plan #66 Blue Cross Blue Shield of Arizona
Silver

(PPO) Blue PPO Silver - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$518.91
$588.96
$663.16
$926.77
$1,408.31 		$915.88
$985.93
$1,060.13
$1,323.74 		$1,312.85
$1,382.90
$1,457.10
$1,720.71 		$1,709.82
$1,779.87
$1,854.07
$2,117.68 		$396.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,037.82
$1,177.92
$1,326.32
$1,853.54
$2,816.62 		$1,434.79
$1,574.89
$1,723.29
$2,250.51 		$1,831.76
$1,971.86
$2,120.26
$2,647.48 		$2,228.73
$2,368.83
$2,517.23
$3,044.45 		$396.97

ADVERTISEMENT

Bright HealthCare from Bright Health Company of Arizona

Local: 1-800-922-7186 | Toll Free: 1-800-922-7186

Toc - Plan #67 Bright HealthCare from Bright Health Company of Arizona
Gold

(HMO) Gold 1000 Direct ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.33
$465.73
$524.41
$732.86
$1,113.65 		$724.24
$779.64
$838.32
$1,046.77 		$1,038.15
$1,093.55
$1,152.23
$1,360.68 		$1,352.06
$1,407.46
$1,466.14
$1,674.59 		$313.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.66
$931.46
$1,048.82
$1,465.72
$2,227.30 		$1,134.57
$1,245.37
$1,362.73
$1,779.63 		$1,448.48
$1,559.28
$1,676.64
$2,093.54 		$1,762.39
$1,873.19
$1,990.55
$2,407.45 		$313.91
Toc - Plan #68 Bright HealthCare from Bright Health Company of Arizona
Silver

(HMO) Silver 3000 Direct ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.53
$327.48
$368.74
$515.31
$783.06 		$509.25
$548.20
$589.46
$736.03 		$729.97
$768.92
$810.18
$956.75 		$950.69
$989.64
$1,030.90
$1,177.47 		$220.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.06
$654.96
$737.48
$1,030.62
$1,566.12 		$797.78
$875.68
$958.20
$1,251.34 		$1,018.50
$1,096.40
$1,178.92
$1,472.06 		$1,239.22
$1,317.12
$1,399.64
$1,692.78 		$220.72
Toc - Plan #69 Bright HealthCare from Bright Health Company of Arizona
Silver

(HMO) Silver $0 Deductible ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306.37
$347.73
$391.54
$547.17
$831.48 		$540.74
$582.10
$625.91
$781.54 		$775.11
$816.47
$860.28
$1,015.91 		$1,009.48
$1,050.84
$1,094.65
$1,250.28 		$234.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.74
$695.46
$783.08
$1,094.34
$1,662.96 		$847.11
$929.83
$1,017.45
$1,328.71 		$1,081.48
$1,164.20
$1,251.82
$1,563.08 		$1,315.85
$1,398.57
$1,486.19
$1,797.45 		$234.37
Toc - Plan #70 Bright HealthCare from Bright Health Company of Arizona
Expanded Bronze

(HMO) Bronze 8700 + $0 Mental Health Direct ($0 Telehealth + $0 Primary Care + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$227.19
$257.86
$290.35
$405.76
$616.59 		$400.99
$431.66
$464.15
$579.56 		$574.79
$605.46
$637.95
$753.36 		$748.59
$779.26
$811.75
$927.16 		$173.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$454.38
$515.72
$580.70
$811.52
$1,233.18 		$628.18
$689.52
$754.50
$985.32 		$801.98
$863.32
$928.30
$1,159.12 		$975.78
$1,037.12
$1,102.10
$1,332.92 		$173.80
Toc - Plan #71 Bright HealthCare from Bright Health Company of Arizona
Expanded Bronze

(HMO) Bronze 7200 Direct ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$235.59
$267.39
$301.08
$420.76
$639.39 		$415.82
$447.62
$481.31
$600.99 		$596.05
$627.85
$661.54
$781.22 		$776.28
$808.08
$841.77
$961.45 		$180.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$471.18
$534.78
$602.16
$841.52
$1,278.78 		$651.41
$715.01
$782.39
$1,021.75 		$831.64
$895.24
$962.62
$1,201.98 		$1,011.87
$1,075.47
$1,142.85
$1,382.21 		$180.23
Toc - Plan #72 Bright HealthCare from Bright Health Company of Arizona
Expanded Bronze

