Obamacare 2023 Rates for Caldwell County

Obamacare > Rates > North Carolina > Caldwell County

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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 Lenoir, NC.

The health insurance rates listed below are for calendar year 2023.

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, 102 Plans and 2023 Rates for Caldwell County, North Carolina

Below, you’ll find a summary of the 102 plans for Caldwell County, North Carolina 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

Caldwell County Resources

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Blue Cross and Blue Shield of NC

Local: 1-800-324-4973 | Toll Free: 1-800-324-4973

Toc - Plan #1 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Simple | $0 Deductible | 3 Free PCP | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$557.22
$632.44
$712.13
$995.19
$1,512.30 		$983.49
$1,058.71
$1,138.40
$1,421.46 		$1,409.76
$1,484.98
$1,564.67
$1,847.73 		$1,836.03
$1,911.25
$1,990.94
$2,274.00 		$426.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,114.44
$1,264.88
$1,424.26
$1,990.38
$3,024.60 		$1,540.71
$1,691.15
$1,850.53
$2,416.65 		$1,966.98
$2,117.42
$2,276.80
$2,842.92 		$2,393.25
$2,543.69
$2,703.07
$3,269.19 		$426.27
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 Annual Deductible
$9,100 $18,200 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 		$515.92
$585.57
$659.35
$921.43
$1,400.21 		$910.60
$980.25
$1,054.03
$1,316.11 		$1,305.28
$1,374.93
$1,448.71
$1,710.79 		$1,699.96
$1,769.61
$1,843.39
$2,105.47 		$394.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,031.84
$1,171.14
$1,318.70
$1,842.86
$2,800.42 		$1,426.52
$1,565.82
$1,713.38
$2,237.54 		$1,821.20
$1,960.50
$2,108.06
$2,632.22 		$2,215.88
$2,355.18
$2,502.74
$3,026.90 		$394.68
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 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 		$536.46
$608.88
$685.60
$958.12
$1,455.95 		$946.85
$1,019.27
$1,095.99
$1,368.51 		$1,357.24
$1,429.66
$1,506.38
$1,778.90 		$1,767.63
$1,840.05
$1,916.77
$2,189.29 		$410.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,072.92
$1,217.76
$1,371.20
$1,916.24
$2,911.90 		$1,483.31
$1,628.15
$1,781.59
$2,326.63 		$1,893.70
$2,038.54
$2,191.98
$2,737.02 		$2,304.09
$2,448.93
$2,602.37
$3,147.41 		$410.39
Toc - Plan #4 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 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 		$376.60
$427.44
$481.29
$672.61
$1,022.09 		$664.70
$715.54
$769.39
$960.71 		$952.80
$1,003.64
$1,057.49
$1,248.81 		$1,240.90
$1,291.74
$1,345.59
$1,536.91 		$288.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.20
$854.88
$962.58
$1,345.22
$2,044.18 		$1,041.30
$1,142.98
$1,250.68
$1,633.32 		$1,329.40
$1,431.08
$1,538.78
$1,921.42 		$1,617.50
$1,719.18
$1,826.88
$2,209.52 		$288.10
Toc - Plan #5 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$9,100 $18,200 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 		$530.04
$601.60
$677.39
$946.65
$1,438.53 		$935.52
$1,007.08
$1,082.87
$1,352.13 		$1,341.00
$1,412.56
$1,488.35
$1,757.61 		$1,746.48
$1,818.04
$1,893.83
$2,163.09 		$405.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,060.08
$1,203.20
$1,354.78
$1,893.30
$2,877.06 		$1,465.56
$1,608.68
$1,760.26
$2,298.78 		$1,871.04
$2,014.16
$2,165.74
$2,704.26 		$2,276.52
$2,419.64
$2,571.22
$3,109.74 		$405.48
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 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 		$544.83
$618.38
$696.29
$973.07
$1,478.67 		$961.62
$1,035.17
$1,113.08
$1,389.86 		$1,378.41
$1,451.96
$1,529.87
$1,806.65 		$1,795.20
$1,868.75
$1,946.66
$2,223.44 		$416.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,089.66
$1,236.76
$1,392.58
$1,946.14
$2,957.34 		$1,506.45
$1,653.55
$1,809.37
$2,362.93 		$1,923.24
$2,070.34
$2,226.16
$2,779.72 		$2,340.03
$2,487.13
$2,642.95
$3,196.51 		$416.79
Toc - Plan #7 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$395.19
$448.54
$505.05
$705.81
$1,072.55 		$697.51
$750.86
$807.37
$1,008.13 		$999.83
$1,053.18
$1,109.69
$1,310.45 		$1,302.15
$1,355.50
$1,412.01
$1,612.77 		$302.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.38
$897.08
$1,010.10
$1,411.62
$2,145.10 		$1,092.70
$1,199.40
$1,312.42
$1,713.94 		$1,395.02
$1,501.72
$1,614.74
$2,016.26 		$1,697.34
$1,804.04
$1,917.06
$2,318.58 		$302.32
Toc - Plan #8 Blue Cross and Blue Shield of NC
Catastrophic

(PPO) Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$276.72
$314.08
$353.65
$494.22
$751.02 		$488.41
$525.77
$565.34
$705.91 		$700.10
$737.46
$777.03
$917.60 		$911.79
$949.15
$988.72
$1,129.29 		$211.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.44
$628.16
$707.30
$988.44
$1,502.04 		$765.13
$839.85
$918.99
$1,200.13 		$976.82
$1,051.54
$1,130.68
$1,411.82 		$1,188.51
$1,263.23
$1,342.37
$1,623.51 		$211.69
Toc - Plan #9 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 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 		$538.63
$611.35
$688.37
$961.99
$1,461.84 		$950.68
$1,023.40
$1,100.42
$1,374.04 		$1,362.73
$1,435.45
$1,512.47
$1,786.09 		$1,774.78
$1,847.50
$1,924.52
$2,198.14 		$412.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,077.26
$1,222.70
$1,376.74
$1,923.98
$2,923.68 		$1,489.31
$1,634.75
$1,788.79
$2,336.03 		$1,901.36
$2,046.80
$2,200.84
$2,748.08 		$2,313.41
$2,458.85
$2,612.89
$3,160.13 		$412.05
Toc - Plan #10 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 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 		$397.97
$451.70
$508.61
$710.77
$1,080.09 		$702.42
$756.15
$813.06
$1,015.22 		$1,006.87
$1,060.60
$1,117.51
$1,319.67 		$1,311.32
$1,365.05
$1,421.96
$1,624.12 		$304.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.94
$903.40
$1,017.22
$1,421.54
$2,160.18 		$1,100.39
$1,207.85
$1,321.67
$1,725.99 		$1,404.84
$1,512.30
$1,626.12
$2,030.44 		$1,709.29
$1,816.75
$1,930.57
$2,334.89 		$304.45
Toc - Plan #11 Blue Cross and Blue Shield of NC
Bronze

(PPO) Blue Advantage Bronze 9100 | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$377.32
$428.26
$482.21
$673.89
$1,024.05 		$665.97
$716.91
$770.86
$962.54 		$954.62
$1,005.56
$1,059.51
$1,251.19 		$1,243.27
$1,294.21
$1,348.16
$1,539.84 		$288.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.64
$856.52
$964.42
$1,347.78
$2,048.10 		$1,043.29
$1,145.17
$1,253.07
$1,636.43 		$1,331.94
$1,433.82
$1,541.72
$1,925.08 		$1,620.59
$1,722.47
$1,830.37
$2,213.73 		$288.65
Toc - Plan #12 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold Standard 2000 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$528.09
$599.38
$674.90
$943.17
$1,433.24 		$932.08
$1,003.37
$1,078.89
$1,347.16 		$1,336.07
$1,407.36
$1,482.88
$1,751.15 		$1,740.06
$1,811.35
$1,886.87
$2,155.14 		$403.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,056.18
$1,198.76
$1,349.80
$1,886.34
$2,866.48 		$1,460.17
$1,602.75
$1,753.79
$2,290.33 		$1,864.16
$2,006.74
$2,157.78
$2,694.32 		$2,268.15
$2,410.73
$2,561.77
$3,098.31 		$403.99
Toc - Plan #13 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Standard 5800 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$534.22
$606.34
$682.73
$954.12
$1,449.87 		$942.90
$1,015.02
$1,091.41
$1,362.80 		$1,351.58
$1,423.70
$1,500.09
$1,771.48 		$1,760.26
$1,832.38
$1,908.77
$2,180.16 		$408.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,068.44
$1,212.68
$1,365.46
$1,908.24
$2,899.74 		$1,477.12
$1,621.36
$1,774.14
$2,316.92 		$1,885.80
$2,030.04
$2,182.82
$2,725.60 		$2,294.48
$2,438.72
$2,591.50
$3,134.28 		$408.68
Toc - Plan #14 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze Standard 7500 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$377.04
$427.94
$481.86
$673.39
$1,023.29 		$665.48
$716.38
$770.30
$961.83 		$953.92
$1,004.82
$1,058.74
$1,250.27 		$1,242.36
$1,293.26
$1,347.18
$1,538.71 		$288.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.08
$855.88
$963.72
$1,346.78
$2,046.58 		$1,042.52
$1,144.32
$1,252.16
$1,635.22 		$1,330.96
$1,432.76
$1,540.60
$1,923.66 		$1,619.40
$1,721.20
$1,829.04
$2,212.10 		$288.44
Toc - Plan #15 Blue Cross and Blue Shield of NC
Bronze

