Obamacare 2023 Rates for Nash County

Obamacare > Rates > North Carolina > Nash 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 Nashville, 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, 81 Plans and 2023 Rates for Nash County, North Carolina

Below, you’ll find a summary of the 81 plans for Nash 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 |

Nash 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
Gold

(EPO) Blue Home Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with UNC Health Alliance

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 		$414.13
$470.04
$529.26
$739.64
$1,123.95 		$730.94
$786.85
$846.07
$1,056.45 		$1,047.75
$1,103.66
$1,162.88
$1,373.26 		$1,364.56
$1,420.47
$1,479.69
$1,690.07 		$316.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.26
$940.08
$1,058.52
$1,479.28
$2,247.90 		$1,145.07
$1,256.89
$1,375.33
$1,796.09 		$1,461.88
$1,573.70
$1,692.14
$2,112.90 		$1,778.69
$1,890.51
$2,008.95
$2,429.71 		$316.81
Toc - Plan #16 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Home Gold Standard 2000 | with UNC Health Alliance

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 		$412.63
$468.34
$527.34
$736.96
$1,119.88 		$728.29
$784.00
$843.00
$1,052.62 		$1,043.95
$1,099.66
$1,158.66
$1,368.28 		$1,359.61
$1,415.32
$1,474.32
$1,683.94 		$315.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.26
$936.68
$1,054.68
$1,473.92
$2,239.76 		$1,140.92
$1,252.34
$1,370.34
$1,789.58 		$1,456.58
$1,568.00
$1,686.00
$2,105.24 		$1,772.24
$1,883.66
$2,001.66
$2,420.90 		$315.66
Toc - Plan #17 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance

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 		$425.70
$483.17
$544.04
$760.30
$1,155.35 		$751.36
$808.83
$869.70
$1,085.96 		$1,077.02
$1,134.49
$1,195.36
$1,411.62 		$1,402.68
$1,460.15
$1,521.02
$1,737.28 		$325.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.40
$966.34
$1,088.08
$1,520.60
$2,310.70 		$1,177.06
$1,292.00
$1,413.74
$1,846.26 		$1,502.72
$1,617.66
$1,739.40
$2,171.92 		$1,828.38
$1,943.32
$2,065.06
$2,497.58 		$325.66
Toc - Plan #18 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Simple | $0 Deductible | 3 Free PCP | with UNC Health Alliance

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 		$435.41
$494.19
$556.45
$777.64
$1,181.70 		$768.50
$827.28
$889.54
$1,110.73 		$1,101.59
$1,160.37
$1,222.63
$1,443.82 		$1,434.68
$1,493.46
$1,555.72
$1,776.91 		$333.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.82
$988.38
$1,112.90
$1,555.28
$2,363.40 		$1,203.91
$1,321.47
$1,445.99
$1,888.37 		$1,537.00
$1,654.56
$1,779.08
$2,221.46 		$1,870.09
$1,987.65
$2,112.17
$2,554.55 		$333.09
Toc - Plan #19 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with UNC Health Alliance

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 		$403.15
$457.58
$515.23
$720.03
$1,094.15 		$711.56
$765.99
$823.64
$1,028.44 		$1,019.97
$1,074.40
$1,132.05
$1,336.85 		$1,328.38
$1,382.81
$1,440.46
$1,645.26 		$308.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.30
$915.16
$1,030.46
$1,440.06
$2,188.30 		$1,114.71
$1,223.57
$1,338.87
$1,748.47 		$1,423.12
$1,531.98
$1,647.28
$2,056.88 		$1,731.53
$1,840.39
$1,955.69
$2,365.29 		$308.41
Toc - Plan #20 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with UNC Health Alliance

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 		$419.17
$475.76
$535.70
$748.64
$1,137.63 		$739.84
$796.43
$856.37
$1,069.31 		$1,060.51
$1,117.10
$1,177.04
$1,389.98 		$1,381.18
$1,437.77
$1,497.71
$1,710.65 		$320.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.34
$951.52
$1,071.40
$1,497.28
$2,275.26 		$1,159.01
$1,272.19
$1,392.07
$1,817.95 		$1,479.68
$1,592.86
$1,712.74
$2,138.62 		$1,800.35
$1,913.53
$2,033.41
$2,459.29 		$320.67
Toc - Plan #21 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance

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 		$420.85
$477.66
$537.85
$751.64
$1,142.19 		$742.80
$799.61
$859.80
$1,073.59 		$1,064.75
$1,121.56
$1,181.75
$1,395.54 		$1,386.70
$1,443.51
$1,503.70
$1,717.49 		$321.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.70
$955.32
$1,075.70
$1,503.28
$2,284.38 		$1,163.65
$1,277.27
$1,397.65
$1,825.23 		$1,485.60
$1,599.22
$1,719.60
$2,147.18 		$1,807.55
$1,921.17
$2,041.55
$2,469.13 		$321.95
Toc - Plan #22 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Standard 5800 | with UNC Health Alliance

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 		$417.35
$473.69
$533.37
$745.39
$1,132.69 		$736.62
$792.96
$852.64
$1,064.66 		$1,055.89
$1,112.23
$1,171.91
$1,383.93 		$1,375.16
$1,431.50
$1,491.18
$1,703.20 		$319.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.70
$947.38
$1,066.74
$1,490.78
$2,265.38 		$1,153.97
$1,266.65
$1,386.01
$1,810.05 		$1,473.24
$1,585.92
$1,705.28
$2,129.32 		$1,792.51
$1,905.19
$2,024.55
$2,448.59 		$319.27
Toc - Plan #23 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with UNC Health Alliance

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 		$310.94
$352.92
$397.38
$555.34
$843.89 		$548.81
$590.79
$635.25
$793.21 		$786.68
$828.66
$873.12
$1,031.08 		$1,024.55
$1,066.53
$1,110.99
$1,268.95 		$237.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.88
$705.84
$794.76
$1,110.68
$1,687.78 		$859.75
$943.71
$1,032.63
$1,348.55 		$1,097.62
$1,181.58
$1,270.50
$1,586.42 		$1,335.49
$1,419.45
$1,508.37
$1,824.29 		$237.87
Toc - Plan #24 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with UNC Health Alliance

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 		$294.19
$333.91
$375.97
$525.42
$798.43 		$519.25
$558.97
$601.03
$750.48 		$744.31
$784.03
$826.09
$975.54 		$969.37
$1,009.09
$1,051.15
$1,200.60 		$225.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.38
$667.82
$751.94
$1,050.84
$1,596.86 		$813.44
$892.88
$977.00
$1,275.90 		$1,038.50
$1,117.94
$1,202.06
$1,500.96 		$1,263.56
$1,343.00
$1,427.12
$1,726.02 		$225.06
Toc - Plan #25 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze Standard 7500 | with UNC Health Alliance

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 		$294.60
$334.37
$376.50
$526.16
$799.54 		$519.97
$559.74
$601.87
$751.53 		$745.34
$785.11
$827.24
$976.90 		$970.71
$1,010.48
$1,052.61
$1,202.27 		$225.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.20
$668.74
$753.00
$1,052.32
$1,599.08 		$814.57
$894.11
$978.37
$1,277.69 		$1,039.94
$1,119.48
$1,203.74
$1,503.06 		$1,265.31
$1,344.85
$1,429.11
$1,728.43 		$225.37
Toc - Plan #26 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze 7500 | HSA Eligible | Integrated | with UNC Health Alliance

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 		$308.76
$350.44
$394.60
$551.45
$837.97 		$544.96
$586.64
$630.80
$787.65 		$781.16
$822.84
$867.00
$1,023.85 		$1,017.36
$1,059.04
$1,103.20
$1,260.05 		$236.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.52
$700.88
$789.20
$1,102.90
$1,675.94 		$853.72
$937.08
$1,025.40
$1,339.10 		$1,089.92
$1,173.28
$1,261.60
$1,575.30 		$1,326.12
$1,409.48
$1,497.80
$1,811.50 		$236.20
Toc - Plan #27 Blue Cross and Blue Shield of NC
Bronze

(EPO) Blue Home Bronze 9100 | Integrated | with UNC Health Alliance

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 		$294.78
$334.58
$376.73
$526.48
$800.03 		$520.29
$560.09
$602.24
$751.99 		$745.80
$785.60
$827.75
$977.50 		$971.31
$1,011.11
$1,053.26
$1,203.01 		$225.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.56
$669.16
$753.46
$1,052.96
$1,600.06 		$815.07
$894.67
$978.97
$1,278.47 		$1,040.58
$1,120.18
$1,204.48
$1,503.98 		$1,266.09
$1,345.69
$1,429.99
$1,729.49 		$225.51
Toc - Plan #28 Blue Cross and Blue Shield of NC
Catastrophic

