Obamacare 2022 Rates for Stark County

Obamacare > Rates > Ohio > Stark 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 Stark County, OH.

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, 161 Plans and 2022 Rates for Stark County, Ohio

Below, you’ll find a summary of the 161 plans for Stark County, Ohio 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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AultCare Insurance Company

Local: 1-330-363-6360 | Toll Free: 1-800-344-8858 | TTY: 1-711--
Toc - Plan #1 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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 		$425.14
$482.53
$543.32
$759.29
$1,153.81 		$750.37
$807.76
$868.55
$1,084.52 		$1,075.60
$1,132.99
$1,193.78
$1,409.75 		$1,400.83
$1,458.22
$1,519.01
$1,734.98 		$325.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.28
$965.06
$1,086.64
$1,518.58
$2,307.62 		$1,175.51
$1,290.29
$1,411.87
$1,843.81 		$1,500.74
$1,615.52
$1,737.10
$2,169.04 		$1,825.97
$1,940.75
$2,062.33
$2,494.27 		$325.23
Toc - Plan #2 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$550.64
$624.97
$703.71
$983.43
$1,494.41 		$971.87
$1,046.20
$1,124.94
$1,404.66 		$1,393.10
$1,467.43
$1,546.17
$1,825.89 		$1,814.33
$1,888.66
$1,967.40
$2,247.12 		$421.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,101.28
$1,249.94
$1,407.42
$1,966.86
$2,988.82 		$1,522.51
$1,671.17
$1,828.65
$2,388.09 		$1,943.74
$2,092.40
$2,249.88
$2,809.32 		$2,364.97
$2,513.63
$2,671.11
$3,230.55 		$421.23
Toc - Plan #3 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 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 		$687.11
$779.87
$878.12
$1,227.17
$1,864.81 		$1,212.75
$1,305.51
$1,403.76
$1,752.81 		$1,738.39
$1,831.15
$1,929.40
$2,278.45 		$2,264.03
$2,356.79
$2,455.04
$2,804.09 		$525.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,374.22
$1,559.74
$1,756.24
$2,454.34
$3,729.62 		$1,899.86
$2,085.38
$2,281.88
$2,979.98 		$2,425.50
$2,611.02
$2,807.52
$3,505.62 		$2,951.14
$3,136.66
$3,333.16
$4,031.26 		$525.64
Toc - Plan #4 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$205.51
$233.25
$262.64
$367.04
$557.75 		$362.72
$390.46
$419.85
$524.25 		$519.93
$547.67
$577.06
$681.46 		$677.14
$704.88
$734.27
$838.67 		$157.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$411.02
$466.50
$525.28
$734.08
$1,115.50 		$568.23
$623.71
$682.49
$891.29 		$725.44
$780.92
$839.70
$1,048.50 		$882.65
$938.13
$996.91
$1,205.71 		$157.21
Toc - Plan #5 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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 		$325.63
$369.58
$416.15
$581.56
$883.74 		$574.73
$618.68
$665.25
$830.66 		$823.83
$867.78
$914.35
$1,079.76 		$1,072.93
$1,116.88
$1,163.45
$1,328.86 		$249.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.26
$739.16
$832.30
$1,163.12
$1,767.48 		$900.36
$988.26
$1,081.40
$1,412.22 		$1,149.46
$1,237.36
$1,330.50
$1,661.32 		$1,398.56
$1,486.46
$1,579.60
$1,910.42 		$249.10
Toc - Plan #6 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$420.75
$477.54
$537.71
$751.45
$1,141.90 		$742.62
$799.41
$859.58
$1,073.32 		$1,064.49
$1,121.28
$1,181.45
$1,395.19 		$1,386.36
$1,443.15
$1,503.32
$1,717.06 		$321.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.50
$955.08
$1,075.42
$1,502.90
$2,283.80 		$1,163.37
$1,276.95
$1,397.29
$1,824.77 		$1,485.24
$1,598.82
$1,719.16
$2,146.64 		$1,807.11
$1,920.69
$2,041.03
$2,468.51 		$321.87
Toc - Plan #7 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 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 		$525.98
$596.98
$672.19
$939.39
$1,427.49 		$928.35
$999.35
$1,074.56
$1,341.76 		$1,330.72
$1,401.72
$1,476.93
$1,744.13 		$1,733.09
$1,804.09
$1,879.30
$2,146.50 		$402.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.96
$1,193.96
$1,344.38
$1,878.78
$2,854.98 		$1,454.33
$1,596.33
$1,746.75
$2,281.15 		$1,856.70
$1,998.70
$2,149.12
$2,683.52 		$2,259.07
$2,401.07
$2,551.49
$3,085.89 		$402.37
Toc - Plan #8 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$271.28
$307.89
$346.69
$484.49
$736.23 		$478.80
$515.41
$554.21
$692.01 		$686.32
$722.93
$761.73
$899.53 		$893.84
$930.45
$969.25
$1,107.05 		$207.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.56
$615.78
$693.38
$968.98
$1,472.46 		$750.08
$823.30
$900.90
$1,176.50 		$957.60
$1,030.82
$1,108.42
$1,384.02 		$1,165.12
$1,238.34
$1,315.94
$1,591.54 		$207.52
Toc - Plan #9 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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 		$429.83
$487.85
$549.31
$767.66
$1,166.54 		$758.64
$816.66
$878.12
$1,096.47 		$1,087.45
$1,145.47
$1,206.93
$1,425.28 		$1,416.26
$1,474.28
$1,535.74
$1,754.09 		$328.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.66
$975.70
$1,098.62
$1,535.32
$2,333.08 		$1,188.47
$1,304.51
$1,427.43
$1,864.13 		$1,517.28
$1,633.32
$1,756.24
$2,192.94 		$1,846.09
$1,962.13
$2,085.05
$2,521.75 		$328.81
Toc - Plan #10 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$555.39
$630.36
$709.78
$991.91
$1,507.30 		$980.26
$1,055.23
$1,134.65
$1,416.78 		$1,405.13
$1,480.10
$1,559.52
$1,841.65 		$1,830.00
$1,904.97
$1,984.39
$2,266.52 		$424.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,110.78
$1,260.72
$1,419.56
$1,983.82
$3,014.60 		$1,535.65
$1,685.59
$1,844.43
$2,408.69 		$1,960.52
$2,110.46
$2,269.30
$2,833.56 		$2,385.39
$2,535.33
$2,694.17
$3,258.43 		$424.87
Toc - Plan #11 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 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 		$694.29
$788.01
$887.30
$1,239.99
$1,884.29 		$1,225.42
$1,319.14
$1,418.43
$1,771.12 		$1,756.55
$1,850.27
$1,949.56
$2,302.25 		$2,287.68
$2,381.40
$2,480.69
$2,833.38 		$531.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,388.58
$1,576.02
$1,774.60
$2,479.98
$3,768.58 		$1,919.71
$2,107.15
$2,305.73
$3,011.11 		$2,450.84
$2,638.28
$2,836.86
$3,542.24 		$2,981.97
$3,169.41
$3,367.99
$4,073.37 		$531.13
Toc - Plan #12 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$268.34
$304.56
$342.93
$479.25
$728.27 		$473.62
$509.84
$548.21
$684.53 		$678.90
$715.12
$753.49
$889.81 		$884.18
$920.40
$958.77
$1,095.09 		$205.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.68
$609.12
$685.86
$958.50
$1,456.54 		$741.96
$814.40
$891.14
$1,163.78 		$947.24
$1,019.68
$1,096.42
$1,369.06 		$1,152.52
$1,224.96
$1,301.70
$1,574.34 		$205.28
Toc - Plan #13 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1000 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,600 $13,200 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 		$520.54
$590.81
$665.25
$929.68
$1,412.73 		$918.75
$989.02
$1,063.46
$1,327.89 		$1,316.96
$1,387.23
$1,461.67
$1,726.10 		$1,715.17
$1,785.44
$1,859.88
$2,124.31 		$398.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,041.08
$1,181.62
$1,330.50
$1,859.36
$2,825.46 		$1,439.29
$1,579.83
$1,728.71
$2,257.57 		$1,837.50
$1,978.04
$2,126.92
$2,655.78 		$2,235.71
$2,376.25
$2,525.13
$3,053.99 		$398.21
Toc - Plan #14 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$417.15
$473.46
$533.11
$745.02
$1,132.13 		$736.27
$792.58
$852.23
$1,064.14 		$1,055.39
$1,111.70
$1,171.35
$1,383.26 		$1,374.51
$1,430.82
$1,490.47
$1,702.38 		$319.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.30
$946.92
$1,066.22
$1,490.04
$2,264.26 		$1,153.42
$1,266.04
$1,385.34
$1,809.16 		$1,472.54
$1,585.16
$1,704.46
$2,128.28 		$1,791.66
$1,904.28
$2,023.58
$2,447.40 		$319.12
Toc - Plan #15 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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 		$322.08
$365.55
$411.61
$575.22
$874.10 		$568.46
$611.93
$657.99
$821.60 		$814.84
$858.31
$904.37
$1,067.98 		$1,061.22
$1,104.69
$1,150.75
$1,314.36 		$246.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.16
$731.10
$823.22
$1,150.44
$1,748.20 		$890.54
$977.48
$1,069.60
$1,396.82 		$1,136.92
$1,223.86
$1,315.98
$1,643.20 		$1,383.30
$1,470.24
$1,562.36
$1,889.58 		$246.38
Toc - Plan #16 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$203.29
$230.73
$259.80
$363.07
$551.72 		$358.80
$386.24
$415.31
$518.58 		$514.31
$541.75
$570.82
$674.09 		$669.82
$697.26
$726.33
$829.60 		$155.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$406.58
$461.46
$519.60
$726.14
$1,103.44 		$562.09
$616.97
$675.11
$881.65 		$717.60
$772.48
$830.62
$1,037.16 		$873.11
$927.99
$986.13
$1,192.67 		$155.51
Toc - Plan #17 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$479.29
$543.98
$612.52
$856.00
$1,300.77 		$845.94
$910.63
$979.17
$1,222.65 		$1,212.59
$1,277.28
$1,345.82
$1,589.30 		$1,579.24
$1,643.93
$1,712.47
$1,955.95 		$366.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.58
$1,087.96
$1,225.04
$1,712.00
$2,601.54 		$1,325.23
$1,454.61
$1,591.69
$2,078.65 		$1,691.88
$1,821.26
$1,958.34
$2,445.30 		$2,058.53
$2,187.91
$2,324.99
$2,811.95 		$366.65
Toc - Plan #18 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$363.10
$412.11
$464.03
$648.48
$985.43 		$640.87
$689.88
$741.80
$926.25 		$918.64
$967.65
$1,019.57
$1,204.02 		$1,196.41
$1,245.42
$1,297.34
$1,481.79 		$277.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.20
$824.22
$928.06
$1,296.96
$1,970.86 		$1,003.97
$1,101.99
$1,205.83
$1,574.73 		$1,281.74
$1,379.76
$1,483.60
$1,852.50 		$1,559.51
$1,657.53
$1,761.37
$2,130.27 		$277.77
Toc - Plan #19 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$474.19
$538.20
$606.01
$846.89
$1,286.94 		$836.94
$900.95
$968.76
$1,209.64 		$1,199.69
$1,263.70
$1,331.51
$1,572.39 		$1,562.44
$1,626.45
$1,694.26
$1,935.14 		$362.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$948.38
$1,076.40
$1,212.02
$1,693.78
$2,573.88 		$1,311.13
$1,439.15
$1,574.77
$2,056.53 		$1,673.88
$1,801.90
$1,937.52
$2,419.28 		$2,036.63
$2,164.65
$2,300.27
$2,782.03 		$362.75
Toc - Plan #20 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$359.24
$407.73
$459.10
$641.59
$974.95 		$634.05
$682.54
$733.91
$916.40 		$908.86
$957.35
$1,008.72
$1,191.21 		$1,183.67
$1,232.16
$1,283.53
$1,466.02 		$274.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.48
$815.46
$918.20
$1,283.18
$1,949.90 		$993.29
$1,090.27
$1,193.01
$1,557.99 		$1,268.10
$1,365.08
$1,467.82
$1,832.80 		$1,542.91
$1,639.89
$1,742.63
$2,107.61 		$274.81
Toc - Plan #21 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$431.63
$489.89
$551.62
$770.88
$1,171.43 		$761.82
$820.08
$881.81
$1,101.07 		$1,092.01
$1,150.27
$1,212.00
$1,431.26 		$1,422.20
$1,480.46
$1,542.19
$1,761.45 		$330.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.26
$979.78
$1,103.24
$1,541.76
$2,342.86 		$1,193.45
$1,309.97
$1,433.43
$1,871.95 		$1,523.64
$1,640.16
$1,763.62
$2,202.14 		$1,853.83
$1,970.35
$2,093.81
$2,532.33 		$330.19
Toc - Plan #22 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$326.99
$371.13
$417.89
$584.00
$887.45 		$577.14
$621.28
$668.04
$834.15 		$827.29
$871.43
$918.19
$1,084.30 		$1,077.44
$1,121.58
$1,168.34
$1,334.45 		$250.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.98
$742.26
$835.78
$1,168.00
$1,774.90 		$904.13
$992.41
$1,085.93
$1,418.15 		$1,154.28
$1,242.56
$1,336.08
$1,668.30 		$1,404.43
$1,492.71
$1,586.23
$1,918.45 		$250.15
Toc - Plan #23 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$426.96
$484.59
$545.64
$762.54
$1,158.75 		$753.58
$811.21
$872.26
$1,089.16 		$1,080.20
$1,137.83
$1,198.88
$1,415.78 		$1,406.82
$1,464.45
$1,525.50
$1,742.40 		$326.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.92
$969.18
$1,091.28
$1,525.08
$2,317.50 		$1,180.54
$1,295.80
$1,417.90
$1,851.70 		$1,507.16
$1,622.42
$1,744.52
$2,178.32 		$1,833.78
$1,949.04
$2,071.14
$2,504.94 		$326.62
Toc - Plan #24 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$323.45
$367.11
$413.37
$577.68
$877.84 		$570.89
$614.55
$660.81
$825.12 		$818.33
$861.99
$908.25
$1,072.56 		$1,065.77
$1,109.43
$1,155.69
$1,320.00 		$247.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.90
$734.22
$826.74
$1,155.36
$1,755.68 		$894.34
$981.66
$1,074.18
$1,402.80 		$1,141.78
$1,229.10
$1,321.62
$1,650.24 		$1,389.22
$1,476.54
$1,569.06
$1,897.68 		$247.44
Toc - Plan #25 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze Standard Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$6,650 $13,300 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 		$310.14
$352.01
$396.36
$553.90
$841.71 		$547.39
$589.26
$633.61
$791.15 		$784.64
$826.51
$870.86
$1,028.40 		$1,021.89
$1,063.76
$1,108.11
$1,265.65 		$237.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620.28
$704.02
$792.72
$1,107.80
$1,683.42 		$857.53
$941.27
$1,029.97
$1,345.05 		$1,094.78
$1,178.52
$1,267.22
$1,582.30 		$1,332.03
$1,415.77
$1,504.47
$1,819.55 		$237.25
Toc - Plan #26 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 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 		$357.50
$405.75
$456.87
$638.48
$970.23 		$630.98
$679.23
$730.35
$911.96 		$904.46
$952.71
$1,003.83
$1,185.44 		$1,177.94
$1,226.19
$1,277.31
$1,458.92 		$273.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.00
$811.50
$913.74
$1,276.96
$1,940.46 		$988.48
$1,084.98
$1,187.22
$1,550.44 		$1,261.96
$1,358.46
$1,460.70
$1,823.92 		$1,535.44
$1,631.94
$1,734.18
$2,097.40 		$273.48
Toc - Plan #27 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 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 		$270.83
$307.39
$346.12
$483.70
$735.02 		$478.01
$514.57
$553.30
$690.88 		$685.19
$721.75
$760.48
$898.06 		$892.37
$928.93
$967.66
$1,105.24 		$207.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.66
$614.78
$692.24
$967.40
$1,470.04 		$748.84
$821.96
$899.42
$1,174.58 		$956.02
$1,029.14
$1,106.60
$1,381.76 		$1,163.20
$1,236.32
$1,313.78
$1,588.94 		$207.18
Toc - Plan #28 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 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 		$353.50
$401.22
$451.77
$631.34
$959.39 		$623.92
$671.64
$722.19
$901.76 		$894.34
$942.06
$992.61
$1,172.18 		$1,164.76
$1,212.48
$1,263.03
$1,442.60 		$270.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.00
$802.44
$903.54
$1,262.68
$1,918.78 		$977.42
$1,072.86
$1,173.96
$1,533.10 		$1,247.84
$1,343.28
$1,444.38
$1,803.52 		$1,518.26
$1,613.70
$1,714.80
$2,073.94 		$270.42
Toc - Plan #29 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 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 		$267.81
$303.95
$342.25
$478.29
$726.81 		$472.68
$508.82
$547.12
$683.16 		$677.55
$713.69
$751.99
$888.03 		$882.42
$918.56
$956.86
$1,092.90 		$204.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$535.62
$607.90
$684.50
$956.58
$1,453.62 		$740.49
$812.77
$889.37
$1,161.45 		$945.36
$1,017.64
$1,094.24
$1,366.32 		$1,150.23
$1,222.51
$1,299.11
$1,571.19 		$204.87
Toc - Plan #30 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 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 		$347.85
$394.81
$444.55
$621.25
$944.06 		$613.95
$660.91
$710.65
$887.35 		$880.05
$927.01
$976.75
$1,153.45 		$1,146.15
$1,193.11
$1,242.85
$1,419.55 		$266.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.70
$789.62
$889.10
$1,242.50
$1,888.12 		$961.80
$1,055.72
$1,155.20
$1,508.60 		$1,227.90
$1,321.82
$1,421.30
$1,774.70 		$1,494.00
$1,587.92
$1,687.40
$2,040.80 		$266.10
Toc - Plan #31 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 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 		$263.53
$299.10
$336.78
$470.65
$715.19 		$465.12
$500.69
$538.37
$672.24 		$666.71
$702.28
$739.96
$873.83 		$868.30
$903.87
$941.55
$1,075.42 		$201.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527.06
$598.20
$673.56
$941.30
$1,430.38 		$728.65
$799.79
$875.15
$1,142.89 		$930.24
$1,001.38
$1,076.74
$1,344.48 		$1,131.83
$1,202.97
$1,278.33
$1,546.07 		$201.59
Toc - Plan #32 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 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 		$344.02
$390.46
$439.66
$614.42
$933.67 		$607.20
$653.64
$702.84
$877.60 		$870.38
$916.82
$966.02
$1,140.78 		$1,133.56
$1,180.00
$1,229.20
$1,403.96 		$263.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.04
$780.92
$879.32
$1,228.84
$1,867.34 		$951.22
$1,044.10
$1,142.50
$1,492.02 		$1,214.40
$1,307.28
$1,405.68
$1,755.20 		$1,477.58
$1,570.46
$1,668.86
$2,018.38 		$263.18
Toc - Plan #33 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 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 		$260.63
$295.80
$333.07
$465.47
$707.33 		$460.01
$495.18
$532.45
$664.85 		$659.39
$694.56
$731.83
$864.23 		$858.77
$893.94
$931.21
$1,063.61 		$199.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.26
$591.60
$666.14
$930.94
$1,414.66 		$720.64
$790.98
$865.52
$1,130.32 		$920.02
$990.36
$1,064.90
$1,329.70 		$1,119.40
$1,189.74
$1,264.28
$1,529.08 		$199.38
Toc - Plan #34 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$359.99
$408.58
$460.06
$642.93
$976.99 		$635.38
$683.97
$735.45
$918.32 		$910.77
$959.36
$1,010.84
$1,193.71 		$1,186.16
$1,234.75
$1,286.23
$1,469.10 		$275.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.98
$817.16
$920.12
$1,285.86
$1,953.98 		$995.37
$1,092.55
$1,195.51
$1,561.25 		$1,270.76
$1,367.94
$1,470.90
$1,836.64 		$1,546.15
$1,643.33
$1,746.29
$2,112.03 		$275.39
Toc - Plan #35 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$272.72
$309.53
$348.53
$487.07
$740.15 		$481.35
$518.16
$557.16
$695.70 		$689.98
$726.79
$765.79
$904.33 		$898.61
$935.42
$974.42
$1,112.96 		$208.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$545.44
$619.06
$697.06
$974.14
$1,480.30 		$754.07
$827.69
$905.69
$1,182.77 		$962.70
$1,036.32
$1,114.32
$1,391.40 		$1,171.33
$1,244.95
$1,322.95
$1,600.03 		$208.63
Toc - Plan #36 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$356.38
$404.49
$455.45
$636.49
$967.21 		$629.01
$677.12
$728.08
$909.12 		$901.64
$949.75
$1,000.71
$1,181.75 		$1,174.27
$1,222.38
$1,273.34
$1,454.38 		$272.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.76
$808.98
$910.90
$1,272.98
$1,934.42 		$985.39
$1,081.61
$1,183.53
$1,545.61 		$1,258.02
$1,354.24
$1,456.16
$1,818.24 		$1,530.65
$1,626.87
$1,728.79
$2,090.87 		$272.63
Toc - Plan #37 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