(POS) Blue Value Bronze 9100 | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$331.61
$376.38
$423.80
$592.26
$899.99 		$585.29
$630.06
$677.48
$845.94 		$838.97
$883.74
$931.16
$1,099.62 		$1,092.65
$1,137.42
$1,184.84
$1,353.30 		$253.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.22
$752.76
$847.60
$1,184.52
$1,799.98 		$916.90
$1,006.44
$1,101.28
$1,438.20 		$1,170.58
$1,260.12
$1,354.96
$1,691.88 		$1,424.26
$1,513.80
$1,608.64
$1,945.56 		$253.68
Toc - Plan #16 Blue Cross and Blue Shield of NC
Gold

(POS) Blue Value Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$9,100 $18,200 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 		$465.80
$528.68
$595.29
$831.92
$1,264.18 		$822.14
$885.02
$951.63
$1,188.26 		$1,178.48
$1,241.36
$1,307.97
$1,544.60 		$1,534.82
$1,597.70
$1,664.31
$1,900.94 		$356.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$931.60
$1,057.36
$1,190.58
$1,663.84
$2,528.36 		$1,287.94
$1,413.70
$1,546.92
$2,020.18 		$1,644.28
$1,770.04
$1,903.26
$2,376.52 		$2,000.62
$2,126.38
$2,259.60
$2,732.86 		$356.34
Toc - Plan #17 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze 7500 | HSA Eligible | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$347.29
$394.17
$443.84
$620.26
$942.55 		$612.97
$659.85
$709.52
$885.94 		$878.65
$925.53
$975.20
$1,151.62 		$1,144.33
$1,191.21
$1,240.88
$1,417.30 		$265.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.58
$788.34
$887.68
$1,240.52
$1,885.10 		$960.26
$1,054.02
$1,153.36
$1,506.20 		$1,225.94
$1,319.70
$1,419.04
$1,771.88 		$1,491.62
$1,585.38
$1,684.72
$2,037.56 		$265.68
Toc - Plan #18 Blue Cross and Blue Shield of NC
Catastrophic

(POS) Blue Value Catastrophic 9100 | 3 PCP $35 | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$243.21
$276.04
$310.82
$434.37
$660.07 		$429.27
$462.10
$496.88
$620.43 		$615.33
$648.16
$682.94
$806.49 		$801.39
$834.22
$869.00
$992.55 		$186.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.42
$552.08
$621.64
$868.74
$1,320.14 		$672.48
$738.14
$807.70
$1,054.80 		$858.54
$924.20
$993.76
$1,240.86 		$1,044.60
$1,110.26
$1,179.82
$1,426.92 		$186.06
Toc - Plan #19 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 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 		$473.34
$537.24
$604.93
$845.39
$1,284.64 		$835.45
$899.35
$967.04
$1,207.50 		$1,197.56
$1,261.46
$1,329.15
$1,569.61 		$1,559.67
$1,623.57
$1,691.26
$1,931.72 		$362.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946.68
$1,074.48
$1,209.86
$1,690.78
$2,569.28 		$1,308.79
$1,436.59
$1,571.97
$2,052.89 		$1,670.90
$1,798.70
$1,934.08
$2,415.00 		$2,033.01
$2,160.81
$2,296.19
$2,777.11 		$362.11
Toc - Plan #20 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 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 		$349.75
$396.97
$446.98
$624.65
$949.22 		$617.31
$664.53
$714.54
$892.21 		$884.87
$932.09
$982.10
$1,159.77 		$1,152.43
$1,199.65
$1,249.66
$1,427.33 		$267.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.50
$793.94
$893.96
$1,249.30
$1,898.44 		$967.06
$1,061.50
$1,161.52
$1,516.86 		$1,234.62
$1,329.06
$1,429.08
$1,784.42 		$1,502.18
$1,596.62
$1,696.64
$2,051.98 		$267.56
Toc - Plan #21 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 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 		$478.83
$543.47
$611.94
$855.19
$1,299.54 		$845.13
$909.77
$978.24
$1,221.49 		$1,211.43
$1,276.07
$1,344.54
$1,587.79 		$1,577.73
$1,642.37
$1,710.84
$1,954.09 		$366.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.66
$1,086.94
$1,223.88
$1,710.38
$2,599.08 		$1,323.96
$1,453.24
$1,590.18
$2,076.68 		$1,690.26
$1,819.54
$1,956.48
$2,442.98 		$2,056.56
$2,185.84
$2,322.78
$2,809.28 		$366.30
Toc - Plan #22 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Simple | $0 Deductible | 3 Free PCP | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$489.72
$555.83
$625.86
$874.64
$1,329.10 		$864.36
$930.47
$1,000.50
$1,249.28 		$1,239.00
$1,305.11
$1,375.14
$1,623.92 		$1,613.64
$1,679.75
$1,749.78
$1,998.56 		$374.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$979.44
$1,111.66
$1,251.72
$1,749.28
$2,658.20 		$1,354.08
$1,486.30
$1,626.36
$2,123.92 		$1,728.72
$1,860.94
$2,001.00
$2,498.56 		$2,103.36
$2,235.58
$2,375.64
$2,873.20 		$374.64
Toc - Plan #23 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 Annual Deductible
$9,100 $18,200 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 		$453.45
$514.67
$579.51
$809.86
$1,230.66 		$800.34
$861.56
$926.40
$1,156.75 		$1,147.23
$1,208.45
$1,273.29
$1,503.64 		$1,494.12
$1,555.34
$1,620.18
$1,850.53 		$346.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906.90
$1,029.34
$1,159.02
$1,619.72
$2,461.32 		$1,253.79
$1,376.23
$1,505.91
$1,966.61 		$1,600.68
$1,723.12
$1,852.80
$2,313.50 		$1,947.57
$2,070.01
$2,199.69
$2,660.39 		$346.89
Toc - Plan #24 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 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 		$471.44
$535.08
$602.50
$841.99
$1,279.49 		$832.09
$895.73
$963.15
$1,202.64 		$1,192.74
$1,256.38
$1,323.80
$1,563.29 		$1,553.39
$1,617.03
$1,684.45
$1,923.94 		$360.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.88
$1,070.16
$1,205.00
$1,683.98
$2,558.98 		$1,303.53
$1,430.81
$1,565.65
$2,044.63 		$1,664.18
$1,791.46
$1,926.30
$2,405.28 		$2,024.83
$2,152.11
$2,286.95
$2,765.93 		$360.65
Toc - Plan #25 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 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 		$330.96
$375.64
$422.97
$591.09
$898.23 		$584.14
$628.82
$676.15
$844.27 		$837.32
$882.00
$929.33
$1,097.45 		$1,090.50
$1,135.18
$1,182.51
$1,350.63 		$253.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$661.92
$751.28
$845.94
$1,182.18
$1,796.46 		$915.10
$1,004.46
$1,099.12
$1,435.36 		$1,168.28
$1,257.64
$1,352.30
$1,688.54 		$1,421.46
$1,510.82
$1,605.48
$1,941.72 		$253.18
Toc - Plan #26 Blue Cross and Blue Shield of NC
Gold