(EPO) Blue Home Catastrophic 9100 | 3 PCP $35 | Integrated | with UNC Health Alliance

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 		$216.22
$245.41
$276.33
$386.17
$586.82 		$381.63
$410.82
$441.74
$551.58 		$547.04
$576.23
$607.15
$716.99 		$712.45
$741.64
$772.56
$882.40 		$165.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432.44
$490.82
$552.66
$772.34
$1,173.64 		$597.85
$656.23
$718.07
$937.75 		$763.26
$821.64
$883.48
$1,103.16 		$928.67
$987.05
$1,048.89
$1,268.57 		$165.41

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #29 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 		$602.87
$684.25
$770.46
$1,076.71
$1,636.16 		$1,064.06
$1,145.44
$1,231.65
$1,537.90 		$1,525.25
$1,606.63
$1,692.84
$1,999.09 		$1,986.44
$2,067.82
$2,154.03
$2,460.28 		$461.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,205.74
$1,368.50
$1,540.92
$2,153.42
$3,272.32 		$1,666.93
$1,829.69
$2,002.11
$2,614.61 		$2,128.12
$2,290.88
$2,463.30
$3,075.80 		$2,589.31
$2,752.07
$2,924.49
$3,536.99 		$461.19
Toc - Plan #30 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 		$773.40
$877.80
$988.40
$1,381.28
$2,098.99 		$1,365.05
$1,469.45
$1,580.05
$1,972.93 		$1,956.70
$2,061.10
$2,171.70
$2,564.58 		$2,548.35
$2,652.75
$2,763.35
$3,156.23 		$591.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,546.80
$1,755.60
$1,976.80
$2,762.56
$4,197.98 		$2,138.45
$2,347.25
$2,568.45
$3,354.21 		$2,730.10
$2,938.90
$3,160.10
$3,945.86 		$3,321.75
$3,530.55
$3,751.75
$4,537.51 		$591.65
Toc - Plan #31 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 		$800.24
$908.26
$1,022.70
$1,429.21
$2,171.83 		$1,412.42
$1,520.44
$1,634.88
$2,041.39 		$2,024.60
$2,132.62
$2,247.06
$2,653.57 		$2,636.78
$2,744.80
$2,859.24
$3,265.75 		$612.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,600.48
$1,816.52
$2,045.40
$2,858.42
$4,343.66 		$2,212.66
$2,428.70
$2,657.58
$3,470.60 		$2,824.84
$3,040.88
$3,269.76
$4,082.78 		$3,437.02
$3,653.06
$3,881.94
$4,694.96 		$612.18
Toc - Plan #32 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 		$603.88
$685.39
$771.74
$1,078.50
$1,638.89 		$1,065.84
$1,147.35
$1,233.70
$1,540.46 		$1,527.80
$1,609.31
$1,695.66
$2,002.42 		$1,989.76
$2,071.27
$2,157.62
$2,464.38 		$461.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,207.76
$1,370.78
$1,543.48
$2,157.00
$3,277.78 		$1,669.72
$1,832.74
$2,005.44
$2,618.96 		$2,131.68
$2,294.70
$2,467.40
$3,080.92 		$2,593.64
$2,756.66
$2,929.36
$3,542.88 		$461.96
Toc - Plan #33 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 		$764.05
$867.18
$976.44
$1,364.57
$2,073.59 		$1,348.54
$1,451.67
$1,560.93
$1,949.06 		$1,933.03
$2,036.16
$2,145.42
$2,533.55 		$2,517.52
$2,620.65
$2,729.91
$3,118.04 		$584.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,528.10
$1,734.36
$1,952.88
$2,729.14
$4,147.18 		$2,112.59
$2,318.85
$2,537.37
$3,313.63 		$2,697.08
$2,903.34
$3,121.86
$3,898.12 		$3,281.57
$3,487.83
$3,706.35
$4,482.61 		$584.49
Toc - Plan #34 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 		$778.12
$883.16
$994.43
$1,389.71
$2,111.80 		$1,373.38
$1,478.42
$1,589.69
$1,984.97 		$1,968.64
$2,073.68
$2,184.95
$2,580.23 		$2,563.90
$2,668.94
$2,780.21
$3,175.49 		$595.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,556.24
$1,766.32
$1,988.86
$2,779.42
$4,223.60 		$2,151.50
$2,361.58
$2,584.12
$3,374.68 		$2,746.76
$2,956.84
$3,179.38
$3,969.94 		$3,342.02
$3,552.10
$3,774.64
$4,565.20 		$595.26