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 		$269.99
$306.43
$345.04
$482.19
$732.74 		$476.53
$512.97
$551.58
$688.73 		$683.07
$719.51
$758.12
$895.27 		$889.61
$926.05
$964.66
$1,101.81 		$206.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.98
$612.86
$690.08
$964.38
$1,465.48 		$746.52
$819.40
$896.62
$1,170.92 		$953.06
$1,025.94
$1,103.16
$1,377.46 		$1,159.60
$1,232.48
$1,309.70
$1,584.00 		$206.54
Toc - Plan #38 AultCare Insurance Company
Silver

(PPO) AultCare Silver 7900 Premier Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 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 		$304.17
$345.22
$388.72
$543.23
$825.49 		$536.85
$577.90
$621.40
$775.91 		$769.53
$810.58
$854.08
$1,008.59 		$1,002.21
$1,043.26
$1,086.76
$1,241.27 		$232.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.34
$690.44
$777.44
$1,086.46
$1,650.98 		$841.02
$923.12
$1,010.12
$1,319.14 		$1,073.70
$1,155.80
$1,242.80
$1,551.82 		$1,306.38
$1,388.48
$1,475.48
$1,784.50 		$232.68
Toc - Plan #39 AultCare Insurance Company
Silver

(PPO) AultCare Silver 7900 Premier Select No Pediatric Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-344-8858

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 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 		$300.79
$341.39
$384.41
$537.21
$816.34 		$530.89
$571.49
$614.51
$767.31 		$760.99
$801.59
$844.61
$997.41 		$991.09
$1,031.69
$1,074.71
$1,227.51 		$230.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.58
$682.78
$768.82
$1,074.42
$1,632.68 		$831.68
$912.88
$998.92
$1,304.52 		$1,061.78
$1,142.98
$1,229.02
$1,534.62 		$1,291.88
$1,373.08
$1,459.12
$1,764.72 		$230.10

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1808 | Toll Free: 1-855-748-1808