(POS) Blue Value Gold Standard 2000 | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$464.04
$526.69
$593.04
$828.78
$1,259.40 		$819.03
$881.68
$948.03
$1,183.77 		$1,174.02
$1,236.67
$1,303.02
$1,538.76 		$1,529.01
$1,591.66
$1,658.01
$1,893.75 		$354.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$928.08
$1,053.38
$1,186.08
$1,657.56
$2,518.80 		$1,283.07
$1,408.37
$1,541.07
$2,012.55 		$1,638.06
$1,763.36
$1,896.06
$2,367.54 		$1,993.05
$2,118.35
$2,251.05
$2,722.53 		$354.99
Toc - Plan #27 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Standard 5800 | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$469.49
$532.87
$600.01
$838.51
$1,274.20 		$828.65
$892.03
$959.17
$1,197.67 		$1,187.81
$1,251.19
$1,318.33
$1,556.83 		$1,546.97
$1,610.35
$1,677.49
$1,915.99 		$359.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$938.98
$1,065.74
$1,200.02
$1,677.02
$2,548.40 		$1,298.14
$1,424.90
$1,559.18
$2,036.18 		$1,657.30
$1,784.06
$1,918.34
$2,395.34 		$2,016.46
$2,143.22
$2,277.50
$2,754.50 		$359.16
Toc - Plan #28 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze Standard 7500 | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$331.36
$376.09
$423.48
$591.81
$899.31 		$584.85
$629.58
$676.97
$845.30 		$838.34
$883.07
$930.46
$1,098.79 		$1,091.83
$1,136.56
$1,183.95
$1,352.28 		$253.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.72
$752.18
$846.96
$1,183.62
$1,798.62 		$916.21
$1,005.67
$1,100.45
$1,437.11 		$1,169.70
$1,259.16
$1,353.94
$1,690.60 		$1,423.19
$1,512.65
$1,607.43
$1,944.09 		$253.49

ADVERTISEMENT

AmeriHealth Caritas Next

Local: 1-984-245-3613 | Toll Free: 1-833-613-2262 | TTY: 1-844-214-2471
Toc - Plan #29 AmeriHealth Caritas Next
Bronze

(HMO) AmeriHealth Caritas Next Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$263.34
$298.89
$336.54
$470.32
$714.69 		$464.79
$500.34
$537.99
$671.77 		$666.24
$701.79
$739.44
$873.22 		$867.69
$903.24
$940.89
$1,074.67 		$201.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.68
$597.78
$673.08
$940.64
$1,429.38 		$728.13
$799.23
$874.53
$1,142.09 		$929.58
$1,000.68
$1,075.98
$1,343.54 		$1,131.03
$1,202.13
$1,277.43
$1,544.99 		$201.45
Toc - Plan #30 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$296.50
$336.53
$378.93
$529.55
$804.70 		$523.33
$563.36
$605.76
$756.38 		$750.16
$790.19
$832.59
$983.21 		$976.99
$1,017.02
$1,059.42
$1,210.04 		$226.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$593.00
$673.06
$757.86
$1,059.10
$1,609.40 		$819.83
$899.89
$984.69
$1,285.93 		$1,046.66
$1,126.72
$1,211.52
$1,512.76 		$1,273.49
$1,353.55
$1,438.35
$1,739.59 		$226.83
Toc - Plan #31 AmeriHealth Caritas Next
Silver

(HMO) AmeriHealth Caritas Next Silver + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$404.02
$458.56
$516.33
$721.57
$1,096.50 		$713.09
$767.63
$825.40
$1,030.64 		$1,022.16
$1,076.70
$1,134.47
$1,339.71 		$1,331.23
$1,385.77
$1,443.54
$1,648.78 		$309.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.04
$917.12
$1,032.66
$1,443.14
$2,193.00 		$1,117.11
$1,226.19
$1,341.73
$1,752.21 		$1,426.18
$1,535.26
$1,650.80
$2,061.28 		$1,735.25
$1,844.33
$1,959.87
$2,370.35 		$309.07
Toc - Plan #32 AmeriHealth Caritas Next
Gold

(HMO) AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$495.93
$562.88
$633.80
$885.73
$1,345.95 		$875.32
$942.27
$1,013.19
$1,265.12 		$1,254.71
$1,321.66
$1,392.58
$1,644.51 		$1,634.10
$1,701.05
$1,771.97
$2,023.90 		$379.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.86
$1,125.76
$1,267.60
$1,771.46
$2,691.90 		$1,371.25
$1,505.15
$1,646.99
$2,150.85 		$1,750.64
$1,884.54
$2,026.38
$2,530.24 		$2,130.03
$2,263.93
$2,405.77
$2,909.63 		$379.39

ADVERTISEMENT

WellCare of North Carolina

Local: 1-833-705-2175 | Toll Free: 1-833-705-2175

Toc - Plan #33 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 Annual Deductible
$9,100 $18,200 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 		$686.31
$778.95
$877.10
$1,225.74
$1,862.63 		$1,211.33
$1,303.97
$1,402.12
$1,750.76 		$1,736.35
$1,828.99
$1,927.14
$2,275.78 		$2,261.37
$2,354.01
$2,452.16
$2,800.80 		$525.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,372.62
$1,557.90
$1,754.20
$2,451.48
$3,725.26 		$1,897.64
$2,082.92
$2,279.22
$2,976.50 		$2,422.66
$2,607.94
$2,804.24
$3,501.52 		$2,947.68
$3,132.96
$3,329.26
$4,026.54 		$525.02
Toc - Plan #34 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,100 $16,200 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 		$880.45
$999.30
$1,125.20
$1,572.47
$2,389.52 		$1,553.99
$1,672.84
$1,798.74
$2,246.01 		$2,227.53
$2,346.38
$2,472.28
$2,919.55 		$2,901.07
$3,019.92
$3,145.82
$3,593.09 		$673.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,760.90
$1,998.60
$2,250.40
$3,144.94
$4,779.04 		$2,434.44
$2,672.14
$2,923.94
$3,818.48 		$3,107.98
$3,345.68
$3,597.48
$4,492.02 		$3,781.52
$4,019.22
$4,271.02
$5,165.56 		$673.54
Toc - Plan #35 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 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 		$911.00
$1,033.98
$1,164.25
$1,627.03
$2,472.43 		$1,607.91
$1,730.89
$1,861.16
$2,323.94 		$2,304.82
$2,427.80
$2,558.07
$3,020.85 		$3,001.73
$3,124.71
$3,254.98
$3,717.76 		$696.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,822.00
$2,067.96
$2,328.50
$3,254.06
$4,944.86 		$2,518.91
$2,764.87
$3,025.41
$3,950.97 		$3,215.82
$3,461.78
$3,722.32
$4,647.88 		$3,912.73
$4,158.69
$4,419.23
$5,344.79 		$696.91
Toc - Plan #36 WellCare of North Carolina
Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$687.46
$780.25
$878.56
$1,227.78
$1,865.73 		$1,213.36
$1,306.15
$1,404.46
$1,753.68 		$1,739.26
$1,832.05
$1,930.36
$2,279.58 		$2,265.16
$2,357.95
$2,456.26
$2,805.48 		$525.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,374.92
$1,560.50
$1,757.12
$2,455.56
$3,731.46 		$1,900.82
$2,086.40
$2,283.02
$2,981.46 		$2,426.72
$2,612.30
$2,808.92
$3,507.36 		$2,952.62
$3,138.20
$3,334.82
$4,033.26 		$525.90
Toc - Plan #37 WellCare of North Carolina
Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$869.80
$987.21
$1,111.59
$1,553.44
$2,360.60 		$1,535.19
$1,652.60
$1,776.98
$2,218.83 		$2,200.58
$2,317.99
$2,442.37
$2,884.22 		$2,865.97
$2,983.38
$3,107.76
$3,549.61 		$665.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,739.60
$1,974.42
$2,223.18
$3,106.88
$4,721.20 		$2,404.99
$2,639.81
$2,888.57
$3,772.27 		$3,070.38
$3,305.20
$3,553.96
$4,437.66 		$3,735.77
$3,970.59
$4,219.35
$5,103.05 		$665.39
Toc - Plan #38 WellCare of North Carolina
Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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 		$885.82
$1,005.40
$1,132.07
$1,582.06
$2,404.09 		$1,563.47
$1,683.05
$1,809.72
$2,259.71 		$2,241.12
$2,360.70
$2,487.37
$2,937.36 		$2,918.77
$3,038.35
$3,165.02
$3,615.01 		$677.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,771.64
$2,010.80
$2,264.14
$3,164.12
$4,808.18 		$2,449.29
$2,688.45
$2,941.79
$3,841.77 		$3,126.94
$3,366.10
$3,619.44
$4,519.42 		$3,804.59
$4,043.75
$4,297.09
$5,197.07 		$677.65