(HMO) Bronze 5300 HSA Direct

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$247.63
$281.06
$316.47
$442.27
$672.08 		$437.07
$470.50
$505.91
$631.71 		$626.51
$659.94
$695.35
$821.15 		$815.95
$849.38
$884.79
$1,010.59 		$189.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$495.26
$562.12
$632.94
$884.54
$1,344.16 		$684.70
$751.56
$822.38
$1,073.98 		$874.14
$941.00
$1,011.82
$1,263.42 		$1,063.58
$1,130.44
$1,201.26
$1,452.86 		$189.44
Toc - Plan #73 Bright HealthCare from Bright Health Company of Arizona
Expanded Bronze

(HMO) Bronze $0 Medical Deductible Direct ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Presc

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$265.73
$301.61
$339.61
$474.60
$721.20 		$469.02
$504.90
$542.90
$677.89 		$672.31
$708.19
$746.19
$881.18 		$875.60
$911.48
$949.48
$1,084.47 		$203.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531.46
$603.22
$679.22
$949.20
$1,442.40 		$734.75
$806.51
$882.51
$1,152.49 		$938.04
$1,009.80
$1,085.80
$1,355.78 		$1,141.33
$1,213.09
$1,289.09
$1,559.07 		$203.29
Toc - Plan #74 Bright HealthCare from Bright Health Company of Arizona
Catastrophic

(HMO) Catastrophic 8700 Direct ($0 Primary Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$214.48
$243.44
$274.11
$383.07
$582.11 		$378.56
$407.52
$438.19
$547.15 		$542.64
$571.60
$602.27
$711.23 		$706.72
$735.68
$766.35
$875.31 		$164.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$428.96
$486.88
$548.22
$766.14
$1,164.22 		$593.04
$650.96
$712.30
$930.22 		$757.12
$815.04
$876.38
$1,094.30 		$921.20
$979.12
$1,040.46
$1,258.38 		$164.08
Toc - Plan #75 Bright HealthCare from Bright Health Company of Arizona
Silver

(HMO) Silver 5000 Direct ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.03
$323.51
$364.27
$509.06
$773.57 		$503.08
$541.56
$582.32
$727.11 		$721.13
$759.61
$800.37
$945.16 		$939.18
$977.66
$1,018.42
$1,163.21 		$218.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.06
$647.02
$728.54
$1,018.12
$1,547.14 		$788.11
$865.07
$946.59
$1,236.17 		$1,006.16
$1,083.12
$1,164.64
$1,454.22 		$1,224.21
$1,301.17
$1,382.69
$1,672.27 		$218.05
Toc - Plan #76 Bright HealthCare from Bright Health Company of Arizona
Silver

(HMO) Silver 4000 Direct ($35 Primary Care + $15 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276.83
$314.21
$353.79
$494.42
$751.33 		$488.61
$525.99
$565.57
$706.20 		$700.39
$737.77
$777.35
$917.98 		$912.17
$949.55
$989.13
$1,129.76 		$211.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.66
$628.42
$707.58
$988.84
$1,502.66 		$765.44
$840.20
$919.36
$1,200.62 		$977.22
$1,051.98
$1,131.14
$1,412.40 		$1,189.00
$1,263.76
$1,342.92
$1,624.18 		$211.78
Toc - Plan #77 Bright HealthCare from Bright Health Company of Arizona
Silver

(HMO) Silver 6700 ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289.03
$328.05
$369.38
$516.21
$784.44 		$510.14
$549.16
$590.49
$737.32 		$731.25
$770.27
$811.60
$958.43 		$952.36
$991.38
$1,032.71
$1,179.54 		$221.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.06
$656.10
$738.76
$1,032.42
$1,568.88 		$799.17
$877.21
$959.87
$1,253.53 		$1,020.28
$1,098.32
$1,180.98
$1,474.64 		$1,241.39
$1,319.43
$1,402.09
$1,695.75 		$221.11
Toc - Plan #78 Bright HealthCare from Bright Health Company of Arizona
Expanded Bronze

(HMO) Bronze 7200 + Adult Dental & Vision Direct ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription L

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$248.55
$282.10
$317.64
$443.90
$674.55 		$438.69
$472.24
$507.78
$634.04 		$628.83
$662.38
$697.92
$824.18 		$818.97
$852.52
$888.06
$1,014.32 		$190.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$497.10
$564.20
$635.28
$887.80
$1,349.10 		$687.24
$754.34
$825.42
$1,077.94 		$877.38
$944.48
$1,015.56
$1,268.08 		$1,067.52
$1,134.62
$1,205.70
$1,458.22 		$190.14
Toc - Plan #79 Bright HealthCare from Bright Health Company of Arizona
Silver