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #35 Aetna CVS Health
Expanded Bronze

(HMO) Bronze: Aetna network of doctors & hospitals+ Low-cost MinuteClinic+ $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,100 $14,200 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 		$313.72
$356.07
$400.94
$560.31
$851.44 		$553.72
$596.07
$640.94
$800.31 		$793.72
$836.07
$880.94
$1,040.31 		$1,033.72
$1,076.07
$1,120.94
$1,280.31 		$240.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.44
$712.14
$801.88
$1,120.62
$1,702.88 		$867.44
$952.14
$1,041.88
$1,360.62 		$1,107.44
$1,192.14
$1,281.88
$1,600.62 		$1,347.44
$1,432.14
$1,521.88
$1,840.62 		$240.00
Toc - Plan #36 Aetna CVS Health
Expanded Bronze

(HMO) Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$8,800 $17,600 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 		$282.30
$320.41
$360.78
$504.19
$766.17 		$498.26
$536.37
$576.74
$720.15 		$714.22
$752.33
$792.70
$936.11 		$930.18
$968.29
$1,008.66
$1,152.07 		$215.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.60
$640.82
$721.56
$1,008.38
$1,532.34 		$780.56
$856.78
$937.52
$1,224.34 		$996.52
$1,072.74
$1,153.48
$1,440.30 		$1,212.48
$1,288.70
$1,369.44
$1,656.26 		$215.96
Toc - Plan #37 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$462.98
$525.48
$591.69
$826.88
$1,256.53 		$817.16
$879.66
$945.87
$1,181.06 		$1,171.34
$1,233.84
$1,300.05
$1,535.24 		$1,525.52
$1,588.02
$1,654.23
$1,889.42 		$354.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.96
$1,050.96
$1,183.38
$1,653.76
$2,513.06 		$1,280.14
$1,405.14
$1,537.56
$2,007.94 		$1,634.32
$1,759.32
$1,891.74
$2,362.12 		$1,988.50
$2,113.50
$2,245.92
$2,716.30 		$354.18
Toc - Plan #38 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$4,300 $8,600 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 		$434.47
$493.13
$555.26
$775.97
$1,179.16 		$766.84
$825.50
$887.63
$1,108.34 		$1,099.21
$1,157.87
$1,220.00
$1,440.71 		$1,431.58
$1,490.24
$1,552.37
$1,773.08 		$332.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.94
$986.26
$1,110.52
$1,551.94
$2,358.32 		$1,201.31
$1,318.63
$1,442.89
$1,884.31 		$1,533.68
$1,651.00
$1,775.26
$2,216.68 		$1,866.05
$1,983.37
$2,107.63
$2,549.05 		$332.37
Toc - Plan #39 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.39
$468.06
$527.03
$736.52
$1,119.22 		$727.87
$783.54
$842.51
$1,052.00 		$1,043.35
$1,099.02
$1,157.99
$1,367.48 		$1,358.83
$1,414.50
$1,473.47
$1,682.96 		$315.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.78
$936.12
$1,054.06
$1,473.04
$2,238.44 		$1,140.26
$1,251.60
$1,369.54
$1,788.52 		$1,455.74
$1,567.08
$1,685.02
$2,104.00 		$1,771.22
$1,882.56
$2,000.50
$2,419.48 		$315.48
Toc - Plan #40 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

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 		$292.59
$332.09
$373.93
$522.56
$794.08 		$516.42
$555.92
$597.76
$746.39 		$740.25
$779.75
$821.59
$970.22 		$964.08
$1,003.58
$1,045.42
$1,194.05 		$223.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.18
$664.18
$747.86
$1,045.12
$1,588.16 		$809.01
$888.01
$971.69
$1,268.95 		$1,032.84
$1,111.84
$1,195.52
$1,492.78 		$1,256.67
$1,335.67
$1,419.35
$1,716.61 		$223.83
Toc - Plan #41 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