Toc - Plan #40 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$282.89
$321.08
$361.53
$505.24
$767.76 		$499.30
$537.49
$577.94
$721.65 		$715.71
$753.90
$794.35
$938.06 		$932.12
$970.31
$1,010.76
$1,154.47 		$216.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.78
$642.16
$723.06
$1,010.48
$1,535.52 		$782.19
$858.57
$939.47
$1,226.89 		$998.60
$1,074.98
$1,155.88
$1,443.30 		$1,215.01
$1,291.39
$1,372.29
$1,659.71 		$216.41
Toc - Plan #41 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$270.07
$306.53
$345.15
$482.35
$732.97 		$476.67
$513.13
$551.75
$688.95 		$683.27
$719.73
$758.35
$895.55 		$889.87
$926.33
$964.95
$1,102.15 		$206.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.14
$613.06
$690.30
$964.70
$1,465.94 		$746.74
$819.66
$896.90
$1,171.30 		$953.34
$1,026.26
$1,103.50
$1,377.90 		$1,159.94
$1,232.86
$1,310.10
$1,584.50 		$206.60
Toc - Plan #42 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$370.13
$420.10
$473.03
$661.05
$1,004.53 		$653.28
$703.25
$756.18
$944.20 		$936.43
$986.40
$1,039.33
$1,227.35 		$1,219.58
$1,269.55
$1,322.48
$1,510.50 		$283.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.26
$840.20
$946.06
$1,322.10
$2,009.06 		$1,023.41
$1,123.35
$1,229.21
$1,605.25 		$1,306.56
$1,406.50
$1,512.36
$1,888.40 		$1,589.71
$1,689.65
$1,795.51
$2,171.55 		$283.15
Toc - Plan #43 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X HMO 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$2,500 $7,500 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 		$481.45
$546.45
$615.29
$859.87
$1,306.66 		$849.76
$914.76
$983.60
$1,228.18 		$1,218.07
$1,283.07
$1,351.91
$1,596.49 		$1,586.38
$1,651.38
$1,720.22
$1,964.80 		$368.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$962.90
$1,092.90
$1,230.58
$1,719.74
$2,613.32 		$1,331.21
$1,461.21
$1,598.89
$2,088.05 		$1,699.52
$1,829.52
$1,967.20
$2,456.36 		$2,067.83
$2,197.83
$2,335.51
$2,824.67 		$368.31
Toc - Plan #44 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6850 0 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$288.16
$327.06
$368.27
$514.65
$782.07 		$508.60
$547.50
$588.71
$735.09 		$729.04
$767.94
$809.15
$955.53 		$949.48
$988.38
$1,029.59
$1,175.97 		$220.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.32
$654.12
$736.54
$1,029.30
$1,564.14 		$796.76
$874.56
$956.98
$1,249.74 		$1,017.20
$1,095.00
$1,177.42
$1,470.18 		$1,237.64
$1,315.44
$1,397.86
$1,690.62 		$220.44
Toc - Plan #45 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3200 10 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 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 		$376.44
$427.26
$481.09
$672.32
$1,021.66 		$664.42
$715.24
$769.07
$960.30 		$952.40
$1,003.22
$1,057.05
$1,248.28 		$1,240.38
$1,291.20
$1,345.03
$1,536.26 		$287.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.88
$854.52
$962.18
$1,344.64
$2,043.32 		$1,040.86
$1,142.50
$1,250.16
$1,632.62 		$1,328.84
$1,430.48
$1,538.14
$1,920.60 		$1,616.82
$1,718.46
$1,826.12
$2,208.58 		$287.98
Toc - Plan #46 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$379.01
$430.18
$484.37
$676.91
$1,028.63 		$668.95
$720.12
$774.31
$966.85 		$958.89
$1,010.06
$1,064.25
$1,256.79 		$1,248.83
$1,300.00
$1,354.19
$1,546.73 		$289.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.02
$860.36
$968.74
$1,353.82
$2,057.26 		$1,047.96
$1,150.30
$1,258.68
$1,643.76 		$1,337.90
$1,440.24
$1,548.62
$1,933.70 		$1,627.84
$1,730.18
$1,838.56
$2,223.64 		$289.94
Toc - Plan #47 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000 20 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$287.00
$325.75
$366.79
$512.58
$778.92 		$506.56
$545.31
$586.35
$732.14 		$726.12
$764.87
$805.91
$951.70 		$945.68
$984.43
$1,025.47
$1,171.26 		$219.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.00
$651.50
$733.58
$1,025.16
$1,557.84 		$793.56
$871.06
$953.14
$1,244.72 		$1,013.12
$1,090.62
$1,172.70
$1,464.28 		$1,232.68
$1,310.18
$1,392.26
$1,683.84 		$219.56
Toc - Plan #48 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 6100 0 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$352.86
$400.50
$450.96
$630.21
$957.66 		$622.80
$670.44
$720.90
$900.15 		$892.74
$940.38
$990.84
$1,170.09 		$1,162.68
$1,210.32
$1,260.78
$1,440.03 		$269.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.72
$801.00
$901.92
$1,260.42
$1,915.32 		$975.66
$1,070.94
$1,171.86
$1,530.36 		$1,245.60
$1,340.88
$1,441.80
$1,800.30 		$1,515.54
$1,610.82
$1,711.74
$2,070.24 		$269.94
Toc - Plan #49 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$368.66
$418.43
$471.15
$658.43
$1,000.54 		$650.68
$700.45
$753.17
$940.45 		$932.70
$982.47
$1,035.19
$1,222.47 		$1,214.72
$1,264.49
$1,317.21
$1,504.49 		$282.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.32
$836.86
$942.30
$1,316.86
$2,001.08 		$1,019.34
$1,118.88
$1,224.32
$1,598.88 		$1,301.36
$1,400.90
$1,506.34
$1,880.90 		$1,583.38
$1,682.92
$1,788.36
$2,162.92 		$282.02
Toc - Plan #50 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$385.53
$437.58
$492.71
$688.56
$1,046.33 		$680.46
$732.51
$787.64
$983.49 		$975.39
$1,027.44
$1,082.57
$1,278.42 		$1,270.32
$1,322.37
$1,377.50
$1,573.35 		$294.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.06
$875.16
$985.42
$1,377.12
$2,092.66 		$1,065.99
$1,170.09
$1,280.35
$1,672.05 		$1,360.92
$1,465.02
$1,575.28
$1,966.98 		$1,655.85
$1,759.95
$1,870.21
$2,261.91 		$294.93
Toc - Plan #51 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$358.10
$406.44
$457.65
$639.57
$971.88 		$632.05
$680.39
$731.60
$913.52 		$906.00
$954.34
$1,005.55
$1,187.47 		$1,179.95
$1,228.29
$1,279.50
$1,461.42 		$273.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.20
$812.88
$915.30
$1,279.14
$1,943.76 		$990.15
$1,086.83
$1,189.25
$1,553.09 		$1,264.10
$1,360.78
$1,463.20
$1,827.04 		$1,538.05
$1,634.73
$1,737.15
$2,100.99 		$273.95
Toc - Plan #52 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway X HMO 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$221.10
$250.95
$282.57
$394.88
$600.07 		$390.24
$420.09
$451.71
$564.02 		$559.38
$589.23
$620.85
$733.16 		$728.52
$758.37
$789.99
$902.30 		$169.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$442.20
$501.90
$565.14
$789.76
$1,200.14 		$611.34
$671.04
$734.28
$958.90 		$780.48
$840.18
$903.42
$1,128.04 		$949.62
$1,009.32
$1,072.56
$1,297.18 		$169.14
Toc - Plan #53 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 2600

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$395.53
$448.93
$505.49
$706.42
$1,073.47 		$698.11
$751.51
$808.07
$1,009.00 		$1,000.69
$1,054.09
$1,110.65
$1,311.58 		$1,303.27
$1,356.67
$1,413.23
$1,614.16 		$302.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.06
$897.86
$1,010.98
$1,412.84
$2,146.94 		$1,093.64
$1,200.44
$1,313.56
$1,715.42 		$1,396.22
$1,503.02
$1,616.14
$2,018.00 		$1,698.80
$1,805.60
$1,918.72
$2,320.58 		$302.58
Toc - Plan #54 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 6900 25

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 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 		$353.17
$400.85
$451.35
$630.76
$958.50 		$623.35
$671.03
$721.53
$900.94 		$893.53
$941.21
$991.71
$1,171.12 		$1,163.71
$1,211.39
$1,261.89
$1,441.30 		$270.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.34
$801.70
$902.70
$1,261.52
$1,917.00 		$976.52
$1,071.88
$1,172.88
$1,531.70 		$1,246.70
$1,342.06
$1,443.06
$1,801.88 		$1,516.88
$1,612.24
$1,713.24
$2,072.06 		$270.18
Toc - Plan #55 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$291.04
$330.33
$371.95
$519.80
$789.88 		$513.69
$552.98
$594.60
$742.45 		$736.34
$775.63
$817.25
$965.10 		$958.99
$998.28
$1,039.90
$1,187.75 		$222.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.08
$660.66
$743.90
$1,039.60
$1,579.76 		$804.73
$883.31
$966.55
$1,262.25 		$1,027.38
$1,105.96
$1,189.20
$1,484.90 		$1,250.03
$1,328.61
$1,411.85
$1,707.55 		$222.65
Toc - Plan #56 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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 		$277.47
$314.93
$354.61
$495.56
$753.05 		$489.73
$527.19
$566.87
$707.82 		$701.99
$739.45
$779.13
$920.08 		$914.25
$951.71
$991.39
$1,132.34 		$212.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.94
$629.86
$709.22
$991.12
$1,506.10 		$767.20
$842.12
$921.48
$1,203.38 		$979.46
$1,054.38
$1,133.74
$1,415.64 		$1,191.72
$1,266.64
$1,346.00
$1,627.90 		$212.26

ADVERTISEMENT

Ambetter from Buckeye Health

Local: 1-877-687-1189 | Toll Free: 1-877-687-1189 | TTY: 1-877-941-9236
Toc - Plan #57 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$337.66
$383.23
$431.51
$603.04
$916.37 		$595.96
$641.53
$689.81
$861.34 		$854.26
$899.83
$948.11
$1,119.64 		$1,112.56
$1,158.13
$1,206.41
$1,377.94 		$258.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.32
$766.46
$863.02
$1,206.08
$1,832.74 		$933.62
$1,024.76
$1,121.32
$1,464.38 		$1,191.92
$1,283.06
$1,379.62
$1,722.68 		$1,450.22
$1,541.36
$1,637.92
$1,980.98 		$258.30
Toc - Plan #58 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$333.81
$378.86
$426.59
$596.16
$905.92 		$589.16
$634.21
$681.94
$851.51 		$844.51
$889.56
$937.29
$1,106.86 		$1,099.86
$1,144.91
$1,192.64
$1,362.21 		$255.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.62
$757.72
$853.18
$1,192.32
$1,811.84 		$922.97
$1,013.07
$1,108.53
$1,447.67 		$1,178.32
$1,268.42
$1,363.88
$1,703.02 		$1,433.67
$1,523.77
$1,619.23
$1,958.37 		$255.35
Toc - Plan #59 Ambetter from Buckeye Health
Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$378.14
$429.18
$483.25
$675.34
$1,026.24 		$667.41
$718.45
$772.52
$964.61 		$956.68
$1,007.72
$1,061.79
$1,253.88 		$1,245.95
$1,296.99
$1,351.06
$1,543.15 		$289.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.28
$858.36
$966.50
$1,350.68
$2,052.48 		$1,045.55
$1,147.63
$1,255.77
$1,639.95 		$1,334.82
$1,436.90
$1,545.04
$1,929.22 		$1,624.09
$1,726.17
$1,834.31
$2,218.49 		$289.27
Toc - Plan #60 Ambetter from Buckeye Health
Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$266.28
$302.21
$340.29
$475.55
$722.65 		$469.97
$505.90
$543.98
$679.24 		$673.66
$709.59
$747.67
$882.93 		$877.35
$913.28
$951.36
$1,086.62 		$203.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$532.56
$604.42
$680.58
$951.10
$1,445.30 		$736.25
$808.11
$884.27
$1,154.79 		$939.94
$1,011.80
$1,087.96
$1,358.48 		$1,143.63
$1,215.49
$1,291.65
$1,562.17 		$203.69
Toc - Plan #61 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$290.52
$329.73
$371.27
$518.85
$788.45 		$512.76
$551.97
$593.51
$741.09 		$735.00
$774.21
$815.75
$963.33 		$957.24
$996.45
$1,037.99
$1,185.57 		$222.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.04
$659.46
$742.54
$1,037.70
$1,576.90 		$803.28
$881.70
$964.78
$1,259.94 		$1,025.52
$1,103.94
$1,187.02
$1,482.18 		$1,247.76
$1,326.18
$1,409.26
$1,704.42 		$222.24
Toc - Plan #62 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$278.74
$316.35
$356.21
$497.81
$756.46 		$491.97
$529.58
$569.44
$711.04 		$705.20
$742.81
$782.67
$924.27 		$918.43
$956.04
$995.90
$1,137.50 		$213.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.48
$632.70
$712.42
$995.62
$1,512.92 		$770.71
$845.93
$925.65
$1,208.85 		$983.94
$1,059.16
$1,138.88
$1,422.08 		$1,197.17
$1,272.39
$1,352.11
$1,635.31 		$213.23
Toc - Plan #63 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 24