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5357 | Toll Free: 1-800-980-5357 | TTY: 1-800-980-5357
Toc - Plan #39 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 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 		$603.10
$684.52
$770.76
$1,077.14
$1,636.82 		$1,064.47
$1,145.89
$1,232.13
$1,538.51 		$1,525.84
$1,607.26
$1,693.50
$1,999.88 		$1,987.21
$2,068.63
$2,154.87
$2,461.25 		$461.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,206.20
$1,369.04
$1,541.52
$2,154.28
$3,273.64 		$1,667.57
$1,830.41
$2,002.89
$2,615.65 		$2,128.94
$2,291.78
$2,464.26
$3,077.02 		$2,590.31
$2,753.15
$2,925.63
$3,538.39 		$461.37
Toc - Plan #40 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 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 		$595.41
$675.79
$760.93
$1,063.40
$1,615.94 		$1,050.90
$1,131.28
$1,216.42
$1,518.89 		$1,506.39
$1,586.77
$1,671.91
$1,974.38 		$1,961.88
$2,042.26
$2,127.40
$2,429.87 		$455.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,190.82
$1,351.58
$1,521.86
$2,126.80
$3,231.88 		$1,646.31
$1,807.07
$1,977.35
$2,582.29 		$2,101.80
$2,262.56
$2,432.84
$3,037.78 		$2,557.29
$2,718.05
$2,888.33
$3,493.27 		$455.49
Toc - Plan #41 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 Annual Deductible
$9,100 $18,200 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 		$594.45
$674.71
$759.71
$1,061.69
$1,613.35 		$1,049.21
$1,129.47
$1,214.47
$1,516.45 		$1,503.97
$1,584.23
$1,669.23
$1,971.21 		$1,958.73
$2,038.99
$2,123.99
$2,425.97 		$454.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,188.90
$1,349.42
$1,519.42
$2,123.38
$3,226.70 		$1,643.66
$1,804.18
$1,974.18
$2,578.14 		$2,098.42
$2,258.94
$2,428.94
$3,032.90 		$2,553.18
$2,713.70
$2,883.70
$3,487.66 		$454.76
Toc - Plan #42 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded Saver ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 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 		$420.01
$476.71
$536.77
$750.14
$1,139.91 		$741.32
$798.02
$858.08
$1,071.45 		$1,062.63
$1,119.33
$1,179.39
$1,392.76 		$1,383.94
$1,440.64
$1,500.70
$1,714.07 		$321.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.02
$953.42
$1,073.54
$1,500.28
$2,279.82 		$1,161.33
$1,274.73
$1,394.85
$1,821.59 		$1,482.64
$1,596.04
$1,716.16
$2,142.90 		$1,803.95
$1,917.35
$2,037.47
$2,464.21 		$321.31
Toc - Plan #43 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$626.43
$711.00
$800.58
$1,118.81
$1,700.14 		$1,105.65
$1,190.22
$1,279.80
$1,598.03 		$1,584.87
$1,669.44
$1,759.02
$2,077.25 		$2,064.09
$2,148.66
$2,238.24
$2,556.47 		$479.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,252.86
$1,422.00
$1,601.16
$2,237.62
$3,400.28 		$1,732.08
$1,901.22
$2,080.38
$2,716.84 		$2,211.30
$2,380.44
$2,559.60
$3,196.06 		$2,690.52
$2,859.66
$3,038.82
$3,675.28 		$479.22
Toc - Plan #44 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$649.73
$737.44
$830.35
$1,160.41
$1,763.36 		$1,146.77
$1,234.48
$1,327.39
$1,657.45 		$1,643.81
$1,731.52
$1,824.43
$2,154.49 		$2,140.85
$2,228.56
$2,321.47
$2,651.53 		$497.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,299.46
$1,474.88
$1,660.70
$2,320.82
$3,526.72 		$1,796.50
$1,971.92
$2,157.74
$2,817.86 		$2,293.54
$2,468.96
$2,654.78
$3,314.90 		$2,790.58
$2,966.00
$3,151.82
$3,811.94 		$497.04
Toc - Plan #45 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$446.70
$507.00
$570.88
$797.80
$1,212.34 		$788.42
$848.72
$912.60
$1,139.52 		$1,130.14
$1,190.44
$1,254.32
$1,481.24 		$1,471.86
$1,532.16
$1,596.04
$1,822.96 		$341.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893.40
$1,014.00
$1,141.76
$1,595.60
$2,424.68 		$1,235.12
$1,355.72
$1,483.48
$1,937.32 		$1,576.84
$1,697.44
$1,825.20
$2,279.04 		$1,918.56
$2,039.16
$2,166.92
$2,620.76 		$341.72
Toc - Plan #46 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 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 		$594.83
$675.13
$760.20
$1,062.37
$1,614.37 		$1,049.88
$1,130.18
$1,215.25
$1,517.42 		$1,504.93
$1,585.23
$1,670.30
$1,972.47 		$1,959.98
$2,040.28
$2,125.35
$2,427.52 		$455.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,189.66
$1,350.26
$1,520.40
$2,124.74
$3,228.74 		$1,644.71
$1,805.31
$1,975.45
$2,579.79 		$2,099.76
$2,260.36
$2,430.50
$3,034.84 		$2,554.81
$2,715.41
$2,885.55
$3,489.89 		$455.05
Toc - Plan #47 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 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 		$425.16
$482.56
$543.36
$759.34
$1,153.89 		$750.41
$807.81
$868.61
$1,084.59 		$1,075.66
$1,133.06
$1,193.86
$1,409.84 		$1,400.91
$1,458.31
$1,519.11
$1,735.09 		$325.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.32
$965.12
$1,086.72
$1,518.68
$2,307.78 		$1,175.57
$1,290.37
$1,411.97
$1,843.93 		$1,500.82
$1,615.62
$1,737.22
$2,169.18 		$1,826.07
$1,940.87
$2,062.47
$2,494.43 		$325.25
Toc - Plan #48 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$613.87
$696.75
$784.53
$1,096.38
$1,666.06 		$1,083.48
$1,166.36
$1,254.14
$1,565.99 		$1,553.09
$1,635.97
$1,723.75
$2,035.60 		$2,022.70
$2,105.58
$2,193.36
$2,505.21 		$469.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,227.74
$1,393.50
$1,569.06
$2,192.76
$3,332.12 		$1,697.35
$1,863.11
$2,038.67
$2,662.37 		$2,166.96
$2,332.72
$2,508.28
$3,131.98 		$2,636.57
$2,802.33
$2,977.89
$3,601.59 		$469.61
Toc - Plan #49 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$603.74
$685.24
$771.58
$1,078.28
$1,638.55 		$1,065.60
$1,147.10
$1,233.44
$1,540.14 		$1,527.46
$1,608.96
$1,695.30
$2,002.00 		$1,989.32
$2,070.82
$2,157.16
$2,463.86 		$461.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,207.48
$1,370.48
$1,543.16
$2,156.56
$3,277.10 		$1,669.34
$1,832.34
$2,005.02
$2,618.42 		$2,131.20
$2,294.20
$2,466.88
$3,080.28 		$2,593.06
$2,756.06
$2,928.74
$3,542.14 		$461.86
Toc - Plan #50 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $2,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 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 		$589.49
$669.07
$753.37
$1,052.83
$1,599.88 		$1,040.45
$1,120.03
$1,204.33
$1,503.79 		$1,491.41
$1,570.99
$1,655.29
$1,954.75 		$1,942.37
$2,021.95
$2,106.25
$2,405.71 		$450.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,178.98
$1,338.14
$1,506.74
$2,105.66
$3,199.76 		$1,629.94
$1,789.10
$1,957.70
$2,556.62 		$2,080.90
$2,240.06
$2,408.66
$3,007.58 		$2,531.86
$2,691.02
$2,859.62
$3,458.54 		$450.96
Toc - Plan #51 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 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 		$621.53
$705.44
$794.31
$1,110.05
$1,686.83 		$1,097.00
$1,180.91
$1,269.78
$1,585.52 		$1,572.47
$1,656.38
$1,745.25
$2,060.99 		$2,047.94
$2,131.85
$2,220.72
$2,536.46 		$475.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,243.06
$1,410.88
$1,588.62
$2,220.10
$3,373.66 		$1,718.53
$1,886.35
$2,064.09
$2,695.57 		$2,194.00
$2,361.82
$2,539.56
$3,171.04 		$2,669.47
$2,837.29
$3,015.03
$3,646.51 		$475.47
Toc - Plan #52 UnitedHealthcare
Silver