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 		$454.45
$515.80
$580.79
$811.65
$1,233.39 		$802.11
$863.46
$928.45
$1,159.31 		$1,149.77
$1,211.12
$1,276.11
$1,506.97 		$1,497.43
$1,558.78
$1,623.77
$1,854.63 		$347.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.90
$1,031.60
$1,161.58
$1,623.30
$2,466.78 		$1,256.56
$1,379.26
$1,509.24
$1,970.96 		$1,604.22
$1,726.92
$1,856.90
$2,318.62 		$1,951.88
$2,074.58
$2,204.56
$2,666.28 		$347.66
Toc - Plan #42 Aetna CVS Health
Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.56
$484.15
$545.15
$761.84
$1,157.69 		$752.88
$810.47
$871.47
$1,088.16 		$1,079.20
$1,136.79
$1,197.79
$1,414.48 		$1,405.52
$1,463.11
$1,524.11
$1,740.80 		$326.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.12
$968.30
$1,090.30
$1,523.68
$2,315.38 		$1,179.44
$1,294.62
$1,416.62
$1,850.00 		$1,505.76
$1,620.94
$1,742.94
$2,176.32 		$1,832.08
$1,947.26
$2,069.26
$2,502.64 		$326.32
Toc - Plan #43 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

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 		$402.75
$457.12
$514.71
$719.30
$1,093.05 		$710.85
$765.22
$822.81
$1,027.40 		$1,018.95
$1,073.32
$1,130.91
$1,335.50 		$1,327.05
$1,381.42
$1,439.01
$1,643.60 		$308.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.50
$914.24
$1,029.42
$1,438.60
$2,186.10 		$1,113.60
$1,222.34
$1,337.52
$1,746.70 		$1,421.70
$1,530.44
$1,645.62
$2,054.80 		$1,729.80
$1,838.54
$1,953.72
$2,362.90 		$308.10

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #44 Cigna Healthcare
Gold

(HMO) Cigna Connect 2100

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

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$782.96
$888.66
$1,000.62
$1,398.36
$2,124.95 		$1,381.92
$1,487.62
$1,599.58
$1,997.32 		$1,980.88
$2,086.58
$2,198.54
$2,596.28 		$2,579.84
$2,685.54
$2,797.50
$3,195.24 		$598.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,565.92
$1,777.32
$2,001.24
$2,796.72
$4,249.90 		$2,164.88
$2,376.28
$2,600.20
$3,395.68 		$2,763.84
$2,975.24
$3,199.16
$3,994.64 		$3,362.80
$3,574.20
$3,798.12
$4,593.60 		$598.96
Toc - Plan #45 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.64
$522.83
$588.70
$822.70
$1,250.18 		$813.03
$875.22
$941.09
$1,175.09 		$1,165.42
$1,227.61
$1,293.48
$1,527.48 		$1,517.81
$1,580.00
$1,645.87
$1,879.87 		$352.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.28
$1,045.66
$1,177.40
$1,645.40
$2,500.36 		$1,273.67
$1,398.05
$1,529.79
$1,997.79 		$1,626.06
$1,750.44
$1,882.18
$2,350.18 		$1,978.45
$2,102.83
$2,234.57
$2,702.57 		$352.39
Toc - Plan #46 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7800

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

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$484.90
$550.36
$619.70
$866.03
$1,316.02 		$855.85
$921.31
$990.65
$1,236.98 		$1,226.80
$1,292.26
$1,361.60
$1,607.93 		$1,597.75
$1,663.21
$1,732.55
$1,978.88 		$370.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.80
$1,100.72
$1,239.40
$1,732.06
$2,632.04 		$1,340.75
$1,471.67
$1,610.35
$2,103.01 		$1,711.70
$1,842.62
$1,981.30
$2,473.96 		$2,082.65
$2,213.57
$2,352.25
$2,844.91 		$370.95
Toc - Plan #47 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5900

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$478.63
$543.24
$611.68
$854.83
$1,298.99 		$844.78
$909.39
$977.83
$1,220.98 		$1,210.93
$1,275.54
$1,343.98
$1,587.13 		$1,577.08
$1,641.69
$1,710.13
$1,953.28 		$366.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.26
$1,086.48
$1,223.36
$1,709.66
$2,597.98 		$1,323.41
$1,452.63
$1,589.51
$2,075.81 		$1,689.56
$1,818.78
$1,955.66
$2,441.96 		$2,055.71
$2,184.93
$2,321.81
$2,808.11 		$366.15
Toc - Plan #48 Cigna Healthcare
Silver