(HMO) Silver 6700 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Presc

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.99
$342.76
$385.94
$539.35
$819.60 		$533.01
$573.78
$616.96
$770.37 		$764.03
$804.80
$847.98
$1,001.39 		$995.05
$1,035.82
$1,079.00
$1,232.41 		$231.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.98
$685.52
$771.88
$1,078.70
$1,639.20 		$835.00
$916.54
$1,002.90
$1,309.72 		$1,066.02
$1,147.56
$1,233.92
$1,540.74 		$1,297.04
$1,378.58
$1,464.94
$1,771.76 		$231.02
Toc - Plan #80 Bright HealthCare from Bright Health Company of Arizona
Gold

(HMO) Gold $0 Ded + Adult Dental & Vision Direct ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription L

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$457.53
$519.29
$584.72
$817.14
$1,241.73 		$807.54
$869.30
$934.73
$1,167.15 		$1,157.55
$1,219.31
$1,284.74
$1,517.16 		$1,507.56
$1,569.32
$1,634.75
$1,867.17 		$350.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.06
$1,038.58
$1,169.44
$1,634.28
$2,483.46 		$1,265.07
$1,388.59
$1,519.45
$1,984.29 		$1,615.08
$1,738.60
$1,869.46
$2,334.30 		$1,965.09
$2,088.61
$2,219.47
$2,684.31 		$350.01
Toc - Plan #81 Bright HealthCare from Bright Health Company of Arizona
Expanded Bronze

(HMO) Bronze 8700 ($25 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-922-7186

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$224.21
$254.47
$286.54
$400.43
$608.50 		$395.73
$425.99
$458.06
$571.95 		$567.25
$597.51
$629.58
$743.47 		$738.77
$769.03
$801.10
$914.99 		$171.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$448.42
$508.94
$573.08
$800.86
$1,217.00 		$619.94
$680.46
$744.60
$972.38 		$791.46
$851.98
$916.12
$1,143.90 		$962.98
$1,023.50
$1,087.64
$1,315.42 		$171.52

ADVERTISEMENT

Ambetter from Arizona Complete Health

Local: 1-888-926-5057 | Toll Free: 1-888-926-5057 | TTY: 1-888-926-5180
Toc - Plan #82 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$334.65
$379.82
$427.68
$597.68
$908.23 		$590.65
$635.82
$683.68
$853.68 		$846.65
$891.82
$939.68
$1,109.68 		$1,102.65
$1,147.82
$1,195.68
$1,365.68 		$256.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.30
$759.64
$855.36
$1,195.36
$1,816.46 		$925.30
$1,015.64
$1,111.36
$1,451.36 		$1,181.30
$1,271.64
$1,367.36
$1,707.36 		$1,437.30
$1,527.64
$1,623.36
$1,963.36 		$256.00
Toc - Plan #83 Ambetter from Arizona Complete Health
Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$278.70
$316.32
$356.18
$497.76
$756.39 		$491.91
$529.53
$569.39
$710.97 		$705.12
$742.74
$782.60
$924.18 		$918.33
$955.95
$995.81
$1,137.39 		$213.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.40
$632.64
$712.36
$995.52
$1,512.78 		$770.61
$845.85
$925.57
$1,208.73 		$983.82
$1,059.06
$1,138.78
$1,421.94 		$1,197.03
$1,272.27
$1,351.99
$1,635.15 		$213.21
Toc - Plan #84 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304.19
$345.26
$388.76
$543.29
$825.58 		$536.90
$577.97
$621.47
$776.00 		$769.61
$810.68
$854.18
$1,008.71 		$1,002.32
$1,043.39
$1,086.89
$1,241.42 		$232.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.38
$690.52
$777.52
$1,086.58
$1,651.16 		$841.09
$923.23
$1,010.23
$1,319.29 		$1,073.80
$1,155.94
$1,242.94
$1,552.00 		$1,306.51
$1,388.65
$1,475.65
$1,784.71 		$232.71
Toc - Plan #85 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.11
$367.87
$414.22
$578.87
$879.65 		$572.06
$615.82
$662.17
$826.82 		$820.01
$863.77
$910.12
$1,074.77 		$1,067.96
$1,111.72
$1,158.07
$1,322.72 		$247.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.22
$735.74
$828.44
$1,157.74
$1,759.30 		$896.17
$983.69
$1,076.39
$1,405.69 		$1,144.12
$1,231.64
$1,324.34
$1,653.64 		$1,392.07
$1,479.59
$1,572.29
$1,901.59 		$247.95
Toc - Plan #86 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.48
$363.74
$409.57
$572.37
$869.77 		$565.64
$608.90
$654.73
$817.53 		$810.80
$854.06
$899.89
$1,062.69 		$1,055.96
$1,099.22
$1,145.05
$1,307.85 		$245.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.96
$727.48
$819.14
$1,144.74
$1,739.54 		$886.12
$972.64
$1,064.30
$1,389.90 		$1,131.28
$1,217.80
$1,309.46
$1,635.06 		$1,376.44
$1,462.96
$1,554.62
$1,880.22 		$245.16
Toc - Plan #87 Ambetter from Arizona Complete Health
Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.99
$442.64
$498.41
$696.52
$1,058.44 		$688.33
$740.98
$796.75
$994.86 		$986.67
$1,039.32
$1,095.09
$1,293.20 		$1,285.01
$1,337.66
$1,393.43
$1,591.54 		$298.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.98
$885.28
$996.82
$1,393.04
$2,116.88 		$1,078.32
$1,183.62
$1,295.16
$1,691.38 		$1,376.66
$1,481.96
$1,593.50
$1,989.72 		$1,675.00
$1,780.30
$1,891.84
$2,288.06 		$298.34
Toc - Plan #88 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 29