(HMO) UHC Silver Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$592.80
$672.83
$757.60
$1,058.74
$1,608.86 		$1,046.29
$1,126.32
$1,211.09
$1,512.23 		$1,499.78
$1,579.81
$1,664.58
$1,965.72 		$1,953.27
$2,033.30
$2,118.07
$2,419.21 		$453.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,185.60
$1,345.66
$1,515.20
$2,117.48
$3,217.72 		$1,639.09
$1,799.15
$1,968.69
$2,570.97 		$2,092.58
$2,252.64
$2,422.18
$3,024.46 		$2,546.07
$2,706.13
$2,875.67
$3,477.95 		$453.49
Toc - Plan #53 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$406.26
$461.11
$519.20
$725.58
$1,102.59 		$717.05
$771.90
$829.99
$1,036.37 		$1,027.84
$1,082.69
$1,140.78
$1,347.16 		$1,338.63
$1,393.48
$1,451.57
$1,657.95 		$310.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.52
$922.22
$1,038.40
$1,451.16
$2,205.18 		$1,123.31
$1,233.01
$1,349.19
$1,761.95 		$1,434.10
$1,543.80
$1,659.98
$2,072.74 		$1,744.89
$1,854.59
$1,970.77
$2,383.53 		$310.79
Toc - Plan #54 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$404.86
$459.51
$517.40
$723.07
$1,098.78 		$714.57
$769.22
$827.11
$1,032.78 		$1,024.28
$1,078.93
$1,136.82
$1,342.49 		$1,333.99
$1,388.64
$1,446.53
$1,652.20 		$309.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.72
$919.02
$1,034.80
$1,446.14
$2,197.56 		$1,119.43
$1,228.73
$1,344.51
$1,755.85 		$1,429.14
$1,538.44
$1,654.22
$2,065.56 		$1,738.85
$1,848.15
$1,963.93
$2,375.27 		$309.71
Toc - Plan #55 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$425.86
$483.35
$544.25
$760.58
$1,155.78 		$751.64
$809.13
$870.03
$1,086.36 		$1,077.42
$1,134.91
$1,195.81
$1,412.14 		$1,403.20
$1,460.69
$1,521.59
$1,737.92 		$325.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.72
$966.70
$1,088.50
$1,521.16
$2,311.56 		$1,177.50
$1,292.48
$1,414.28
$1,846.94 		$1,503.28
$1,618.26
$1,740.06
$2,172.72 		$1,829.06
$1,944.04
$2,065.84
$2,498.50 		$325.78
Toc - Plan #56 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $6,350 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,100 $18,200 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 		$414.68
$470.67
$529.97
$740.62
$1,125.45 		$731.91
$787.90
$847.20
$1,057.85 		$1,049.14
$1,105.13
$1,164.43
$1,375.08 		$1,366.37
$1,422.36
$1,481.66
$1,692.31 		$317.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.36
$941.34
$1,059.94
$1,481.24
$2,250.90 		$1,146.59
$1,258.57
$1,377.17
$1,798.47 		$1,463.82
$1,575.80
$1,694.40
$2,115.70 		$1,781.05
$1,893.03
$2,011.63
$2,432.93 		$317.23