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 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 		$343.97
$390.39
$439.58
$614.31
$933.51 		$607.10
$653.52
$702.71
$877.44 		$870.23
$916.65
$965.84
$1,140.57 		$1,133.36
$1,179.78
$1,228.97
$1,403.70 		$263.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.94
$780.78
$879.16
$1,228.62
$1,867.02 		$951.07
$1,043.91
$1,142.29
$1,491.75 		$1,214.20
$1,307.04
$1,405.42
$1,754.88 		$1,477.33
$1,570.17
$1,668.55
$2,018.01 		$263.13
Toc - Plan #64 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$286.17
$324.79
$365.71
$511.07
$776.62 		$505.08
$543.70
$584.62
$729.98 		$723.99
$762.61
$803.53
$948.89 		$942.90
$981.52
$1,022.44
$1,167.80 		$218.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.34
$649.58
$731.42
$1,022.14
$1,553.24 		$791.25
$868.49
$950.33
$1,241.05 		$1,010.16
$1,087.40
$1,169.24
$1,459.96 		$1,229.07
$1,306.31
$1,388.15
$1,678.87 		$218.91
Toc - Plan #65 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$309.33
$351.08
$395.31
$552.44
$839.49 		$545.96
$587.71
$631.94
$789.07 		$782.59
$824.34
$868.57
$1,025.70 		$1,019.22
$1,060.97
$1,105.20
$1,262.33 		$236.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.66
$702.16
$790.62
$1,104.88
$1,678.98 		$855.29
$938.79
$1,027.25
$1,341.51 		$1,091.92
$1,175.42
$1,263.88
$1,578.14 		$1,328.55
$1,412.05
$1,500.51
$1,814.77 		$236.63
Toc - Plan #66 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$323.98
$367.71
$414.04
$578.61
$879.26 		$571.82
$615.55
$661.88
$826.45 		$819.66
$863.39
$909.72
$1,074.29 		$1,067.50
$1,111.23
$1,157.56
$1,322.13 		$247.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.96
$735.42
$828.08
$1,157.22
$1,758.52 		$895.80
$983.26
$1,075.92
$1,405.06 		$1,143.64
$1,231.10
$1,323.76
$1,652.90 		$1,391.48
$1,478.94
$1,571.60
$1,900.74 		$247.84
Toc - Plan #67 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$318.07
$361.00
$406.48
$568.06
$863.22 		$561.39
$604.32
$649.80
$811.38 		$804.71
$847.64
$893.12
$1,054.70 		$1,048.03
$1,090.96
$1,136.44
$1,298.02 		$243.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.14
$722.00
$812.96
$1,136.12
$1,726.44 		$879.46
$965.32
$1,056.28
$1,379.44 		$1,122.78
$1,208.64
$1,299.60
$1,622.76 		$1,366.10
$1,451.96
$1,542.92
$1,866.08 		$243.32
Toc - Plan #68 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$317.90
$360.81
$406.27
$567.76
$862.76 		$561.09
$604.00
$649.46
$810.95 		$804.28
$847.19
$892.65
$1,054.14 		$1,047.47
$1,090.38
$1,135.84
$1,297.33 		$243.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.80
$721.62
$812.54
$1,135.52
$1,725.52 		$878.99
$964.81
$1,055.73
$1,378.71 		$1,122.18
$1,208.00
$1,298.92
$1,621.90 		$1,365.37
$1,451.19
$1,542.11
$1,865.09 		$243.19
Toc - Plan #69 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$324.49
$368.28
$414.68
$579.52
$880.63 		$572.72
$616.51
$662.91
$827.75 		$820.95
$864.74
$911.14
$1,075.98 		$1,069.18
$1,112.97
$1,159.37
$1,324.21 		$248.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.98
$736.56
$829.36
$1,159.04
$1,761.26 		$897.21
$984.79
$1,077.59
$1,407.27 		$1,145.44
$1,233.02
$1,325.82
$1,655.50 		$1,393.67
$1,481.25
$1,574.05
$1,903.73 		$248.23
Toc - Plan #70 Ambetter from Buckeye Health
Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$355.42
$403.39
$454.21
$634.76
$964.57 		$627.31
$675.28
$726.10
$906.65 		$899.20
$947.17
$997.99
$1,178.54 		$1,171.09
$1,219.06
$1,269.88
$1,450.43 		$271.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.84
$806.78
$908.42
$1,269.52
$1,929.14 		$982.73
$1,078.67
$1,180.31
$1,541.41 		$1,254.62
$1,350.56
$1,452.20
$1,813.30 		$1,526.51
$1,622.45
$1,724.09
$2,085.19 		$271.89
Toc - Plan #71 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$345.57
$392.21
$441.63
$617.17
$937.85 		$609.92
$656.56
$705.98
$881.52 		$874.27
$920.91
$970.33
$1,145.87 		$1,138.62
$1,185.26
$1,234.68
$1,410.22 		$264.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.14
$784.42
$883.26
$1,234.34
$1,875.70 		$955.49
$1,048.77
$1,147.61
$1,498.69 		$1,219.84
$1,313.12
$1,411.96
$1,763.04 		$1,484.19
$1,577.47
$1,676.31
$2,027.39 		$264.35
Toc - Plan #72 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$349.56
$396.73
$446.72
$624.29
$948.67 		$616.96
$664.13
$714.12
$891.69 		$884.36
$931.53
$981.52
$1,159.09 		$1,151.76
$1,198.93
$1,248.92
$1,426.49 		$267.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.12
$793.46
$893.44
$1,248.58
$1,897.34 		$966.52
$1,060.86
$1,160.84
$1,515.98 		$1,233.92
$1,328.26
$1,428.24
$1,783.38 		$1,501.32
$1,595.66
$1,695.64
$2,050.78 		$267.40
Toc - Plan #73 Ambetter from Buckeye Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$391.47
$444.30
$500.28
$699.14
$1,062.41 		$690.93
$743.76
$799.74
$998.60 		$990.39
$1,043.22
$1,099.20
$1,298.06 		$1,289.85
$1,342.68
$1,398.66
$1,597.52 		$299.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.94
$888.60
$1,000.56
$1,398.28
$2,124.82 		$1,082.40
$1,188.06
$1,300.02
$1,697.74 		$1,381.86
$1,487.52
$1,599.48
$1,997.20 		$1,681.32
$1,786.98
$1,898.94
$2,296.66 		$299.46
Toc - Plan #74 Ambetter from Buckeye Health
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$275.66
$312.86
$352.28
$492.31
$748.12 		$486.53
$523.73
$563.15
$703.18 		$697.40
$734.60
$774.02
$914.05 		$908.27
$945.47
$984.89
$1,124.92 		$210.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.32
$625.72
$704.56
$984.62
$1,496.24 		$762.19
$836.59
$915.43
$1,195.49 		$973.06
$1,047.46
$1,126.30
$1,406.36 		$1,183.93
$1,258.33
$1,337.17
$1,617.23 		$210.87
Toc - Plan #75 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$300.76
$341.35
$384.36
$537.14
$816.23 		$530.83
$571.42
$614.43
$767.21 		$760.90
$801.49
$844.50
$997.28 		$990.97
$1,031.56
$1,074.57
$1,227.35 		$230.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.52
$682.70
$768.72
$1,074.28
$1,632.46 		$831.59
$912.77
$998.79
$1,304.35 		$1,061.66
$1,142.84
$1,228.86
$1,534.42 		$1,291.73
$1,372.91
$1,458.93
$1,764.49 		$230.07
Toc - Plan #76 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 10 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$288.56
$327.50
$368.77
$515.35
$783.12 		$509.30
$548.24
$589.51
$736.09 		$730.04
$768.98
$810.25
$956.83 		$950.78
$989.72
$1,030.99
$1,177.57 		$220.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.12
$655.00
$737.54
$1,030.70
$1,566.24 		$797.86
$875.74
$958.28
$1,251.44 		$1,018.60
$1,096.48
$1,179.02
$1,472.18 		$1,239.34
$1,317.22
$1,399.76
$1,692.92 		$220.74
Toc - Plan #77 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 24 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 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 		$356.09
$404.15
$455.07
$635.96
$966.41 		$628.49
$676.55
$727.47
$908.36 		$900.89
$948.95
$999.87
$1,180.76 		$1,173.29
$1,221.35
$1,272.27
$1,453.16 		$272.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.18
$808.30
$910.14
$1,271.92
$1,932.82 		$984.58
$1,080.70
$1,182.54
$1,544.32 		$1,256.98
$1,353.10
$1,454.94
$1,816.72 		$1,529.38
$1,625.50
$1,727.34
$2,089.12 		$272.40
Toc - Plan #78 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$296.25
$336.23
$378.59
$529.08
$803.99 		$522.87
$562.85
$605.21
$755.70 		$749.49
$789.47
$831.83
$982.32 		$976.11
$1,016.09
$1,058.45
$1,208.94 		$226.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.50
$672.46
$757.18
$1,058.16
$1,607.98 		$819.12
$899.08
$983.80
$1,284.78 		$1,045.74
$1,125.70
$1,210.42
$1,511.40 		$1,272.36
$1,352.32
$1,437.04
$1,738.02 		$226.62
Toc - Plan #79 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$320.23
$363.45
$409.24
$571.91
$869.07 		$565.20
$608.42
$654.21
$816.88 		$810.17
$853.39
$899.18
$1,061.85 		$1,055.14
$1,098.36
$1,144.15
$1,306.82 		$244.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.46
$726.90
$818.48
$1,143.82
$1,738.14 		$885.43
$971.87
$1,063.45
$1,388.79 		$1,130.40
$1,216.84
$1,308.42
$1,633.76 		$1,375.37
$1,461.81
$1,553.39
$1,878.73 		$244.97
Toc - Plan #80 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$335.40
$380.67
$428.63
$599.00
$910.25 		$591.97
$637.24
$685.20
$855.57 		$848.54
$893.81
$941.77
$1,112.14 		$1,105.11
$1,150.38
$1,198.34
$1,368.71 		$256.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.80
$761.34
$857.26
$1,198.00
$1,820.50 		$927.37
$1,017.91
$1,113.83
$1,454.57 		$1,183.94
$1,274.48
$1,370.40
$1,711.14 		$1,440.51
$1,531.05
$1,626.97
$1,967.71 		$256.57
Toc - Plan #81 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$329.28
$373.72
$420.81
$588.08
$893.64 		$581.17
$625.61
$672.70
$839.97 		$833.06
$877.50
$924.59
$1,091.86 		$1,084.95
$1,129.39
$1,176.48
$1,343.75 		$251.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.56
$747.44
$841.62
$1,176.16
$1,787.28 		$910.45
$999.33
$1,093.51
$1,428.05 		$1,162.34
$1,251.22
$1,345.40
$1,679.94 		$1,414.23
$1,503.11
$1,597.29
$1,931.83 		$251.89
Toc - Plan #82 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$335.92
$381.26
$429.30
$599.94
$911.67 		$592.89
$638.23
$686.27
$856.91 		$849.86
$895.20
$943.24
$1,113.88 		$1,106.83
$1,152.17
$1,200.21
$1,370.85 		$256.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.84
$762.52
$858.60
$1,199.88
$1,823.34 		$928.81
$1,019.49
$1,115.57
$1,456.85 		$1,185.78
$1,276.46
$1,372.54
$1,713.82 		$1,442.75
$1,533.43
$1,629.51
$1,970.79 		$256.97
Toc - Plan #83 Ambetter from Buckeye Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$367.94
$417.60
$470.22
$657.13
$998.57 		$649.41
$699.07
$751.69
$938.60 		$930.88
$980.54
$1,033.16
$1,220.07 		$1,212.35
$1,262.01
$1,314.63
$1,501.54 		$281.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.88
$835.20
$940.44
$1,314.26
$1,997.14 		$1,017.35
$1,116.67
$1,221.91
$1,595.73 		$1,298.82
$1,398.14
$1,503.38
$1,877.20 		$1,580.29
$1,679.61
$1,784.85
$2,158.67 		$281.47