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.74
$359.50
$404.79
$565.70
$859.63 		$559.05
$601.81
$647.10
$808.01 		$801.36
$844.12
$889.41
$1,050.32 		$1,043.67
$1,086.43
$1,131.72
$1,292.63 		$242.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.48
$719.00
$809.58
$1,131.40
$1,719.26 		$875.79
$961.31
$1,051.89
$1,373.71 		$1,118.10
$1,203.62
$1,294.20
$1,616.02 		$1,360.41
$1,445.93
$1,536.51
$1,858.33 		$242.31
Toc - Plan #89 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 28

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.81
$386.82
$435.56
$608.69
$924.96 		$601.53
$647.54
$696.28
$869.41 		$862.25
$908.26
$957.00
$1,130.13 		$1,122.97
$1,168.98
$1,217.72
$1,390.85 		$260.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.62
$773.64
$871.12
$1,217.38
$1,849.92 		$942.34
$1,034.36
$1,131.84
$1,478.10 		$1,203.06
$1,295.08
$1,392.56
$1,738.82 		$1,463.78
$1,555.80
$1,653.28
$1,999.54 		$260.72
Toc - Plan #90 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.27
$368.05
$414.42
$579.15
$880.08 		$572.34
$616.12
$662.49
$827.22 		$820.41
$864.19
$910.56
$1,075.29 		$1,068.48
$1,112.26
$1,158.63
$1,323.36 		$248.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.54
$736.10
$828.84
$1,158.30
$1,760.16 		$896.61
$984.17
$1,076.91
$1,406.37 		$1,144.68
$1,232.24
$1,324.98
$1,654.44 		$1,392.75
$1,480.31
$1,573.05
$1,902.51 		$248.07
Toc - Plan #91 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$339.33
$385.14
$433.67
$606.05
$920.95 		$598.92
$644.73
$693.26
$865.64 		$858.51
$904.32
$952.85
$1,125.23 		$1,118.10
$1,163.91
$1,212.44
$1,384.82 		$259.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.66
$770.28
$867.34
$1,212.10
$1,841.90 		$938.25
$1,029.87
$1,126.93
$1,471.69 		$1,197.84
$1,289.46
$1,386.52
$1,731.28 		$1,457.43
$1,549.05
$1,646.11
$1,990.87 		$259.59
Toc - Plan #92 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.16
$346.36
$390.00
$545.02
$828.21 		$538.61
$579.81
$623.45
$778.47 		$772.06
$813.26
$856.90
$1,011.92 		$1,005.51
$1,046.71
$1,090.35
$1,245.37 		$233.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.32
$692.72
$780.00
$1,090.04
$1,656.42 		$843.77
$926.17
$1,013.45
$1,323.49 		$1,077.22
$1,159.62
$1,246.90
$1,556.94 		$1,310.67
$1,393.07
$1,480.35
$1,790.39 		$233.45
Toc - Plan #93 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.14
$346.33
$389.97
$544.98
$828.15 		$538.57
$579.76
$623.40
$778.41 		$772.00
$813.19
$856.83
$1,011.84 		$1,005.43
$1,046.62
$1,090.26
$1,245.27 		$233.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.28
$692.66
$779.94
$1,089.96
$1,656.30 		$843.71
$926.09
$1,013.37
$1,323.39 		$1,077.14
$1,159.52
$1,246.80
$1,556.82 		$1,310.57
$1,392.95
$1,480.23
$1,790.25 		$233.43
Toc - Plan #94 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.64
$353.71
$398.28
$556.59
$845.80 		$550.05
$592.12
$636.69
$795.00 		$788.46
$830.53
$875.10
$1,033.41 		$1,026.87
$1,068.94
$1,113.51
$1,271.82 		$238.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.28
$707.42
$796.56
$1,113.18
$1,691.60 		$861.69
$945.83
$1,034.97
$1,351.59 		$1,100.10
$1,184.24
$1,273.38
$1,590.00 		$1,338.51
$1,422.65
$1,511.79
$1,828.41 		$238.41
Toc - Plan #95 Ambetter from Arizona Complete Health
Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.65
$416.15
$468.58
$654.84
$995.09 		$647.14
$696.64
$749.07
$935.33 		$927.63
$977.13
$1,029.56
$1,215.82 		$1,208.12
$1,257.62
$1,310.05
$1,496.31 		$280.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.30
$832.30
$937.16
$1,309.68
$1,990.18 		$1,013.79
$1,112.79
$1,217.65
$1,590.17 		$1,294.28