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310 | TTY: 1-833-863-1310
Toc - Plan #57 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$323.45
$367.11
$413.36
$577.67
$877.83 		$570.89
$614.55
$660.80
$825.11 		$818.33
$861.99
$908.24
$1,072.55 		$1,065.77
$1,109.43
$1,155.68
$1,319.99 		$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
$826.72
$1,155.34
$1,755.66 		$894.34
$981.66
$1,074.16
$1,402.78 		$1,141.78
$1,229.10
$1,321.60
$1,650.22 		$1,389.22
$1,476.54
$1,569.04
$1,897.66 		$247.44
Toc - Plan #58 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$355.69
$403.70
$454.56
$635.25
$965.33 		$627.79
$675.80
$726.66
$907.35 		$899.89
$947.90
$998.76
$1,179.45 		$1,171.99
$1,220.00
$1,270.86
$1,451.55 		$272.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.38
$807.40
$909.12
$1,270.50
$1,930.66 		$983.48
$1,079.50
$1,181.22
$1,542.60 		$1,255.58
$1,351.60
$1,453.32
$1,814.70 		$1,527.68
$1,623.70
$1,725.42
$2,086.80 		$272.10
Toc - Plan #59 Ambetter of North Carolina
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$438.64
$497.84
$560.57
$783.39
$1,190.44 		$774.19
$833.39
$896.12
$1,118.94 		$1,109.74
$1,168.94
$1,231.67
$1,454.49 		$1,445.29
$1,504.49
$1,567.22
$1,790.04 		$335.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.28
$995.68
$1,121.14
$1,566.78
$2,380.88 		$1,212.83
$1,331.23
$1,456.69
$1,902.33 		$1,548.38
$1,666.78
$1,792.24
$2,237.88 		$1,883.93
$2,002.33
$2,127.79
$2,573.43 		$335.55
Toc - Plan #60 Ambetter of North Carolina
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 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 		$457.59
$519.35
$584.78
$817.23
$1,241.86 		$807.64
$869.40
$934.83
$1,167.28 		$1,157.69
$1,219.45
$1,284.88
$1,517.33 		$1,507.74
$1,569.50
$1,634.93
$1,867.38 		$350.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.18
$1,038.70
$1,169.56
$1,634.46
$2,483.72 		$1,265.23
$1,388.75
$1,519.61
$1,984.51 		$1,615.28
$1,738.80
$1,869.66
$2,334.56 		$1,965.33
$2,088.85
$2,219.71
$2,684.61 		$350.05
Toc - Plan #61 Ambetter of North Carolina
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$434.56
$493.21
$555.35
$776.10
$1,179.37 		$766.99
$825.64
$887.78
$1,108.53 		$1,099.42
$1,158.07
$1,220.21
$1,440.96 		$1,431.85
$1,490.50
$1,552.64
$1,773.39 		$332.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.12
$986.42
$1,110.70
$1,552.20
$2,358.74 		$1,201.55
$1,318.85
$1,443.13
$1,884.63 		$1,533.98
$1,651.28
$1,775.56
$2,217.06 		$1,866.41
$1,983.71
$2,107.99
$2,549.49 		$332.43
Toc - Plan #62 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$345.12
$391.70
$441.05
$616.37
$936.64 		$609.13
$655.71
$705.06
$880.38 		$873.14
$919.72
$969.07
$1,144.39 		$1,137.15
$1,183.73
$1,233.08
$1,408.40 		$264.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.24
$783.40
$882.10
$1,232.74
$1,873.28 		$954.25
$1,047.41
$1,146.11
$1,496.75 		$1,218.26
$1,311.42
$1,410.12
$1,760.76 		$1,482.27
$1,575.43
$1,674.13
$2,024.77 		$264.01
Toc - Plan #63 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$388.37
$440.79
$496.33
$693.61
$1,054.01 		$685.47
$737.89
$793.43
$990.71 		$982.57
$1,034.99
$1,090.53
$1,287.81 		$1,279.67
$1,332.09
$1,387.63
$1,584.91 		$297.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.74
$881.58
$992.66
$1,387.22
$2,108.02 		$1,073.84
$1,178.68
$1,289.76
$1,684.32 		$1,370.94
$1,475.78
$1,586.86
$1,981.42 		$1,668.04
$1,772.88
$1,883.96
$2,278.52 		$297.10
Toc - Plan #64 Ambetter of North Carolina
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 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 		$433.42
$491.92
$553.90
$774.07
$1,176.27 		$764.98
$823.48
$885.46
$1,105.63 		$1,096.54
$1,155.04
$1,217.02
$1,437.19 		$1,428.10
$1,486.60
$1,548.58
$1,768.75 		$331.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.84
$983.84
$1,107.80
$1,548.14
$2,352.54 		$1,198.40
$1,315.40
$1,439.36
$1,879.70 		$1,529.96
$1,646.96
$1,770.92
$2,211.26 		$1,861.52
$1,978.52
$2,102.48
$2,542.82 		$331.56
Toc - Plan #65 Ambetter of North Carolina
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$433.59
$492.12
$554.12
$774.38
$1,176.75 		$765.28
$823.81
$885.81
$1,106.07 		$1,096.97
$1,155.50
$1,217.50
$1,437.76 		$1,428.66
$1,487.19
$1,549.19
$1,769.45 		$331.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.18
$984.24
$1,108.24
$1,548.76
$2,353.50 		$1,198.87
$1,315.93
$1,439.93
$1,880.45 		$1,530.56
$1,647.62
$1,771.62
$2,212.14 		$1,862.25
$1,979.31
$2,103.31
$2,543.83 		$331.69
Toc - Plan #66 Ambetter of North Carolina
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$338.41
$384.09
$432.48
$604.39
$918.42 		$597.29
$642.97
$691.36
$863.27 		$856.17
$901.85
$950.24
$1,122.15 		$1,115.05
$1,160.73
$1,209.12
$1,381.03 		$258.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$676.82
$768.18
$864.96
$1,208.78
$1,836.84 		$935.70
$1,027.06
$1,123.84
$1,467.66 		$1,194.58
$1,285.94
$1,382.72
$1,726.54 		$1,453.46
$1,544.82
$1,641.60
$1,985.42 		$258.88
Toc - Plan #67 Ambetter of North Carolina
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$429.16
$487.09
$548.46
$766.47
$1,164.72 		$757.46
$815.39
$876.76
$1,094.77 		$1,085.76
$1,143.69
$1,205.06
$1,423.07 		$1,414.06
$1,471.99
$1,533.36
$1,751.37 		$328.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.32
$974.18
$1,096.92
$1,532.94
$2,329.44 		$1,186.62
$1,302.48
$1,425.22
$1,861.24 		$1,514.92
$1,630.78
$1,753.52
$2,189.54 		$1,843.22
$1,959.08
$2,081.82
$2,517.84 		$328.30
Toc - Plan #68 Ambetter of North Carolina
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$434.30
$492.91
$555.02
$775.63
$1,178.65 		$766.53
$825.14
$887.25
$1,107.86 		$1,098.76
$1,157.37
$1,219.48
$1,440.09 		$1,430.99
$1,489.60
$1,551.71
$1,772.32 		$332.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.60
$985.82
$1,110.04
$1,551.26
$2,357.30 		$1,200.83
$1,318.05
$1,442.27
$1,883.49 		$1,533.06
$1,650.28
$1,774.50
$2,215.72 		$1,865.29
$1,982.51
$2,106.73
$2,547.95 		$332.23
Toc - Plan #69 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$337.08
$382.57
$430.77
$602.00
$914.80 		$594.94
$640.43
$688.63
$859.86 		$852.80
$898.29
$946.49
$1,117.72 		$1,110.66
$1,156.15
$1,204.35
$1,375.58 		$257.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.16
$765.14
$861.54
$1,204.00
$1,829.60 		$932.02
$1,023.00
$1,119.40
$1,461.86 		$1,189.88
$1,280.86
$1,377.26
$1,719.72 		$1,447.74
$1,538.72
$1,635.12
$1,977.58 		$257.86
Toc - Plan #70 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$370.68
$420.70
$473.71
$662.01
$1,005.98 		$654.24
$704.26
$757.27
$945.57 		$937.80
$987.82
$1,040.83
$1,229.13 		$1,221.36
$1,271.38
$1,324.39
$1,512.69 		$283.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.36
$841.40
$947.42
$1,324.02
$2,011.96 		$1,024.92
$1,124.96
$1,230.98
$1,607.58 		$1,308.48
$1,408.52
$1,514.54
$1,891.14 		$1,592.04
$1,692.08
$1,798.10
$2,174.70 		$283.56
Toc - Plan #71 Ambetter of North Carolina
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$457.11
$518.81
$584.18
$816.39
$1,240.58 		$806.79
$868.49
$933.86
$1,166.07 		$1,156.47
$1,218.17
$1,283.54
$1,515.75 		$1,506.15
$1,567.85
$1,633.22
$1,865.43 		$349.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$914.22
$1,037.62
$1,168.36
$1,632.78
$2,481.16 		$1,263.90
$1,387.30
$1,518.04
$1,982.46 		$1,613.58
$1,736.98
$1,867.72
$2,332.14 		$1,963.26
$2,086.66
$2,217.40
$2,681.82 		$349.68
Toc - Plan #72 Ambetter of North Carolina
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 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 		$476.86
$541.22
$609.41
$851.65
$1,294.17 		$841.65
$906.01
$974.20
$1,216.44 		$1,206.44
$1,270.80
$1,338.99
$1,581.23 		$1,571.23
$1,635.59
$1,703.78
$1,946.02 		$364.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.72
$1,082.44
$1,218.82
$1,703.30
$2,588.34 		$1,318.51
$1,447.23
$1,583.61
$2,068.09 		$1,683.30
$1,812.02
$1,948.40
$2,432.88 		$2,048.09
$2,176.81
$2,313.19
$2,797.67 		$364.79
Toc - Plan #73 Ambetter of North Carolina
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$452.86
$513.99
$578.75
$808.79
$1,229.04 		$799.29
$860.42
$925.18
$1,155.22 		$1,145.72
$1,206.85
$1,271.61
$1,501.65 		$1,492.15
$1,553.28
$1,618.04
$1,848.08 		$346.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$905.72
$1,027.98
$1,157.50
$1,617.58
$2,458.08 		$1,252.15
$1,374.41
$1,503.93
$1,964.01 		$1,598.58
$1,720.84
$1,850.36
$2,310.44 		$1,945.01
$2,067.27
$2,196.79
$2,656.87 		$346.43
Toc - Plan #74 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$359.66
$408.20
$459.63
$642.33
$976.09 		$634.79
$683.33
$734.76
$917.46 		$909.92
$958.46
$1,009.89
$1,192.59 		$1,185.05
$1,233.59
$1,285.02
$1,467.72 		$275.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.32
$816.40
$919.26
$1,284.66
$1,952.18 		$994.45
$1,091.53
$1,194.39
$1,559.79 		$1,269.58
$1,366.66
$1,469.52
$1,834.92 		$1,544.71
$1,641.79
$1,744.65
$2,110.05 		$275.13
Toc - Plan #75 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$404.73
$459.36
$517.23
$722.83
$1,098.41 		$714.34
$768.97
$826.84
$1,032.44 		$1,023.95
$1,078.58
$1,136.45
$1,342.05 		$1,333.56
$1,388.19
$1,446.06
$1,651.66 		$309.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.46
$918.72
$1,034.46
$1,445.66
$2,196.82 		$1,119.07
$1,228.33
$1,344.07
$1,755.27 		$1,428.68
$1,537.94
$1,653.68
$2,064.88 		$1,738.29
$1,847.55
$1,963.29
$2,374.49 		$309.61
Toc - Plan #76 Ambetter of North Carolina
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$451.86
$512.85
$577.46
$807.00
$1,226.31 		$797.52
$858.51
$923.12
$1,152.66 		$1,143.18
$1,204.17
$1,268.78
$1,498.32 		$1,488.84
$1,549.83
$1,614.44
$1,843.98 		$345.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.72
$1,025.70
$1,154.92
$1,614.00
$2,452.62 		$1,249.38
$1,371.36
$1,500.58
$1,959.66 		$1,595.04
$1,717.02
$1,846.24
$2,305.32 		$1,940.70
$2,062.68
$2,191.90
$2,650.98 		$345.66
Toc - Plan #77 Ambetter of North Carolina
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 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 		$451.67
$512.64
$577.23
$806.67
$1,225.82 		$797.19
$858.16
$922.75
$1,152.19 		$1,142.71
$1,203.68
$1,268.27
$1,497.71 		$1,488.23
$1,549.20
$1,613.79
$1,843.23 		$345.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.34
$1,025.28
$1,154.46
$1,613.34
$2,451.64 		$1,248.86
$1,370.80
$1,499.98
$1,958.86 		$1,594.38
$1,716.32
$1,845.50
$2,304.38 		$1,939.90
$2,061.84
$2,191.02
$2,649.90 		$345.52
Toc - Plan #78 Ambetter of North Carolina
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$337.01
$382.49
$430.68
$601.88
$914.61 		$594.81
$640.29
$688.48
$859.68 		$852.61
$898.09
$946.28
$1,117.48 		$1,110.41
$1,155.89
$1,204.08
$1,375.28 		$257.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.02
$764.98
$861.36
$1,203.76
$1,829.22 		$931.82
$1,022.78
$1,119.16
$1,461.56 		$1,189.62
$1,280.58
$1,376.96
$1,719.36 		$1,447.42
$1,538.38
$1,634.76
$1,977.16 		$257.80
Toc - Plan #79 Ambetter of North Carolina
Silver