ADVERTISEMENT

Oscar Insurance Corporation of Ohio

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

Toc - Plan #84 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple

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 		$333.60
$378.63
$426.33
$595.80
$905.37 		$588.80
$633.83
$681.53
$851.00 		$844.00
$889.03
$936.73
$1,106.20 		$1,099.20
$1,144.23
$1,191.93
$1,361.40 		$255.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.20
$757.26
$852.66
$1,191.60
$1,810.74 		$922.40
$1,012.46
$1,107.86
$1,446.80 		$1,177.60
$1,267.66
$1,363.06
$1,702.00 		$1,432.80
$1,522.86
$1,618.26
$1,957.20 		$255.20
Toc - Plan #85 Oscar Insurance Corporation of Ohio
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 		$339.85
$385.72
$434.31
$606.95
$922.32 		$599.83
$645.70
$694.29
$866.93 		$859.81
$905.68
$954.27
$1,126.91 		$1,119.79
$1,165.66
$1,214.25
$1,386.89 		$259.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.70
$771.44
$868.62
$1,213.90
$1,844.64 		$939.68
$1,031.42
$1,128.60
$1,473.88 		$1,199.66
$1,291.40
$1,388.58
$1,733.86 		$1,459.64
$1,551.38
$1,648.56
$1,993.84 		$259.98
Toc - Plan #86 Oscar Insurance Corporation of Ohio
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 		$334.92
$380.12
$428.01
$598.14
$908.93 		$591.12
$636.32
$684.21
$854.34 		$847.32
$892.52
$940.41
$1,110.54 		$1,103.52
$1,148.72
$1,196.61
$1,366.74 		$256.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.84
$760.24
$856.02
$1,196.28
$1,817.86 		$926.04
$1,016.44
$1,112.22
$1,452.48 		$1,182.24
$1,272.64
$1,368.42
$1,708.68 		$1,438.44
$1,528.84
$1,624.62
$1,964.88 		$256.20
Toc - Plan #87 Oscar Insurance Corporation of Ohio
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 		$390.59
$443.31
$499.16
$697.58
$1,060.03 		$689.38
$742.10
$797.95
$996.37 		$988.17
$1,040.89
$1,096.74
$1,295.16 		$1,286.96
$1,339.68
$1,395.53
$1,593.95 		$298.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.18
$886.62
$998.32
$1,395.16
$2,120.06 		$1,079.97
$1,185.41
$1,297.11
$1,693.95 		$1,378.76
$1,484.20
$1,595.90
$1,992.74 		$1,677.55
$1,782.99
$1,894.69
$2,291.53 		$298.79
Toc - Plan #88 Oscar Insurance Corporation of Ohio
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 		$401.07
$455.20
$512.55
$716.29
$1,088.47 		$707.88
$762.01
$819.36
$1,023.10 		$1,014.69
$1,068.82
$1,126.17
$1,329.91 		$1,321.50
$1,375.63
$1,432.98
$1,636.72 		$306.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.14
$910.40
$1,025.10
$1,432.58
$2,176.94 		$1,108.95
$1,217.21
$1,331.91
$1,739.39 		$1,415.76
$1,524.02
$1,638.72
$2,046.20 		$1,722.57
$1,830.83
$1,945.53
$2,353.01 		$306.81
Toc - Plan #89 Oscar Insurance Corporation of Ohio
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 		$391.20
$444.00
$499.94
$698.66
$1,061.69 		$690.46
$743.26
$799.20
$997.92 		$989.72
$1,042.52
$1,098.46
$1,297.18 		$1,288.98
$1,341.78
$1,397.72
$1,596.44 		$299.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.40
$888.00
$999.88
$1,397.32
$2,123.38 		$1,081.66
$1,187.26
$1,299.14
$1,696.58 		$1,380.92
$1,486.52
$1,598.40
$1,995.84 		$1,680.18
$1,785.78
$1,897.66
$2,295.10 		$299.26
Toc - Plan #90 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$401.15
$455.30
$512.66
$716.44
$1,088.70 		$708.02
$762.17
$819.53
$1,023.31 		$1,014.89
$1,069.04
$1,126.40
$1,330.18 		$1,321.76
$1,375.91
$1,433.27
$1,637.05 		$306.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.30
$910.60
$1,025.32
$1,432.88
$2,177.40 		$1,109.17
$1,217.47
$1,332.19
$1,739.75 		$1,416.04
$1,524.34
$1,639.06
$2,046.62 		$1,722.91
$1,831.21
$1,945.93
$2,353.49 		$306.87
Toc - Plan #91 Oscar Insurance Corporation of Ohio
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 		$240.47
$272.92
$307.31
$429.46
$652.61 		$424.42
$456.87
$491.26
$613.41 		$608.37
$640.82
$675.21
$797.36 		$792.32
$824.77
$859.16
$981.31 		$183.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$480.94
$545.84
$614.62
$858.92
$1,305.22 		$664.89
$729.79
$798.57
$1,042.87 		$848.84
$913.74
$982.52
$1,226.82 		$1,032.79
$1,097.69
$1,166.47
$1,410.77 		$183.95
Toc - Plan #92 Oscar Insurance Corporation of Ohio
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 		$390.63
$443.36
$499.21
$697.65
$1,060.15 		$689.46
$742.19
$798.04
$996.48 		$988.29
$1,041.02
$1,096.87
$1,295.31 		$1,287.12
$1,339.85
$1,395.70
$1,594.14 		$298.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.26
$886.72
$998.42
$1,395.30
$2,120.30 		$1,080.09
$1,185.55
$1,297.25
$1,694.13 		$1,378.92
$1,484.38
$1,596.08
$1,992.96 		$1,677.75
$1,783.21
$1,894.91
$2,291.79 		$298.83
Toc - Plan #93 Oscar Insurance Corporation of Ohio
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 		$460.52
$522.68
$588.54
$822.48
$1,249.84 		$812.81
$874.97
$940.83
$1,174.77 		$1,165.10
$1,227.26
$1,293.12
$1,527.06 		$1,517.39
$1,579.55
$1,645.41
$1,879.35 		$352.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.04
$1,045.36
$1,177.08
$1,644.96
$2,499.68 		$1,273.33
$1,397.65
$1,529.37
$1,997.25 		$1,625.62
$1,749.94
$1,881.66
$2,349.54 		$1,977.91
$2,102.23
$2,233.95
$2,701.83 		$352.29
Toc - Plan #94 Oscar Insurance Corporation of Ohio
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 $10,400 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 		$364.84
$414.09
$466.26
$651.59
$990.16 		$643.94
$693.19
$745.36
$930.69 		$923.04
$972.29
$1,024.46
$1,209.79 		$1,202.14
$1,251.39
$1,303.56
$1,488.89 		$279.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.68
$828.18
$932.52
$1,303.18
$1,980.32 		$1,008.78
$1,107.28
$1,211.62
$1,582.28 		$1,287.88
$1,386.38
$1,490.72
$1,861.38 		$1,566.98
$1,665.48
$1,769.82
$2,140.48 		$279.10
Toc - Plan #95 Oscar Insurance Corporation of Ohio
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 		$391.95
$444.86
$500.91
$700.01
$1,063.74 		$691.79
$744.70
$800.75
$999.85 		$991.63
$1,044.54
$1,100.59
$1,299.69 		$1,291.47
$1,344.38
$1,400.43
$1,599.53 		$299.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.90
$889.72
$1,001.82
$1,400.02
$2,127.48 		$1,083.74
$1,189.56
$1,301.66
$1,699.86 		$1,383.58
$1,489.40
$1,601.50
$1,999.70 		$1,683.42
$1,789.24
$1,901.34
$2,299.54 		$299.84
Toc - Plan #96 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite

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

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 		$404.46
$459.05
$516.89
$722.35
$1,097.69 		$713.87
$768.46
$826.30
$1,031.76 		$1,023.28
$1,077.87
$1,135.71
$1,341.17 		$1,332.69
$1,387.28
$1,445.12
$1,650.58 		$309.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.92
$918.10
$1,033.78
$1,444.70
$2,195.38 		$1,118.33
$1,227.51
$1,343.19
$1,754.11 		$1,427.74
$1,536.92
$1,652.60
$2,063.52 		$1,737.15
$1,846.33
$1,962.01
$2,372.93 		$309.41
Toc - Plan #97 Oscar Insurance Corporation of Ohio
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 		$430.84
$488.99
$550.60
$769.47
$1,169.28 		$760.43
$818.58
$880.19
$1,099.06 		$1,090.02
$1,148.17
$1,209.78
$1,428.65 		$1,419.61
$1,477.76
$1,539.37
$1,758.24 		$329.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.68
$977.98
$1,101.20
$1,538.94
$2,338.56 		$1,191.27
$1,307.57
$1,430.79
$1,868.53 		$1,520.86
$1,637.16
$1,760.38
$2,198.12 		$1,850.45
$1,966.75
$2,089.97
$2,527.71 		$329.59
Toc - Plan #98 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic- Low Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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 		$463.96
$526.58
$592.93
$828.62
$1,259.16 		$818.88
$881.50
$947.85
$1,183.54 		$1,173.80
$1,236.42
$1,302.77
$1,538.46 		$1,528.72
$1,591.34
$1,657.69
$1,893.38 		$354.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.92
$1,053.16
$1,185.86
$1,657.24
$2,518.32 		$1,282.84
$1,408.08
$1,540.78
$2,012.16 		$1,637.76
$1,763.00
$1,895.70
$2,367.08 		$1,992.68
$2,117.92
$2,250.62
$2,722.00 		$354.92
Toc - Plan #99 Oscar Insurance Corporation of Ohio
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 		$351.99
$399.50
$449.83
$628.64
$955.28 		$621.26
$668.77
$719.10
$897.91 		$890.53
$938.04
$988.37
$1,167.18 		$1,159.80
$1,207.31
$1,257.64
$1,436.45 		$269.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.98
$799.00
$899.66
$1,257.28
$1,910.56 		$973.25
$1,068.27
$1,168.93
$1,526.55 		$1,242.52
$1,337.54
$1,438.20
$1,795.82 		$1,511.79
$1,606.81
$1,707.47
$2,065.09 		$269.27
Toc - Plan #100 Oscar Insurance Corporation of Ohio
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 		$378.93
$430.07
$484.26
$676.75
$1,028.38 		$668.80
$719.94
$774.13
$966.62 		$958.67
$1,009.81
$1,064.00
$1,256.49 		$1,248.54
$1,299.68
$1,353.87
$1,546.36 		$289.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.86
$860.14
$968.52
$1,353.50
$2,056.76 		$1,047.73
$1,150.01
$1,258.39
$1,643.37 		$1,337.60
$1,439.88
$1,548.26
$1,933.24 		$1,627.47
$1,729.75
$1,838.13
$2,223.11 		$289.87
Toc - Plan #101 Oscar Insurance Corporation of Ohio
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 		$354.14
$401.94
$452.58
$632.48
$961.11 		$625.05
$672.85
$723.49
$903.39 		$895.96
$943.76
$994.40
$1,174.30 		$1,166.87
$1,214.67
$1,265.31
$1,445.21 		$270.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.28
$803.88
$905.16
$1,264.96
$1,922.22 		$979.19
$1,074.79
$1,176.07
$1,535.87 		$1,250.10
$1,345.70
$1,446.98
$1,806.78 		$1,521.01
$1,616.61
$1,717.89
$2,077.69 		$270.91
Toc - Plan #102 Oscar Insurance Corporation of Ohio
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 		$384.23
$436.09
$491.03
$686.22
$1,042.77 		$678.16
$730.02
$784.96
$980.15 		$972.09
$1,023.95
$1,078.89
$1,274.08 		$1,266.02
$1,317.88
$1,372.82
$1,568.01 		$293.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.46
$872.18
$982.06
$1,372.44
$2,085.54 		$1,062.39
$1,166.11
$1,275.99
$1,666.37 		$1,356.32
$1,460.04
$1,569.92
$1,960.30 		$1,650.25
$1,753.97
$1,863.85
$2,254.23 		$293.93
Toc - Plan #103 Oscar Insurance Corporation of Ohio
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 		$425.03
$482.40
$543.18
$759.09
$1,153.51 		$750.17
$807.54
$868.32
$1,084.23 		$1,075.31
$1,132.68
$1,193.46
$1,409.37 		$1,400.45
$1,457.82
$1,518.60
$1,734.51 		$325.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.06
$964.80
$1,086.36
$1,518.18
$2,307.02 		$1,175.20
$1,289.94
$1,411.50
$1,843.32 		$1,500.34
$1,615.08
$1,736.64
$2,168.46 		$1,825.48
$1,940.22
$2,061.78
$2,493.60 		$325.14
Toc - Plan #104 Oscar Insurance Corporation of Ohio
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 		$409.45
$464.71
$523.26
$731.25
$1,111.21 		$722.67
$777.93
$836.48
$1,044.47 		$1,035.89
$1,091.15
$1,149.70
$1,357.69 		$1,349.11
$1,404.37
$1,462.92
$1,670.91 		$313.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.90
$929.42
$1,046.52
$1,462.50
$2,222.42 		$1,132.12
$1,242.64
$1,359.74
$1,775.72 		$1,445.34
$1,555.86
$1,672.96
$2,088.94 		$1,758.56
$1,869.08
$1,986.18
$2,402.16 		$313.22
Toc - Plan #105 Oscar Insurance Corporation of Ohio
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 		$419.52
$476.15
$536.14
$749.25
$1,138.56 		$740.45
$797.08
$857.07
$1,070.18 		$1,061.38
$1,118.01
$1,178.00
$1,391.11 		$1,382.31
$1,438.94
$1,498.93
$1,712.04 		$320.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.04
$952.30
$1,072.28
$1,498.50
$2,277.12 		$1,159.97
$1,273.23
$1,393.21
$1,819.43 		$1,480.90
$1,594.16
$1,714.14
$2,140.36 		$1,801.83
$1,915.09
$2,035.07
$2,461.29 		$320.93
Toc - Plan #106 Oscar Insurance Corporation of Ohio
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 		$430.78
$488.93
$550.53
$769.36
$1,169.12 		$760.32
$818.47
$880.07
$1,098.90 		$1,089.86
$1,148.01
$1,209.61
$1,428.44 		$1,419.40
$1,477.55
$1,539.15
$1,757.98 		$329.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.56
$977.86
$1,101.06
$1,538.72
$2,338.24 		$1,191.10
$1,307.40
$1,430.60
$1,868.26 		$1,520.64
$1,636.94
$1,760.14
$2,197.80 		$1,850.18
$1,966.48
$2,089.68
$2,527.34 		$329.54
Toc - Plan #107 Oscar Insurance Corporation of Ohio
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 		$415.52
$471.61
$531.03
$742.11
$1,127.70 		$733.39
$789.48
$848.90
$1,059.98 		$1,051.26
$1,107.35
$1,166.77
$1,377.85 		$1,369.13
$1,425.22
$1,484.64
$1,695.72 		$317.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.04
$943.22
$1,062.06
$1,484.22
$2,255.40 		$1,148.91
$1,261.09
$1,379.93
$1,802.09 		$1,466.78
$1,578.96
$1,697.80
$2,119.96 		$1,784.65
$1,896.83
$2,015.67
$2,437.83 		$317.87
Toc - Plan #108 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Simple