(HMO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$565.06
$641.34
$722.15
$1,009.20
$1,533.57 		$997.33
$1,073.61
$1,154.42
$1,441.47 		$1,429.60
$1,505.88
$1,586.69
$1,873.74 		$1,861.87
$1,938.15
$2,018.96
$2,306.01 		$432.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,130.12
$1,282.68
$1,444.30
$2,018.40
$3,067.14 		$1,562.39
$1,714.95
$1,876.57
$2,450.67 		$1,994.66
$2,147.22
$2,308.84
$2,882.94 		$2,426.93
$2,579.49
$2,741.11
$3,315.21 		$432.27
Toc - Plan #49 Cigna Healthcare
Silver

(HMO) Cigna Connect 4500

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$564.28
$640.46
$721.16
$1,007.81
$1,531.47 		$995.96
$1,072.14
$1,152.84
$1,439.49 		$1,427.64
$1,503.82
$1,584.52
$1,871.17 		$1,859.32
$1,935.50
$2,016.20
$2,302.85 		$431.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,128.56
$1,280.92
$1,442.32
$2,015.62
$3,062.94 		$1,560.24
$1,712.60
$1,874.00
$2,447.30 		$1,991.92
$2,144.28
$2,305.68
$2,878.98 		$2,423.60
$2,575.96
$2,737.36
$3,310.66 		$431.68
Toc - Plan #50 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$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 		$566.68
$643.18
$724.21
$1,012.09
$1,537.96 		$1,000.19
$1,076.69
$1,157.72
$1,445.60 		$1,433.70
$1,510.20
$1,591.23
$1,879.11 		$1,867.21
$1,943.71
$2,024.74
$2,312.62 		$433.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,133.36
$1,286.36
$1,448.42
$2,024.18
$3,075.92 		$1,566.87
$1,719.87
$1,881.93
$2,457.69 		$2,000.38
$2,153.38
$2,315.44
$2,891.20 		$2,433.89
$2,586.89
$2,748.95
$3,324.71 		$433.51
Toc - Plan #51 Cigna Healthcare
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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 		$569.59
$646.48
$727.94
$1,017.29
$1,545.87 		$1,005.33
$1,082.22
$1,163.68
$1,453.03 		$1,441.07
$1,517.96
$1,599.42
$1,888.77 		$1,876.81
$1,953.70
$2,035.16
$2,324.51 		$435.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,139.18
$1,292.96
$1,455.88
$2,034.58
$3,091.74 		$1,574.92
$1,728.70
$1,891.62
$2,470.32 		$2,010.66
$2,164.44
$2,327.36
$2,906.06 		$2,446.40
$2,600.18
$2,763.10
$3,341.80 		$435.74
Toc - Plan #52 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7050

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$480.89
$545.81
$614.58
$858.87
$1,305.14 		$848.77
$913.69
$982.46
$1,226.75 		$1,216.65
$1,281.57
$1,350.34
$1,594.63 		$1,584.53
$1,649.45
$1,718.22
$1,962.51 		$367.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$961.78
$1,091.62
$1,229.16
$1,717.74
$2,610.28 		$1,329.66
$1,459.50
$1,597.04
$2,085.62 		$1,697.54
$1,827.38
$1,964.92
$2,453.50 		$2,065.42
$2,195.26
$2,332.80
$2,821.38 		$367.88
Toc - Plan #53 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$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 		$567.91
$644.57
$725.79
$1,014.28
$1,541.30 		$1,002.36
$1,079.02
$1,160.24
$1,448.73 		$1,436.81
$1,513.47
$1,594.69
$1,883.18 		$1,871.26
$1,947.92
$2,029.14
$2,317.63 		$434.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,135.82
$1,289.14
$1,451.58
$2,028.56
$3,082.60 		$1,570.27
$1,723.59
$1,886.03
$2,463.01 		$2,004.72
$2,158.04
$2,320.48
$2,897.46 		$2,439.17
$2,592.49
$2,754.93
$3,331.91 		$434.45
Toc - Plan #54 Cigna Healthcare
Bronze

(HMO) Cigna Simple Choice 9100

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

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 		$456.11
$517.69
$582.91
$814.62
$1,237.89 		$805.04
$866.62
$931.84
$1,163.55 		$1,153.97
$1,215.55
$1,280.77
$1,512.48 		$1,502.90
$1,564.48
$1,629.70
$1,861.41 		$348.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912.22
$1,035.38
$1,165.82
$1,629.24
$2,475.78 		$1,261.15
$1,384.31
$1,514.75
$1,978.17 		$1,610.08
$1,733.24
$1,863.68
$2,327.10 		$1,959.01
$2,082.17
$2,212.61
$2,676.03 		$348.93
Toc - Plan #55 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Simple Choice 7500