$1,393.28
$1,498.14
$1,870.66 		$1,574.77
$1,673.77
$1,778.63
$2,151.15 		$280.49
Toc - Plan #96 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$299.17
$339.56
$382.34
$534.33
$811.96 		$528.04
$568.43
$611.21
$763.20 		$756.91
$797.30
$840.08
$992.07 		$985.78
$1,026.17
$1,068.95
$1,220.94 		$228.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.34
$679.12
$764.68
$1,068.66
$1,623.92 		$827.21
$907.99
$993.55
$1,297.53 		$1,056.08
$1,136.86
$1,222.42
$1,526.40 		$1,284.95
$1,365.73
$1,451.29
$1,755.27 		$228.87
Toc - Plan #97 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 12 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$333.89
$378.97
$426.71
$596.33
$906.18 		$589.32
$634.40
$682.14
$851.76 		$844.75
$889.83
$937.57
$1,107.19 		$1,100.18
$1,145.26
$1,193.00
$1,362.62 		$255.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.78
$757.94
$853.42
$1,192.66
$1,812.36 		$923.21
$1,013.37
$1,108.85
$1,448.09 		$1,178.64
$1,268.80
$1,364.28
$1,703.52 		$1,434.07
$1,524.23
$1,619.71
$1,958.95 		$255.43
Toc - Plan #98 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 4 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348.66
$395.72
$445.58
$622.70
$946.25 		$615.38
$662.44
$712.30
$889.42 		$882.10
$929.16
$979.02
$1,156.14 		$1,148.82
$1,195.88
$1,245.74
$1,422.86 		$266.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.32
$791.44
$891.16
$1,245.40
$1,892.50 		$964.04
$1,058.16
$1,157.88
$1,512.12 		$1,230.76
$1,324.88
$1,424.60
$1,778.84 		$1,497.48
$1,591.60
$1,691.32
$2,045.56 		$266.72
Toc - Plan #99 Ambetter from Arizona Complete Health
Bronze

(HMO) Ambetter Essential Care 1 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290.37
$329.57
$371.09
$518.60
$788.06 		$512.50
$551.70
$593.22
$740.73 		$734.63
$773.83
$815.35
$962.86 		$956.76
$995.96
$1,037.48
$1,184.99 		$222.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.74
$659.14
$742.18
$1,037.20
$1,576.12 		$802.87
$881.27
$964.31
$1,259.33 		$1,025.00
$1,103.40
$1,186.44
$1,481.46 		$1,247.13
$1,325.53
$1,408.57
$1,703.59 		$222.13
Toc - Plan #100 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.93
$359.71
$405.03
$566.03
$860.14 		$559.38
$602.16
$647.48
$808.48 		$801.83
$844.61
$889.93
$1,050.93 		$1,044.28
$1,087.06
$1,132.38
$1,293.38 		$242.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.86
$719.42
$810.06
$1,132.06
$1,720.28 		$876.31
$961.87
$1,052.51
$1,374.51 		$1,118.76
$1,204.32
$1,294.96
$1,616.96 		$1,361.21
$1,446.77
$1,537.41
$1,859.41 		$242.45
Toc - Plan #101 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 11 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$337.68
$383.27
$431.56
$603.10
$916.47 		$596.01
$641.60
$689.89
$861.43 		$854.34
$899.93
$948.22
$1,119.76 		$1,112.67
$1,158.26
$1,206.55
$1,378.09 		$258.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.36
$766.54
$863.12
$1,206.20
$1,832.94 		$933.69
$1,024.87
$1,121.45
$1,464.53 		$1,192.02
$1,283.20
$1,379.78
$1,722.86 		$1,450.35
$1,541.53
$1,638.11
$1,981.19 		$258.33
Toc - Plan #102 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 29 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$330.00
$374.55
$421.74
$589.38
$895.62 		$582.45
$627.00
$674.19
$841.83 		$834.90
$879.45
$926.64
$1,094.28 		$1,087.35
$1,131.90
$1,179.09
$1,346.73 		$252.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.00
$749.10
$843.48
$1,178.76
$1,791.24 		$912.45
$1,001.55
$1,095.93
$1,431.21 		$1,164.90
$1,254.00
$1,348.38
$1,683.66 		$1,417.35
$1,506.45
$1,600.83
$1,936.11 		$252.45
Toc - Plan #103 Ambetter from Arizona Complete Health
Gold