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
$6,550 $13,100 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 		$443.35
$503.19
$566.58
$791.80
$1,203.22 		$782.50
$842.34
$905.73
$1,130.95 		$1,121.65
$1,181.49
$1,244.88
$1,470.10 		$1,460.80
$1,520.64
$1,584.03
$1,809.25 		$339.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.70
$1,006.38
$1,133.16
$1,583.60
$2,406.44 		$1,225.85
$1,345.53
$1,472.31
$1,922.75 		$1,565.00
$1,684.68
$1,811.46
$2,261.90 		$1,904.15
$2,023.83
$2,150.61
$2,601.05 		$339.15
Toc - Plan #109 Oscar Insurance Corporation of Ohio
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 		$498.68
$565.99
$637.30
$890.62
$1,353.38 		$880.16
$947.47
$1,018.78
$1,272.10 		$1,261.64
$1,328.95
$1,400.26
$1,653.58 		$1,643.12
$1,710.43
$1,781.74
$2,035.06 		$381.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$997.36
$1,131.98
$1,274.60
$1,781.24
$2,706.76 		$1,378.84
$1,513.46
$1,656.08
$2,162.72 		$1,760.32
$1,894.94
$2,037.56
$2,544.20 		$2,141.80
$2,276.42
$2,419.04
$2,925.68 		$381.48
Toc - Plan #110 Oscar Insurance Corporation of Ohio
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 		$478.55
$543.14
$611.57
$854.67
$1,298.75 		$844.63
$909.22
$977.65
$1,220.75 		$1,210.71
$1,275.30
$1,343.73
$1,586.83 		$1,576.79
$1,641.38
$1,709.81
$1,952.91 		$366.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.10
$1,086.28
$1,223.14
$1,709.34
$2,597.50 		$1,323.18
$1,452.36
$1,589.22
$2,075.42 		$1,689.26
$1,818.44
$1,955.30
$2,441.50 		$2,055.34
$2,184.52
$2,321.38
$2,807.58 		$366.08
Toc - Plan #111 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$2,850 $5,700 Annual Deductible
$5,500 $11,000 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 		$456.11
$517.67
$582.90
$814.59
$1,237.85 		$805.03
$866.59
$931.82
$1,163.51 		$1,153.95
$1,215.51
$1,280.74
$1,512.43 		$1,502.87
$1,564.43
$1,629.66
$1,861.35 		$348.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912.22
$1,035.34
$1,165.80
$1,629.18
$2,475.70 		$1,261.14
$1,384.26
$1,514.72
$1,978.10 		$1,610.06
$1,733.18
$1,863.64
$2,327.02 		$1,958.98
$2,082.10
$2,212.56
$2,675.94 		$348.92
Toc - Plan #112 Oscar Insurance Corporation of Ohio
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 		$386.44
$438.59
$493.85
$690.16
$1,048.76 		$682.06
$734.21
$789.47
$985.78 		$977.68
$1,029.83
$1,085.09
$1,281.40 		$1,273.30
$1,325.45
$1,380.71
$1,577.02 		$295.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.88
$877.18
$987.70
$1,380.32
$2,097.52 		$1,068.50
$1,172.80
$1,283.32
$1,675.94 		$1,364.12
$1,468.42
$1,578.94
$1,971.56 		$1,659.74
$1,764.04
$1,874.56
$2,267.18 		$295.62
Toc - Plan #113 Oscar Insurance Corporation of Ohio
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 		$395.70
$449.10
$505.69
$706.69
$1,073.89 		$698.40
$751.80
$808.39
$1,009.39 		$1,001.10
$1,054.50
$1,111.09
$1,312.09 		$1,303.80
$1,357.20
$1,413.79
$1,614.79 		$302.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.40
$898.20
$1,011.38
$1,413.38
$2,147.78 		$1,094.10
$1,200.90
$1,314.08
$1,716.08 		$1,396.80
$1,503.60
$1,616.78
$2,018.78 		$1,699.50
$1,806.30
$1,919.48
$2,321.48 		$302.70
Toc - Plan #114 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 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 		$397.98
$451.70
$508.61
$710.78
$1,080.10 		$702.43
$756.15
$813.06
$1,015.23 		$1,006.88
$1,060.60
$1,117.51
$1,319.68 		$1,311.33
$1,365.05
$1,421.96
$1,624.13 		$304.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.96
$903.40
$1,017.22
$1,421.56
$2,160.20 		$1,100.41
$1,207.85
$1,321.67
$1,726.01 		$1,404.86
$1,512.30
$1,626.12
$2,030.46 		$1,709.31
$1,816.75
$1,930.57
$2,334.91 		$304.45

ADVERTISEMENT

SummaCare

Local: 1-330-996-8675 | Toll Free: 1-888-996-8675 | TTY: 1-800-750-0750
Toc - Plan #115 SummaCare
Catastrophic

(HMO) SummaCare Value with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$195.33
$221.68
$249.61
$348.83
$530.09 		$344.75
$371.10
$399.03
$498.25 		$494.17
$520.52
$548.45
$647.67 		$643.59
$669.94
$697.87
$797.09 		$149.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$390.66
$443.36
$499.22
$697.66
$1,060.18 		$540.08
$592.78
$648.64
$847.08 		$689.50
$742.20
$798.06
$996.50 		$838.92
$891.62
$947.48
$1,145.92 		$149.42
Toc - Plan #116 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 8700 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$260.08
$295.18
$332.38
$464.49
$705.84 		$459.04
$494.14
$531.34
$663.45 		$658.00
$693.10
$730.30
$862.41 		$856.96
$892.06
$929.26
$1,061.37 		$198.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520.16
$590.36
$664.76
$928.98
$1,411.68 		$719.12
$789.32
$863.72
$1,127.94 		$918.08
$988.28
$1,062.68
$1,326.90 		$1,117.04
$1,187.24
$1,261.64
$1,525.86 		$198.96
Toc - Plan #117 SummaCare
Silver

(HMO) SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$363.07
$412.08
$464.00
$648.43
$985.36 		$640.81
$689.82
$741.74
$926.17 		$918.55
$967.56
$1,019.48
$1,203.91 		$1,196.29
$1,245.30
$1,297.22
$1,481.65 		$277.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.14
$824.16
$928.00
$1,296.86
$1,970.72 		$1,003.88
$1,101.90
$1,205.74
$1,574.60 		$1,281.62
$1,379.64
$1,483.48
$1,852.34 		$1,559.36
$1,657.38
$1,761.22
$2,130.08 		$277.74
Toc - Plan #118 SummaCare
Silver

(HMO) SummaCare Silver 5000 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$356.83
$404.99
$456.02
$637.28
$968.42 		$629.80
$677.96
$728.99
$910.25 		$902.77
$950.93
$1,001.96
$1,183.22 		$1,175.74
$1,223.90
$1,274.93
$1,456.19 		$272.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.66
$809.98
$912.04
$1,274.56
$1,936.84 		$986.63
$1,082.95
$1,185.01
$1,547.53 		$1,259.60
$1,355.92
$1,457.98
$1,820.50 		$1,532.57
$1,628.89
$1,730.95
$2,093.47 		$272.97
Toc - Plan #119 SummaCare
Silver

(HMO) SummaCare Silver 5000 40 with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$325.10
$368.98
$415.47
$580.62
$882.30 		$573.80
$617.68
$664.17
$829.32 		$822.50
$866.38
$912.87
$1,078.02 		$1,071.20
$1,115.08
$1,161.57
$1,326.72 		$248.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.20
$737.96
$830.94
$1,161.24
$1,764.60 		$898.90
$986.66
$1,079.64
$1,409.94 		$1,147.60
$1,235.36
$1,328.34
$1,658.64 		$1,396.30
$1,484.06
$1,577.04
$1,907.34 		$248.70
Toc - Plan #120 SummaCare
Gold

(HMO) SummaCare Gold 2000 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$378.68
$429.79
$483.94
$676.30
$1,027.71 		$668.36
$719.47
$773.62
$965.98 		$958.04
$1,009.15
$1,063.30
$1,255.66 		$1,247.72
$1,298.83
$1,352.98
$1,545.34 		$289.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.36
$859.58
$967.88
$1,352.60
$2,055.42 		$1,047.04
$1,149.26
$1,257.56
$1,642.28 		$1,336.72
$1,438.94
$1,547.24
$1,931.96 		$1,626.40
$1,728.62
$1,836.92
$2,221.64 		$289.68
Toc - Plan #121 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$287.13
$325.88
$366.94
$512.80
$779.25 		$506.78
$545.53
$586.59
$732.45 		$726.43
$765.18
$806.24
$952.10 		$946.08
$984.83
$1,025.89
$1,171.75 		$219.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.26
$651.76
$733.88
$1,025.60
$1,558.50 		$793.91
$871.41
$953.53
$1,245.25 		$1,013.56
$1,091.06
$1,173.18
$1,464.90 		$1,233.21
$1,310.71
$1,392.83
$1,684.55 		$219.65
Toc - Plan #122 SummaCare
Silver