(HMO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 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 		$424.12
$481.36
$542.01
$757.46
$1,151.03 		$748.56
$805.80
$866.45
$1,081.90 		$1,073.00
$1,130.24
$1,190.89
$1,406.34 		$1,397.44
$1,454.68
$1,515.33
$1,730.78 		$324.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.24
$962.72
$1,084.02
$1,514.92
$2,302.06 		$1,172.68
$1,287.16
$1,408.46
$1,839.36 		$1,497.12
$1,611.60
$1,732.90
$2,163.80 		$1,821.56
$1,936.04
$2,057.34
$2,488.24 		$324.44
Toc - Plan #80 Ambetter of North Carolina
Gold

(HMO) Ambetter Virtual Access Gold - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 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 		$444.60
$504.61
$568.19
$794.04
$1,206.63 		$784.71
$844.72
$908.30
$1,134.15 		$1,124.82
$1,184.83
$1,248.41
$1,474.26 		$1,464.93
$1,524.94
$1,588.52
$1,814.37 		$340.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.20
$1,009.22
$1,136.38
$1,588.08
$2,413.26 		$1,229.31
$1,349.33
$1,476.49
$1,928.19 		$1,569.42
$1,689.44
$1,816.60
$2,268.30 		$1,909.53
$2,029.55
$2,156.71
$2,608.41 		$340.11

ADVERTISEMENT

Friday Health Plans

Local: 1-844-465-5500 | Toll Free: 1-844-465-5500 | TTY: 1-800-659-2656
Toc - Plan #81 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$245.24
$278.35
$313.42
$438.00
$665.58 		$432.85
$465.96
$501.03
$625.61 		$620.46
$653.57
$688.64
$813.22 		$808.07
$841.18
$876.25
$1,000.83 		$187.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$490.48
$556.70
$626.84
$876.00
$1,331.16 		$678.09
$744.31
$814.45
$1,063.61 		$865.70
$931.92
$1,002.06
$1,251.22 		$1,053.31
$1,119.53
$1,189.67
$1,438.83 		$187.61
Toc - Plan #82 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$321.49
$364.89
$410.87
$574.19
$872.53 		$567.43
$610.83
$656.81
$820.13 		$813.37
$856.77
$902.75
$1,066.07 		$1,059.31
$1,102.71
$1,148.69
$1,312.01 		$245.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.98
$729.78
$821.74
$1,148.38
$1,745.06 		$888.92
$975.72
$1,067.68
$1,394.32 		$1,134.86
$1,221.66
$1,313.62
$1,640.26 		$1,380.80
$1,467.60
$1,559.56
$1,886.20 		$245.94
Toc - Plan #83 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$324.72
$368.56
$415.00
$579.96
$881.30 		$573.13
$616.97
$663.41
$828.37 		$821.54
$865.38
$911.82
$1,076.78 		$1,069.95
$1,113.79
$1,160.23
$1,325.19 		$248.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.44
$737.12
$830.00
$1,159.92
$1,762.60 		$897.85
$985.53
$1,078.41
$1,408.33 		$1,146.26
$1,233.94
$1,326.82
$1,656.74 		$1,394.67
$1,482.35
$1,575.23
$1,905.15 		$248.41
Toc - Plan #84 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$343.28
$389.63
$438.72
$613.10
$931.67 		$605.89
$652.24
$701.33
$875.71 		$868.50
$914.85
$963.94
$1,138.32 		$1,131.11
$1,177.46
$1,226.55
$1,400.93 		$262.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.56
$779.26
$877.44
$1,226.20
$1,863.34 		$949.17
$1,041.87
$1,140.05
$1,488.81 		$1,211.78
$1,304.48
$1,402.66
$1,751.42 		$1,474.39
$1,567.09
$1,665.27
$2,014.03 		$262.61
Toc - Plan #85 Friday Health Plans
Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$447.88
$508.35
$572.39
$799.92
$1,215.55 		$790.51
$850.98
$915.02
$1,142.55 		$1,133.14
$1,193.61
$1,257.65
$1,485.18 		$1,475.77
$1,536.24
$1,600.28
$1,827.81 		$342.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.76
$1,016.70
$1,144.78
$1,599.84
$2,431.10 		$1,238.39
$1,359.33
$1,487.41
$1,942.47 		$1,581.02
$1,701.96
$1,830.04
$2,285.10 		$1,923.65
$2,044.59
$2,172.67
$2,627.73 		$342.63
Toc - Plan #86 Friday Health Plans
Gold

(HMO) Friday Gold + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$470.87
$534.44
$601.77
$840.97
$1,277.94 		$831.08
$894.65
$961.98
$1,201.18 		$1,191.29
$1,254.86
$1,322.19
$1,561.39 		$1,551.50
$1,615.07
$1,682.40
$1,921.60 		$360.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.74
$1,068.88
$1,203.54
$1,681.94
$2,555.88 		$1,301.95
$1,429.09
$1,563.75
$2,042.15 		$1,662.16
$1,789.30
$1,923.96
$2,402.36 		$2,022.37
$2,149.51
$2,284.17
$2,762.57 		$360.21
Toc - Plan #87 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$321.26
$364.63
$410.57
$573.77
$871.90 		$567.02
$610.39
$656.33
$819.53 		$812.78
$856.15
$902.09
$1,065.29 		$1,058.54
$1,101.91
$1,147.85
$1,311.05 		$245.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.52
$729.26
$821.14
$1,147.54
$1,743.80 		$888.28
$975.02
$1,066.90
$1,393.30 		$1,134.04
$1,220.78
$1,312.66
$1,639.06 		$1,379.80
$1,466.54
$1,558.42
$1,884.82 		$245.76
Toc - Plan #88 Friday Health Plans
Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$459.74
$521.80
$587.55
$821.09
$1,247.73 		$811.44
$873.50
$939.25
$1,172.79 		$1,163.14
$1,225.20
$1,290.95
$1,524.49 		$1,514.84
$1,576.90
$1,642.65
$1,876.19 		$351.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919.48
$1,043.60
$1,175.10
$1,642.18
$2,495.46 		$1,271.18
$1,395.30
$1,526.80
$1,993.88 		$1,622.88
$1,747.00
$1,878.50
$2,345.58 		$1,974.58
$2,098.70
$2,230.20
$2,697.28 		$351.70
Toc - Plan #89 Friday Health Plans
Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$489.18
$555.22
$625.17
$873.68
$1,327.64 		$863.40
$929.44
$999.39
$1,247.90 		$1,237.62
$1,303.66
$1,373.61
$1,622.12 		$1,611.84
$1,677.88
$1,747.83
$1,996.34 		$374.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$978.36
$1,110.44
$1,250.34
$1,747.36
$2,655.28 		$1,352.58
$1,484.66
$1,624.56
$2,121.58 		$1,726.80
$1,858.88
$1,998.78
$2,495.80 		$2,101.02
$2,233.10
$2,373.00
$2,870.02 		$374.22
Toc - Plan #90 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$321.09
$364.43
$410.35
$573.46
$871.43 		$566.72
$610.06
$655.98
$819.09 		$812.35
$855.69
$901.61
$1,064.72 		$1,057.98
$1,101.32
$1,147.24
$1,310.35 		$245.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.18
$728.86
$820.70
$1,146.92
$1,742.86 		$887.81
$974.49
$1,066.33
$1,392.55 		$1,133.44
$1,220.12
$1,311.96
$1,638.18 		$1,379.07
$1,465.75
$1,557.59
$1,883.81 		$245.63
Toc - Plan #91 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$324.32
$368.10
$414.48
$579.23
$880.20 		$572.42
$616.20
$662.58
$827.33 		$820.52
$864.30
$910.68
$1,075.43 		$1,068.62
$1,112.40
$1,158.78
$1,323.53 		$248.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.64
$736.20
$828.96
$1,158.46
$1,760.40 		$896.74
$984.30
$1,077.06
$1,406.56 		$1,144.84
$1,232.40
$1,325.16
$1,654.66 		$1,392.94
$1,480.50
$1,573.26
$1,902.76 		$248.10
Toc - Plan #92 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$320.85
$364.17
$410.05
$573.05
$870.80 		$566.30
$609.62
$655.50
$818.50 		$811.75
$855.07
$900.95
$1,063.95 		$1,057.20
$1,100.52
$1,146.40
$1,309.40 		$245.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.70
$728.34
$820.10
$1,146.10
$1,741.60 		$887.15
$973.79
$1,065.55
$1,391.55 		$1,132.60
$1,219.24
$1,311.00
$1,637.00 		$1,378.05
$1,464.69
$1,556.45
$1,882.45 		$245.45
Toc - Plan #93 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$447.48
$507.88
$571.87
$799.19
$1,214.45 		$789.80
$850.20
$914.19
$1,141.51 		$1,132.12
$1,192.52
$1,256.51
$1,483.83 		$1,474.44
$1,534.84
$1,598.83
$1,826.15 		$342.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.96
$1,015.76
$1,143.74
$1,598.38
$2,428.90 		$1,237.28
$1,358.08
$1,486.06
$1,940.70 		$1,579.60
$1,700.40
$1,828.38
$2,283.02 		$1,921.92
$2,042.72
$2,170.70
$2,625.34 		$342.32
Toc - Plan #94 Friday Health Plans
Silver