(HMO) Ambetter Secure Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$406.32
$461.17
$519.27
$725.68
$1,102.74 		$717.15
$772.00
$830.10
$1,036.51 		$1,027.98
$1,082.83
$1,140.93
$1,347.34 		$1,338.81
$1,393.66
$1,451.76
$1,658.17 		$310.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.64
$922.34
$1,038.54
$1,451.36
$2,205.48 		$1,123.47
$1,233.17
$1,349.37
$1,762.19 		$1,434.30
$1,544.00
$1,660.20
$2,073.02 		$1,745.13
$1,854.83
$1,971.03
$2,383.85 		$310.83
Toc - Plan #104 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 28 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$355.08
$403.01
$453.79
$634.17
$963.68 		$626.72
$674.65
$725.43
$905.81 		$898.36
$946.29
$997.07
$1,177.45 		$1,170.00
$1,217.93
$1,268.71
$1,449.09 		$271.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.16
$806.02
$907.58
$1,268.34
$1,927.36 		$981.80
$1,077.66
$1,179.22
$1,539.98 		$1,253.44
$1,349.30
$1,450.86
$1,811.62 		$1,525.08
$1,620.94
$1,722.50
$2,083.26 		$271.64
Toc - Plan #105 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$337.85
$383.46
$431.77
$603.40
$916.92 		$596.30
$641.91
$690.22
$861.85 		$854.75
$900.36
$948.67
$1,120.30 		$1,113.20
$1,158.81
$1,207.12
$1,378.75 		$258.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.70
$766.92
$863.54
$1,206.80
$1,833.84 		$934.15
$1,025.37
$1,121.99
$1,465.25 		$1,192.60
$1,283.82
$1,380.44
$1,723.70 		$1,451.05
$1,542.27
$1,638.89
$1,982.15 		$258.45
Toc - Plan #106 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.54
$401.26
$451.82
$631.42
$959.50 		$624.00
$671.72
$722.28
$901.88 		$894.46
$942.18
$992.74
$1,172.34 		$1,164.92
$1,212.64
$1,263.20
$1,442.80 		$270.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.08
$802.52
$903.64
$1,262.84
$1,919.00 		$977.54
$1,072.98
$1,174.10
$1,533.30 		$1,248.00
$1,343.44
$1,444.56
$1,803.76 		$1,518.46
$1,613.90
$1,715.02
$2,074.22 		$270.46
Toc - Plan #107 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 30 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.94
$360.86
$406.32
$567.84
$862.88 		$561.16
$604.08
$649.54
$811.06 		$804.38
$847.30
$892.76
$1,054.28 		$1,047.60
$1,090.52
$1,135.98
$1,297.50 		$243.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.88
$721.72
$812.64
$1,135.68
$1,725.76 		$879.10
$964.94
$1,055.86
$1,378.90 		$1,122.32
$1,208.16
$1,299.08
$1,622.12 		$1,365.54
$1,451.38
$1,542.30
$1,865.34 		$243.22
Toc - Plan #108 Ambetter from Arizona Complete Health
Silver

(HMO) Ambetter Balanced Care 32 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.69
$368.52
$414.95
$579.89
$881.20 		$573.08
$616.91
$663.34
$828.28 		$821.47
$865.30
$911.73
$1,076.67 		$1,069.86
$1,113.69
$1,160.12
$1,325.06 		$248.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.38
$737.04
$829.90
$1,159.78
$1,762.40 		$897.77
$985.43
$1,078.29
$1,408.17 		$1,146.16
$1,233.82
$1,326.68
$1,656.56 		$1,394.55
$1,482.21
$1,575.07
$1,904.95 		$248.39
Toc - Plan #109 Ambetter from Arizona Complete Health
Gold