(HMO) SummaCare Silver 6000 with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$308.20
$349.79
$393.86
$550.42
$836.42 		$543.96
$585.55
$629.62
$786.18 		$779.72
$821.31
$865.38
$1,021.94 		$1,015.48
$1,057.07
$1,101.14
$1,257.70 		$235.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.40
$699.58
$787.72
$1,100.84
$1,672.84 		$852.16
$935.34
$1,023.48
$1,336.60 		$1,087.92
$1,171.10
$1,259.24
$1,572.36 		$1,323.68
$1,406.86
$1,495.00
$1,808.12 		$235.76
Toc - Plan #123 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 8700 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$259.30
$294.30
$331.38
$463.10
$703.72 		$457.66
$492.66
$529.74
$661.46 		$656.02
$691.02
$728.10
$859.82 		$854.38
$889.38
$926.46
$1,058.18 		$198.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518.60
$588.60
$662.76
$926.20
$1,407.44 		$716.96
$786.96
$861.12
$1,124.56 		$915.32
$985.32
$1,059.48
$1,322.92 		$1,113.68
$1,183.68
$1,257.84
$1,521.28 		$198.36
Toc - Plan #124 SummaCare
Bronze

(HMO) SummaCare Bronze 8000 with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$244.74
$277.77
$312.77
$437.09
$664.20 		$431.96
$464.99
$499.99
$624.31 		$619.18
$652.21
$687.21
$811.53 		$806.40
$839.43
$874.43
$998.75 		$187.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$489.48
$555.54
$625.54
$874.18
$1,328.40 		$676.70
$742.76
$812.76
$1,061.40 		$863.92
$929.98
$999.98
$1,248.62 		$1,051.14
$1,117.20
$1,187.20
$1,435.84 		$187.22
Toc - Plan #125 SummaCare
Silver

(HMO) SummaCare Silver 5000 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$356.05
$404.11
$455.02
$635.89
$966.30 		$628.42
$676.48
$727.39
$908.26 		$900.79
$948.85
$999.76
$1,180.63 		$1,173.16
$1,221.22
$1,272.13
$1,453.00 		$272.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.10
$808.22
$910.04
$1,271.78
$1,932.60 		$984.47
$1,080.59
$1,182.41
$1,544.15 		$1,256.84
$1,352.96
$1,454.78
$1,816.52 		$1,529.21
$1,625.33
$1,727.15
$2,088.89 		$272.37
Toc - Plan #126 SummaCare
Silver

(HMO) SummaCare Silver 5000 40 with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$324.06
$367.80
$414.14
$578.76
$879.48 		$571.96
$615.70
$662.04
$826.66 		$819.86
$863.60
$909.94
$1,074.56 		$1,067.76
$1,111.50
$1,157.84
$1,322.46 		$247.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.12
$735.60
$828.28
$1,157.52
$1,758.96 		$896.02
$983.50
$1,076.18
$1,405.42 		$1,143.92
$1,231.40
$1,324.08
$1,653.32 		$1,391.82
$1,479.30
$1,571.98
$1,901.22 		$247.90
Toc - Plan #127 SummaCare
Gold

(HMO) SummaCare Gold 2000 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$377.64
$428.61
$482.61
$674.44
$1,024.88 		$666.53
$717.50
$771.50
$963.33 		$955.42
$1,006.39
$1,060.39
$1,252.22 		$1,244.31
$1,295.28
$1,349.28
$1,541.11 		$288.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.28
$857.22
$965.22
$1,348.88
$2,049.76 		$1,044.17
$1,146.11
$1,254.11
$1,637.77 		$1,333.06
$1,435.00
$1,543.00
$1,926.66 		$1,621.95
$1,723.89
$1,831.89
$2,215.55 		$288.89
Toc - Plan #128 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 7000 HSA with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$286.09
$324.70
$365.61
$510.94
$776.43 		$504.94
$543.55
$584.46
$729.79 		$723.79
$762.40
$803.31
$948.64 		$942.64
$981.25
$1,022.16
$1,167.49 		$218.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.18
$649.40
$731.22
$1,021.88
$1,552.86 		$791.03
$868.25
$950.07
$1,240.73 		$1,009.88
$1,087.10
$1,168.92
$1,459.58 		$1,228.73
$1,305.95
$1,387.77
$1,678.43 		$218.85
Toc - Plan #129 SummaCare
Silver

(HMO) SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$362.03
$410.90
$462.67
$646.57
$982.53 		$638.98
$687.85
$739.62
$923.52 		$915.93
$964.80
$1,016.57
$1,200.47 		$1,192.88
$1,241.75
$1,293.52
$1,477.42 		$276.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.06
$821.80
$925.34
$1,293.14
$1,965.06 		$1,001.01
$1,098.75
$1,202.29
$1,570.09 		$1,277.96
$1,375.70
$1,479.24
$1,847.04 		$1,554.91
$1,652.65
$1,756.19
$2,123.99 		$276.95
Toc - Plan #130 SummaCare
Silver

(HMO) SummaCare Silver 6000 with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$307.42
$348.91
$392.87
$549.03
$834.31 		$542.59
$584.08
$628.04
$784.20 		$777.76
$819.25
$863.21
$1,019.37 		$1,012.93
$1,054.42
$1,098.38
$1,254.54 		$235.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.84
$697.82
$785.74
$1,098.06
$1,668.62 		$850.01
$932.99
$1,020.91
$1,333.23 		$1,085.18
$1,168.16
$1,256.08
$1,568.40 		$1,320.35
$1,403.33
$1,491.25
$1,803.57 		$235.17
Toc - Plan #131 SummaCare
Bronze

(HMO) SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$245.78
$278.95
$314.09
$438.95
$667.02 		$433.79
$466.96
$502.10
$626.96 		$621.80
$654.97
$690.11
$814.97 		$809.81
$842.98
$878.12
$1,002.98 		$188.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$491.56
$557.90
$628.18
$877.90
$1,334.04 		$679.57
$745.91
$816.19
$1,065.91 		$867.58
$933.92
$1,004.20
$1,253.92 		$1,055.59
$1,121.93
$1,192.21
$1,441.93 		$188.01

ADVERTISEMENT

Molina Healthcare

Local: 1-888-296-7677 | Toll Free: 1-888-296-7677

Toc - Plan #132 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$8,550 $17,100 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 		$340.85
$386.86
$435.61
$608.76
$925.07 		$601.60
$647.61
$696.36
$869.51 		$862.35
$908.36
$957.11
$1,130.26 		$1,123.10
$1,169.11
$1,217.86
$1,391.01 		$260.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.70
$773.72
$871.22
$1,217.52
$1,850.14 		$942.45
$1,034.47
$1,131.97
$1,478.27 		$1,203.20
$1,295.22
$1,392.72
$1,739.02 		$1,463.95
$1,555.97
$1,653.47
$1,999.77 		$260.75
Toc - Plan #133 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$290.98
$330.27
$371.88
$519.70
$789.73 		$513.58
$552.87
$594.48
$742.30 		$736.18
$775.47
$817.08
$964.90 		$958.78
$998.07
$1,039.68
$1,187.50 		$222.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.96
$660.54
$743.76
$1,039.40
$1,579.46 		$804.56
$883.14
$966.36
$1,262.00 		$1,027.16
$1,105.74
$1,188.96
$1,484.60 		$1,249.76
$1,328.34
$1,411.56
$1,707.20 		$222.60
Toc - Plan #134 Molina Healthcare
Silver

(HMO) Constant Care Silver 4 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 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 		$288.58
$327.54
$368.81
$515.41
$783.21 		$509.35
$548.31
$589.58
$736.18 		$730.12
$769.08
$810.35
$956.95 		$950.89
$989.85
$1,031.12
$1,177.72 		$220.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.16
$655.08
$737.62
$1,030.82
$1,566.42 		$797.93
$875.85
$958.39
$1,251.59 		$1,018.70
$1,096.62
$1,179.16
$1,472.36 		$1,239.47
$1,317.39
$1,399.93
$1,693.13 		$220.77
Toc - Plan #135 Molina Healthcare
Silver

(HMO) Constant Care Silver 7 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 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 		$283.69
$321.99
$362.55
$506.67
$769.93 		$500.71
$539.01
$579.57
$723.69 		$717.73
$756.03
$796.59
$940.71 		$934.75
$973.05
$1,013.61
$1,157.73 		$217.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.38
$643.98
$725.10
$1,013.34
$1,539.86 		$784.40
$861.00
$942.12
$1,230.36 		$1,001.42
$1,078.02
$1,159.14
$1,447.38 		$1,218.44
$1,295.04
$1,376.16
$1,664.40 		$217.02
Toc - Plan #136 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$8,550 $17,100 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 		$344.71
$391.25
$440.54
$615.66
$935.55 		$608.42
$654.96
$704.25
$879.37 		$872.13
$918.67
$967.96
$1,143.08 		$1,135.84
$1,182.38
$1,231.67
$1,406.79 		$263.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.42
$782.50
$881.08
$1,231.32
$1,871.10 		$953.13
$1,046.21
$1,144.79
$1,495.03 		$1,216.84
$1,309.92
$1,408.50
$1,758.74 		$1,480.55
$1,573.63
$1,672.21
$2,022.45 		$263.71
Toc - Plan #137 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$293.52
$333.14
$375.11
$524.22
$796.60 		$518.06
$557.68
$599.65
$748.76 		$742.60
$782.22
$824.19
$973.30 		$967.14
$1,006.76
$1,048.73
$1,197.84 		$224.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.04
$666.28
$750.22
$1,048.44
$1,593.20 		$811.58
$890.82
$974.76
$1,272.98 		$1,036.12
$1,115.36
$1,199.30
$1,497.52 		$1,260.66
$1,339.90
$1,423.84
$1,722.06 		$224.54
Toc - Plan #138 Molina Healthcare
Silver

(HMO) Constant Care Silver 2 250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 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 		$290.28
$329.46
$370.97
$518.43
$787.81 		$512.34
$551.52
$593.03
$740.49 		$734.40
$773.58
$815.09
$962.55 		$956.46
$995.64
$1,037.15
$1,184.61 		$222.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.56
$658.92
$741.94
$1,036.86
$1,575.62 		$802.62
$880.98
$964.00
$1,258.92 		$1,024.68
$1,103.04
$1,186.06
$1,480.98 		$1,246.74
$1,325.10
$1,408.12
$1,703.04 		$222.06

ADVERTISEMENT

CareSource

Local: 1-800-479-9502 | Toll Free: 1-800-479-9502 | TTY: 1-800-750-0750
Toc - Plan #139 CareSource
Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 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 		$305.43
$346.66
$390.34
$545.49
$828.93 		$539.08
$580.31
$623.99
$779.14 		$772.73
$813.96
$857.64
$1,012.79 		$1,006.38
$1,047.61
$1,091.29
$1,246.44 		$233.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.86
$693.32
$780.68
$1,090.98
$1,657.86 		$844.51
$926.97
$1,014.33
$1,324.63 		$1,078.16
$1,160.62
$1,247.98
$1,558.28 		$1,311.81
$1,394.27
$1,481.63
$1,791.93 		$233.65
Toc - Plan #140 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

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 		$373.47
$423.89
$477.29
$667.01
$1,013.59 		$659.17
$709.59
$762.99
$952.71 		$944.87
$995.29
$1,048.69
$1,238.41 		$1,230.57
$1,280.99
$1,334.39
$1,524.11 		$285.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.94
$847.78
$954.58
$1,334.02
$2,027.18 		$1,032.64
$1,133.48
$1,240.28
$1,619.72 		$1,318.34
$1,419.18
$1,525.98
$1,905.42 		$1,604.04
$1,704.88
$1,811.68
$2,191.12 		$285.70
Toc - Plan #141 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$509.26
$578.01
$650.83
$909.54
$1,382.13 		$898.84
$967.59
$1,040.41
$1,299.12 		$1,288.42
$1,357.17
$1,429.99
$1,688.70 		$1,678.00
$1,746.75
$1,819.57
$2,078.28 		$389.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,018.52
$1,156.02
$1,301.66
$1,819.08
$2,764.26 		$1,408.10
$1,545.60
$1,691.24
$2,208.66 		$1,797.68
$1,935.18
$2,080.82
$2,598.24 		$2,187.26
$2,324.76
$2,470.40
$2,987.82 		$389.58
Toc - Plan #142 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$7,900 $15,800 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 		$394.88
$448.18
$504.65
$705.24
$1,071.69 		$696.96
$750.26
$806.73
$1,007.32 		$999.04
$1,052.34
$1,108.81
$1,309.40 		$1,301.12
$1,354.42
$1,410.89
$1,611.48 		$302.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.76
$896.36
$1,009.30
$1,410.48
$2,143.38 		$1,091.84
$1,198.44
$1,311.38
$1,712.56 		$1,393.92
$1,500.52
$1,613.46
$2,014.64 		$1,696.00
$1,802.60
$1,915.54
$2,316.72 		$302.08
Toc - Plan #143 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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 		$270.35
$306.84
$345.50
$482.84
$733.72 		$477.17
$513.66
$552.32
$689.66 		$683.99
$720.48
$759.14
$896.48 		$890.81
$927.30
$965.96
$1,103.30 		$206.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.70
$613.68
$691.00
$965.68
$1,467.44 		$747.52
$820.50
$897.82
$1,172.50 		$954.34
$1,027.32
$1,104.64
$1,379.32 		$1,161.16
$1,234.14
$1,311.46
$1,586.14 		$206.82
Toc - Plan #144 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,100 $10,200 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 		$408.01
$463.09
$521.43
$728.70
$1,107.33 		$720.13
$775.21
$833.55
$1,040.82 		$1,032.25
$1,087.33
$1,145.67
$1,352.94 		$1,344.37
$1,399.45
$1,457.79
$1,665.06 		$312.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.02
$926.18
$1,042.86
$1,457.40
$2,214.66 		$1,128.14
$1,238.30
$1,354.98
$1,769.52 		$1,440.26
$1,550.42
$1,667.10
$2,081.64 		$1,752.38
$1,862.54
$1,979.22
$2,393.76 		$312.12
Toc - Plan #145 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