(HMO) Friday Silver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$452.92
$514.06
$578.83
$808.91
$1,229.22 		$799.40
$860.54
$925.31
$1,155.39 		$1,145.88
$1,207.02
$1,271.79
$1,501.87 		$1,492.36
$1,553.50
$1,618.27
$1,848.35 		$346.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$905.84
$1,028.12
$1,157.66
$1,617.82
$2,458.44 		$1,252.32
$1,374.60
$1,504.14
$1,964.30 		$1,598.80
$1,721.08
$1,850.62
$2,310.78 		$1,945.28
$2,067.56
$2,197.10
$2,657.26 		$346.48
Toc - Plan #95 Friday Health Plans
Silver

(HMO) Friday Silver Zero Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$462.26
$524.67
$590.77
$825.60
$1,254.58 		$815.89
$878.30
$944.40
$1,179.23 		$1,169.52
$1,231.93
$1,298.03
$1,532.86 		$1,523.15
$1,585.56
$1,651.66
$1,886.49 		$353.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.52
$1,049.34
$1,181.54
$1,651.20
$2,509.16 		$1,278.15
$1,402.97
$1,535.17
$2,004.83 		$1,631.78
$1,756.60
$1,888.80
$2,358.46 		$1,985.41
$2,110.23
$2,242.43
$2,712.09 		$353.63
Toc - Plan #96 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$459.33
$521.34
$587.03
$820.37
$1,246.63 		$810.72
$872.73
$938.42
$1,171.76 		$1,162.11
$1,224.12
$1,289.81
$1,523.15 		$1,513.50
$1,575.51
$1,641.20
$1,874.54 		$351.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.66
$1,042.68
$1,174.06
$1,640.74
$2,493.26 		$1,270.05
$1,394.07
$1,525.45
$1,992.13 		$1,621.44
$1,745.46
$1,876.84
$2,343.52 		$1,972.83
$2,096.85
$2,228.23
$2,694.91 		$351.39
Toc - Plan #97 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$470.46
$533.97
$601.25
$840.25
$1,276.83 		$830.36
$893.87
$961.15
$1,200.15 		$1,190.26
$1,253.77
$1,321.05
$1,560.05 		$1,550.16
$1,613.67
$1,680.95
$1,919.95 		$359.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$940.92
$1,067.94
$1,202.50
$1,680.50
$2,553.66 		$1,300.82
$1,427.84
$1,562.40
$2,040.40 		$1,660.72
$1,787.74
$1,922.30
$2,400.30 		$2,020.62
$2,147.64
$2,282.20
$2,760.20 		$359.90
Toc - Plan #98 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$488.77
$554.76
$624.65
$872.95
$1,326.53 		$862.68
$928.67
$998.56
$1,246.86 		$1,236.59
$1,302.58
$1,372.47
$1,620.77 		$1,610.50
$1,676.49
$1,746.38
$1,994.68 		$373.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$977.54
$1,109.52
$1,249.30
$1,745.90
$2,653.06 		$1,351.45
$1,483.43
$1,623.21
$2,119.81 		$1,725.36
$1,857.34
$1,997.12
$2,493.72 		$2,099.27
$2,231.25
$2,371.03
$2,867.63 		$373.91
Toc - Plan #99 Friday Health Plans
Bronze

(HMO) Friday Standard Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$321.09
$364.43
$410.35
$573.46
$871.43 		$566.72
$610.06
$655.98
$819.09 		$812.35
$855.69
$901.61
$1,064.72 		$1,057.98
$1,101.32
$1,147.24
$1,310.35 		$245.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.18
$728.86
$820.70
$1,146.92
$1,742.86 		$887.81
$974.49
$1,066.33
$1,392.55 		$1,133.44
$1,220.12
$1,311.96
$1,638.18 		$1,379.07
$1,465.75
$1,557.59
$1,883.81 		$245.63
Toc - Plan #100 Friday Health Plans
Expanded Bronze

(HMO) Friday Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.33
$362.44
$408.11
$570.33
$866.67 		$563.62
$606.73
$652.40
$814.62 		$807.91
$851.02
$896.69
$1,058.91 		$1,052.20
$1,095.31
$1,140.98
$1,303.20 		$244.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.66
$724.88
$816.22
$1,140.66
$1,733.34 		$882.95
$969.17
$1,060.51
$1,384.95 		$1,127.24
$1,213.46
$1,304.80
$1,629.24 		$1,371.53
$1,457.75
$1,549.09
$1,873.53 		$244.29
Toc - Plan #101 Friday Health Plans
Silver

(HMO) Friday Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$443.93
$503.87
$567.35
$792.87
$1,204.84 		$783.54
$843.48
$906.96
$1,132.48 		$1,123.15
$1,183.09
$1,246.57
$1,472.09 		$1,462.76
$1,522.70
$1,586.18
$1,811.70 		$339.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.86
$1,007.74
$1,134.70
$1,585.74
$2,409.68 		$1,227.47
$1,347.35
$1,474.31
$1,925.35 		$1,567.08
$1,686.96
$1,813.92
$2,264.96 		$1,906.69
$2,026.57
$2,153.53
$2,604.57 		$339.61
Toc - Plan #102 Friday Health Plans
Gold

(HMO) Friday Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$486.73
$552.43
$622.04
$869.29
$1,320.98 		$859.08
$924.78
$994.39
$1,241.64 		$1,231.43
$1,297.13
$1,366.74
$1,613.99 		$1,603.78
$1,669.48
$1,739.09
$1,986.34 		$372.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.46
$1,104.86
$1,244.08
$1,738.58
$2,641.96 		$1,345.81
$1,477.21
$1,616.43
$2,110.93 		$1,718.16
$1,849.56
$1,988.78
$2,483.28 		$2,090.51
$2,221.91
$2,361.13
$2,855.63 		$372.35

‡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 Caldwell County here.

Caldwell County is in “Rating Area 2” of North Carolina.

Currently, there are 102 plans offered in Rating Area 2.

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2023 Obamacare Plans for Caldwell County, NC

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