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

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 		$475.46
$539.64
$607.63
$849.16
$1,290.39 		$839.18
$903.36
$971.35
$1,212.88 		$1,202.90
$1,267.08
$1,335.07
$1,576.60 		$1,566.62
$1,630.80
$1,698.79
$1,940.32 		$363.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$950.92
$1,079.28
$1,215.26
$1,698.32
$2,580.78 		$1,314.64
$1,443.00
$1,578.98
$2,062.04 		$1,678.36
$1,806.72
$1,942.70
$2,425.76 		$2,042.08
$2,170.44
$2,306.42
$2,789.48 		$363.72
Toc - Plan #56 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 0A

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

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 		$508.26
$576.87
$649.55
$907.75
$1,379.41 		$897.08
$965.69
$1,038.37
$1,296.57 		$1,285.90
$1,354.51
$1,427.19
$1,685.39 		$1,674.72
$1,743.33
$1,816.01
$2,074.21 		$388.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,016.52
$1,153.74
$1,299.10
$1,815.50
$2,758.82 		$1,405.34
$1,542.56
$1,687.92
$2,204.32 		$1,794.16
$1,931.38
$2,076.74
$2,593.14 		$2,182.98
$2,320.20
$2,465.56
$2,981.96 		$388.82
Toc - Plan #57 Cigna Healthcare
Silver

(HMO) Cigna Simple Choice 5800

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

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 		$564.54
$640.76
$721.49
$1,008.27
$1,532.17 		$996.42
$1,072.64
$1,153.37
$1,440.15 		$1,428.30
$1,504.52
$1,585.25
$1,872.03 		$1,860.18
$1,936.40
$2,017.13
$2,303.91 		$431.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,129.08
$1,281.52
$1,442.98
$2,016.54
$3,064.34 		$1,560.96
$1,713.40
$1,874.86
$2,448.42 		$1,992.84
$2,145.28
$2,306.74
$2,880.30 		$2,424.72
$2,577.16
$2,738.62
$3,312.18 		$431.88
Toc - Plan #58 Cigna Healthcare
Gold

(HMO) Cigna Simple Choice 2000

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

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 		$787.03
$893.28
$1,005.83
$1,405.64
$2,136.01 		$1,389.11
$1,495.36
$1,607.91
$2,007.72 		$1,991.19
$2,097.44
$2,209.99
$2,609.80 		$2,593.27
$2,699.52
$2,812.07
$3,211.88 		$602.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,574.06
$1,786.56
$2,011.66
$2,811.28
$4,272.02 		$2,176.14
$2,388.64
$2,613.74
$3,413.36 		$2,778.22
$2,990.72
$3,215.82
$4,015.44 		$3,380.30
$3,592.80
$3,817.90
$4,617.52 		$602.08
Toc - Plan #59 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$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 		$479.01
$543.68
$612.18
$855.52
$1,300.04 		$845.46
$910.13
$978.63
$1,221.97 		$1,211.91
$1,276.58
$1,345.08
$1,588.42 		$1,578.36
$1,643.03
$1,711.53
$1,954.87 		$366.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.02
$1,087.36
$1,224.36
$1,711.04
$2,600.08 		$1,324.47
$1,453.81
$1,590.81
$2,077.49 		$1,690.92
$1,820.26
$1,957.26
$2,443.94 		$2,057.37
$2,186.71
$2,323.71
$2,810.39 		$366.45