(HMO) Ambetter Secure Care 20 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.00
$433.57
$488.19
$682.25
$1,036.75 		$674.23
$725.80
$780.42
$974.48 		$966.46
$1,018.03
$1,072.65
$1,266.71 		$1,258.69
$1,310.26
$1,364.88
$1,558.94 		$292.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.00
$867.14
$976.38
$1,364.50
$2,073.50 		$1,056.23
$1,159.37
$1,268.61
$1,656.73 		$1,348.46
$1,451.60
$1,560.84
$1,948.96 		$1,640.69
$1,743.83
$1,853.07
$2,241.19 		$292.23
Toc - Plan #110 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Ambetter Essential Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.70
$353.78
$398.35
$556.69
$845.95 		$550.15
$592.23
$636.80
$795.14 		$788.60
$830.68
$875.25
$1,033.59 		$1,027.05
$1,069.13
$1,113.70
$1,272.04 		$238.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.40
$707.56
$796.70
$1,113.38
$1,691.90 		$861.85
$946.01
$1,035.15
$1,351.83 		$1,100.30
$1,184.46
$1,273.60
$1,590.28 		$1,338.75
$1,422.91
$1,512.05
$1,828.73 		$238.45

ADVERTISEMENT

Cigna HealthCare of Arizona, Inc

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #111 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 5000 ($0 Tier 1 RX, $0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.03
$416.58
$469.06
$655.51
$996.12 		$647.81
$697.36
$749.84
$936.29 		$928.59
$978.14
$1,030.62
$1,217.07 		$1,209.37
$1,258.92
$1,311.40
$1,497.85 		$280.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.06
$833.16
$938.12
$1,311.02
$1,992.24 		$1,014.84
$1,113.94
$1,218.90
$1,591.80 		$1,295.62
$1,394.72
$1,499.68
$1,872.58 		$1,576.40
$1,675.50
$1,780.46
$2,153.36 		$280.78
Toc - Plan #112 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 7000 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$307.50
$349.02
$392.99
$549.20
$834.57 		$542.74
$584.26
$628.23
$784.44 		$777.98
$819.50
$863.47
$1,019.68 		$1,013.22
$1,054.74
$1,098.71
$1,254.92 		$235.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.00
$698.04
$785.98
$1,098.40
$1,669.14 		$850.24
$933.28
$1,021.22
$1,333.64 		$1,085.48
$1,168.52
$1,256.46
$1,568.88 		$1,320.72
$1,403.76
$1,491.70
$1,804.12 		$235.24
Toc - Plan #113 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 8500 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.36
$355.66
$400.47
$559.66
$850.46 		$553.08
$595.38
$640.19
$799.38 		$792.80
$835.10
$879.91
$1,039.10 		$1,032.52
$1,074.82
$1,119.63
$1,278.82 		$239.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.72
$711.32
$800.94
$1,119.32
$1,700.92 		$866.44
$951.04
$1,040.66
$1,359.04 		$1,106.16
$1,190.76
$1,280.38
$1,598.76 		$1,345.88
$1,430.48
$1,520.10
$1,838.48 		$239.72
Toc - Plan #114 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 4000 ($0 Tier 1 RX, $0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$368.73
$418.50
$471.23
$658.54
$1,000.72 		$650.81
$700.58
$753.31
$940.62 		$932.89
$982.66
$1,035.39
$1,222.70 		$1,214.97
$1,264.74
$1,317.47
$1,504.78 		$282.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.46
$837.00
$942.46
$1,317.08
$2,001.44 		$1,019.54
$1,119.08
$1,224.54
$1,599.16 		$1,301.62
$1,401.16
$1,506.62
$1,881.24 		$1,583.70
$1,683.24
$1,788.70
$2,163.32 		$282.08
Toc - Plan #115 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Cigna Connect 2500 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.15
$506.38
$570.18
$796.83
$1,210.86 		$787.46
$847.69
$911.49
$1,138.14 		$1,128.77
$1,189.00
$1,252.80
$1,479.45 		$1,470.08
$1,530.31
$1,594.11
$1,820.76 		$341.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.30
$1,012.76
$1,140.36
$1,593.66
$2,421.72 		$1,233.61
$1,354.07
$1,481.67
$1,934.97 		$1,574.92
$1,695.38
$1,822.98
$2,276.28 		$1,916.23
$2,036.69
$2,164.29
$2,617.59 		$341.31
Toc - Plan #116 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 3500 Enhanced Diabetes Care ($0 Preferred Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.47
$420.48
$473.45
$661.65
$1,005.44 		$653.88
$703.89
$756.86
$945.06 		$937.29
$987.30
$1,040.27
$1,228.47 		$1,220.70
$1,270.71
$1,323.68
$1,511.88 		$283.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.94
$840.96
$946.90
$1,323.30
$2,010.88 		$1,024.35
$1,124.37
$1,230.31
$1,606.71 		$1,307.76
$1,407.78
$1,513.72
$1,890.12 		$1,591.17
$1,691.19
$1,797.13
$2,173.53 		$283.41
Toc - Plan #117 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 5500 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.40
$413.59
$465.70
$650.82
$988.98 		$643.16
$692.35
$744.46
$929.58 		$921.92
$971.11
$1,023.22
$1,208.34 		$1,200.68
$1,249.87
$1,301.98
$1,487.10 		$278.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.80
$827.18
$931.40
$1,301.64
$1,977.96 		$1,007.56
$1,105.94
$1,210.16
$1,580.40 		$1,286.32
$1,384.70
$1,488.92
$1,859.16 		$1,565.08
$1,663.46
$1,767.68
$2,137.92 		$278.76
Toc - Plan #118 Cigna HealthCare of Arizona, Inc
Bronze