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 		$256.87
$291.54
$328.27
$458.76
$697.13 		$453.37
$488.04
$524.77
$655.26 		$649.87
$684.54
$721.27
$851.76 		$846.37
$881.04
$917.77
$1,048.26 		$196.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$513.74
$583.08
$656.54
$917.52
$1,394.26 		$710.24
$779.58
$853.04
$1,114.02 		$906.74
$976.08
$1,049.54
$1,310.52 		$1,103.24
$1,172.58
$1,246.04
$1,507.02 		$196.50
Toc - Plan #146 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

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 		$380.34
$431.68
$486.07
$679.28
$1,032.23 		$671.30
$722.64
$777.03
$970.24 		$962.26
$1,013.60
$1,067.99
$1,261.20 		$1,253.22
$1,304.56
$1,358.95
$1,552.16 		$290.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.68
$863.36
$972.14
$1,358.56
$2,064.46 		$1,051.64
$1,154.32
$1,263.10
$1,649.52 		$1,342.60
$1,445.28
$1,554.06
$1,940.48 		$1,633.56
$1,736.24
$1,845.02
$2,231.44 		$290.96
Toc - Plan #147 CareSource
Gold

(HMO) CareSource Marketplace Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$517.57
$587.43
$661.44
$924.37
$1,404.66 		$913.50
$983.36
$1,057.37
$1,320.30 		$1,309.43
$1,379.29
$1,453.30
$1,716.23 		$1,705.36
$1,775.22
$1,849.23
$2,112.16 		$395.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,035.14
$1,174.86
$1,322.88
$1,848.74
$2,809.32 		$1,431.07
$1,570.79
$1,718.81
$2,244.67 		$1,827.00
$1,966.72
$2,114.74
$2,640.60 		$2,222.93
$2,362.65
$2,510.67
$3,036.53 		$395.93
Toc - Plan #148 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$7,900 $15,800 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 		$401.74
$455.98
$513.42
$717.51
$1,090.32 		$709.07
$763.31
$820.75
$1,024.84 		$1,016.40
$1,070.64
$1,128.08
$1,332.17 		$1,323.73
$1,377.97
$1,435.41
$1,639.50 		$307.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.48
$911.96
$1,026.84
$1,435.02
$2,180.64 		$1,110.81
$1,219.29
$1,334.17
$1,742.35 		$1,418.14
$1,526.62
$1,641.50
$2,049.68 		$1,725.47
$1,833.95
$1,948.83
$2,357.01 		$307.33
Toc - Plan #149 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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 		$276.32
$313.62
$353.14
$493.51
$749.93 		$487.71
$525.01
$564.53
$704.90 		$699.10
$736.40
$775.92
$916.29 		$910.49
$947.79
$987.31
$1,127.68 		$211.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.64
$627.24
$706.28
$987.02
$1,499.86 		$764.03
$838.63
$917.67
$1,198.41 		$975.42
$1,050.02
$1,129.06
$1,409.80 		$1,186.81
$1,261.41
$1,340.45
$1,621.19 		$211.39
Toc - Plan #150 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,100 $10,200 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 		$414.88
$470.88
$530.21
$740.96
$1,125.96 		$732.26
$788.26
$847.59
$1,058.34 		$1,049.64
$1,105.64
$1,164.97
$1,375.72 		$1,367.02
$1,423.02
$1,482.35
$1,693.10 		$317.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.76
$941.76
$1,060.42
$1,481.92
$2,251.92 		$1,147.14
$1,259.14
$1,377.80
$1,799.30 		$1,464.52
$1,576.52
$1,695.18
$2,116.68 		$1,781.90
$1,893.90
$2,012.56
$2,434.06 		$317.38
Toc - Plan #151 CareSource
Bronze

(HMO) CareSource Marketplace Bronze Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

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 		$262.54
$297.98
$335.52
$468.89
$712.52 		$463.38
$498.82
$536.36
$669.73 		$664.22
$699.66
$737.20
$870.57 		$865.06
$900.50
$938.04
$1,071.41 		$200.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.08
$595.96
$671.04
$937.78
$1,425.04 		$725.92
$796.80
$871.88
$1,138.62 		$926.76
$997.64
$1,072.72
$1,339.46 		$1,127.60
$1,198.48
$1,273.56
$1,540.30 		$200.84

ADVERTISEMENT

MedMutual

Local: 1-888-308-0357 | Toll Free: 1-888-308-0357

Toc - Plan #152 MedMutual
Silver

(HMO) Market HMO 3000 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$398.02
$451.75
$508.67
$710.87
$1,080.23 		$702.51
$756.24
$813.16
$1,015.36 		$1,007.00
$1,060.73
$1,117.65
$1,319.85 		$1,311.49
$1,365.22
$1,422.14
$1,624.34 		$304.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.04
$903.50
$1,017.34
$1,421.74
$2,160.46 		$1,100.53
$1,207.99
$1,321.83
$1,726.23 		$1,405.02
$1,512.48
$1,626.32
$2,030.72 		$1,709.51
$1,816.97
$1,930.81
$2,335.21 		$304.49
Toc - Plan #153 MedMutual
Silver

(HMO) Market HMO 4000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$376.88
$427.76
$481.66
$673.12
$1,022.86 		$665.20
$716.08
$769.98
$961.44 		$953.52
$1,004.40
$1,058.30
$1,249.76 		$1,241.84
$1,292.72
$1,346.62
$1,538.08 		$288.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.76
$855.52
$963.32
$1,346.24
$2,045.72 		$1,042.08
$1,143.84
$1,251.64
$1,634.56 		$1,330.40
$1,432.16
$1,539.96
$1,922.88 		$1,618.72
$1,720.48
$1,828.28
$2,211.20 		$288.32
Toc - Plan #154 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$298.29
$338.56
$381.22
$532.75
$809.57 		$526.48
$566.75
$609.41
$760.94 		$754.67
$794.94
$837.60
$989.13 		$982.86
$1,023.13
$1,065.79
$1,217.32 		$228.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.58
$677.12
$762.44
$1,065.50
$1,619.14 		$824.77
$905.31
$990.63
$1,293.69 		$1,052.96
$1,133.50
$1,218.82
$1,521.88 		$1,281.15
$1,361.69
$1,447.01
$1,750.07 		$228.19
Toc - Plan #155 MedMutual
Bronze

(HMO) Market HMO 8700 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$287.87
$326.74
$367.90
$514.14
$781.29 		$508.09
$546.96
$588.12
$734.36 		$728.31
$767.18
$808.34
$954.58 		$948.53
$987.40
$1,028.56
$1,174.80 		$220.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.74
$653.48
$735.80
$1,028.28
$1,562.58 		$795.96
$873.70
$956.02
$1,248.50 		$1,016.18
$1,093.92
$1,176.24
$1,468.72 		$1,236.40
$1,314.14
$1,396.46
$1,688.94 		$220.22
Toc - Plan #156 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$178.32
$202.39
$227.89
$318.48
$483.96 		$314.74
$338.81
$364.31
$454.90 		$451.16
$475.23
$500.73
$591.32 		$587.58
$611.65
$637.15
$727.74 		$136.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$356.64
$404.78
$455.78
$636.96
$967.92 		$493.06
$541.20
$592.20
$773.38 		$629.48
$677.62
$728.62
$909.80 		$765.90
$814.04
$865.04
$1,046.22 		$136.42
Toc - Plan #157 MedMutual
Silver

(HMO) Market HMO 6500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$397.72
$451.42
$508.29
$710.33
$1,079.42 		$701.98
$755.68
$812.55
$1,014.59 		$1,006.24
$1,059.94
$1,116.81
$1,318.85 		$1,310.50
$1,364.20
$1,421.07
$1,623.11 		$304.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.44
$902.84
$1,016.58
$1,420.66
$2,158.84 		$1,099.70
$1,207.10
$1,320.84
$1,724.92 		$1,403.96
$1,511.36
$1,625.10
$2,029.18 		$1,708.22
$1,815.62
$1,929.36
$2,333.44 		$304.26
Toc - Plan #158 MedMutual
Expanded Bronze

(HMO) Market HMO $0 Deductible Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$337.89
$383.50
$431.82
$603.46
$917.02 		$596.37
$641.98
$690.30
$861.94 		$854.85
$900.46
$948.78
$1,120.42 		$1,113.33
$1,158.94
$1,207.26
$1,378.90 		$258.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.78
$767.00
$863.64
$1,206.92
$1,834.04 		$934.26
$1,025.48
$1,122.12
$1,465.40 		$1,192.74
$1,283.96
$1,380.60
$1,723.88 		$1,451.22
$1,542.44
$1,639.08
$1,982.36 		$258.48
Toc - Plan #159 MedMutual
Silver

(HMO) Market HMO $0 Deductible Silver - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$411.72
$467.30
$526.17
$735.32
$1,117.39 		$726.68
$782.26
$841.13
$1,050.28 		$1,041.64
$1,097.22
$1,156.09
$1,365.24 		$1,356.60
$1,412.18
$1,471.05
$1,680.20 		$314.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.44
$934.60
$1,052.34
$1,470.64
$2,234.78 		$1,138.40
$1,249.56
$1,367.30
$1,785.60 		$1,453.36
$1,564.52
$1,682.26
$2,100.56 		$1,768.32
$1,879.48
$1,997.22
$2,415.52 		$314.96
Toc - Plan #160 MedMutual
Expanded Bronze

(HMO) Market HMO 8000 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$288.77
$327.75
$369.04
$515.74
$783.71 		$509.68
$548.66
$589.95
$736.65 		$730.59
$769.57
$810.86
$957.56 		$951.50
$990.48
$1,031.77
$1,178.47 		$220.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.54
$655.50
$738.08
$1,031.48
$1,567.42 		$798.45
$876.41
$958.99
$1,252.39 		$1,019.36
$1,097.32
$1,179.90
$1,473.30 		$1,240.27
$1,318.23
$1,400.81
$1,694.21 		$220.91
Toc - Plan #161 MedMutual
Gold

(HMO) Market HMO 2500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,750 $11,500 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 		$517.10
$586.91
$660.85
$923.54
$1,403.41 		$912.68
$982.49
$1,056.43
$1,319.12 		$1,308.26
$1,378.07
$1,452.01
$1,714.70 		$1,703.84
$1,773.65
$1,847.59
$2,110.28 		$395.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,034.20
$1,173.82
$1,321.70
$1,847.08
$2,806.82 		$1,429.78
$1,569.40
$1,717.28
$2,242.66 		$1,825.36
$1,964.98
$2,112.86
$2,638.24 		$2,220.94
$2,360.56
$2,508.44
$3,033.82 		$395.58

‡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 Stark County here.

Stark County is in “Rating Area 15” of Ohio.

Currently, there are 161 plans offered in Rating Area 15.

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2022 Obamacare Plans for Stark County, OH

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