(HMO) Cigna Connect 8700 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.48
$342.18
$385.29
$538.44
$818.22 		$532.11
$572.81
$615.92
$769.07 		$762.74
$803.44
$846.55
$999.70 		$993.37
$1,034.07
$1,077.18
$1,230.33 		$230.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.96
$684.36
$770.58
$1,076.88
$1,636.44 		$833.59
$914.99
$1,001.21
$1,307.51 		$1,064.22
$1,145.62
$1,231.84
$1,538.14 		$1,294.85
$1,376.25
$1,462.47
$1,768.77 		$230.63
Toc - Plan #119 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care ($0 Preferred Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.09
$359.90
$405.25
$566.33
$860.59 		$559.67
$602.48
$647.83
$808.91 		$802.25
$845.06
$890.41
$1,051.49 		$1,044.83
$1,087.64
$1,132.99
$1,294.07 		$242.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.18
$719.80
$810.50
$1,132.66
$1,721.18 		$876.76
$962.38
$1,053.08
$1,375.24 		$1,119.34
$1,204.96
$1,295.66
$1,617.82 		$1,361.92
$1,447.54
$1,538.24
$1,860.40 		$242.58
Toc - Plan #120 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect HSA 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.91
$356.29
$401.18
$560.65
$851.96 		$554.05
$596.43
$641.32
$800.79 		$794.19
$836.57
$881.46
$1,040.93 		$1,034.33
$1,076.71
$1,121.60
$1,281.07 		$240.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.82
$712.58
$802.36
$1,121.30
$1,703.92 		$867.96
$952.72
$1,042.50
$1,361.44 		$1,108.10
$1,192.86
$1,282.64
$1,601.58 		$1,348.24
$1,433.00
$1,522.78
$1,841.72 		$240.14
Toc - Plan #121 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.03
$416.58
$469.06
$655.51
$996.12 		$647.81
$697.36
$749.84
$936.29 		$928.59
$978.14
$1,030.62
$1,217.07 		$1,209.37
$1,258.92
$1,311.40
$1,497.85 		$280.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.06
$833.16
$938.12
$1,311.02
$1,992.24 		$1,014.84
$1,113.94
$1,218.90
$1,591.80 		$1,295.62
$1,394.72
$1,499.68
$1,872.58 		$1,576.40
$1,675.50
$1,780.46
$2,153.36 		$280.78
Toc - Plan #122 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Cigna Connect 1250 Enhanced Diabetes Care ($0 Preferred Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$467.66
$530.80
$597.67
$835.25
$1,269.24 		$825.42
$888.56
$955.43
$1,193.01 		$1,183.18
$1,246.32
$1,313.19
$1,550.77 		$1,540.94
$1,604.08
$1,670.95
$1,908.53 		$357.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$935.32
$1,061.60
$1,195.34
$1,670.50
$2,538.48 		$1,293.08
$1,419.36
$1,553.10
$2,028.26 		$1,650.84
$1,777.12
$1,910.86
$2,386.02 		$2,008.60
$2,134.88
$2,268.62
$2,743.78 		$357.76

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Maricopa County here.

Maricopa County is in “Rating Area 4” of Arizona.

Currently, there are 122 plans offered in Rating Area 4.

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2022 Obamacare Plans for Maricopa County, AZ

Plan Browser: 122 Plans
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