ADVERTISEMENT

Friday Health Plans

Local: 1-844-465-5500 | Toll Free: 1-844-465-5500 | TTY: 1-800-659-2656
Toc - Plan #60 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 		$209.79
$238.11
$268.11
$374.68
$569.36 		$370.28
$398.60
$428.60
$535.17 		$530.77
$559.09
$589.09
$695.66 		$691.26
$719.58
$749.58
$856.15 		$160.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$419.58
$476.22
$536.22
$749.36
$1,138.72 		$580.07
$636.71
$696.71
$909.85 		$740.56
$797.20
$857.20
$1,070.34 		$901.05
$957.69
$1,017.69
$1,230.83 		$160.49
Toc - Plan #61 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 		$275.02
$312.14
$351.47
$491.18
$746.39 		$485.41
$522.53
$561.86
$701.57 		$695.80
$732.92
$772.25
$911.96 		$906.19
$943.31
$982.64
$1,122.35 		$210.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.04
$624.28
$702.94
$982.36
$1,492.78 		$760.43
$834.67
$913.33
$1,192.75 		$970.82
$1,045.06
$1,123.72
$1,403.14 		$1,181.21
$1,255.45
$1,334.11
$1,613.53 		$210.39
Toc - Plan #62 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 		$277.78
$315.28
$355.00
$496.12
$753.90 		$490.28
$527.78
$567.50
$708.62 		$702.78
$740.28
$780.00
$921.12 		$915.28
$952.78
$992.50
$1,133.62 		$212.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.56
$630.56
$710.00
$992.24
$1,507.80 		$768.06
$843.06
$922.50
$1,204.74 		$980.56
$1,055.56
$1,135.00
$1,417.24 		$1,193.06
$1,268.06
$1,347.50
$1,629.74 		$212.50
Toc - Plan #63 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 		$293.66
$333.30
$375.29
$524.47
$796.98 		$518.31
$557.95
$599.94
$749.12 		$742.96
$782.60
$824.59
$973.77 		$967.61
$1,007.25
$1,049.24
$1,198.42 		$224.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.32
$666.60
$750.58
$1,048.94
$1,593.96 		$811.97
$891.25
$975.23
$1,273.59 		$1,036.62
$1,115.90
$1,199.88
$1,498.24 		$1,261.27
$1,340.55
$1,424.53
$1,722.89 		$224.65
Toc - Plan #64 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 		$383.13
$434.86
$489.64
$684.28
$1,039.82 		$676.23
$727.96
$782.74
$977.38 		$969.33
$1,021.06
$1,075.84
$1,270.48 		$1,262.43
$1,314.16
$1,368.94
$1,563.58 		$293.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.26
$869.72
$979.28
$1,368.56
$2,079.64 		$1,059.36
$1,162.82
$1,272.38
$1,661.66 		$1,352.46
$1,455.92
$1,565.48
$1,954.76 		$1,645.56
$1,749.02
$1,858.58
$2,247.86 		$293.10
Toc - Plan #65 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 		$402.80
$457.17
$514.78
$719.40
$1,093.19 		$710.94
$765.31
$822.92
$1,027.54 		$1,019.08
$1,073.45
$1,131.06
$1,335.68 		$1,327.22
$1,381.59
$1,439.20
$1,643.82 		$308.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.60
$914.34
$1,029.56
$1,438.80
$2,186.38 		$1,113.74
$1,222.48
$1,337.70
$1,746.94 		$1,421.88
$1,530.62
$1,645.84
$2,055.08 		$1,730.02
$1,838.76
$1,953.98
$2,363.22 		$308.14
Toc - Plan #66 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 		$274.82
$311.92
$351.22
$490.82
$745.85 		$485.06
$522.16
$561.46
$701.06 		$695.30
$732.40
$771.70
$911.30 		$905.54
$942.64
$981.94
$1,121.54 		$210.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.64
$623.84
$702.44
$981.64
$1,491.70 		$759.88
$834.08
$912.68
$1,191.88 		$970.12
$1,044.32
$1,122.92
$1,402.12 		$1,180.36
$1,254.56
$1,333.16
$1,612.36 		$210.24
Toc - Plan #67 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 		$393.28
$446.37
$502.61
$702.39
$1,067.35 		$694.14
$747.23
$803.47
$1,003.25 		$995.00
$1,048.09
$1,104.33
$1,304.11 		$1,295.86
$1,348.95
$1,405.19
$1,604.97 		$300.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.56
$892.74
$1,005.22
$1,404.78
$2,134.70 		$1,087.42
$1,193.60
$1,306.08
$1,705.64 		$1,388.28
$1,494.46
$1,606.94
$2,006.50 		$1,689.14
$1,795.32
$1,907.80
$2,307.36 		$300.86
Toc - Plan #68 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 		$418.46
$474.95
$534.79
$747.37
$1,135.71 		$738.58
$795.07
$854.91
$1,067.49 		$1,058.70
$1,115.19
$1,175.03
$1,387.61 		$1,378.82
$1,435.31
$1,495.15
$1,707.73 		$320.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.92
$949.90
$1,069.58
$1,494.74
$2,271.42 		$1,157.04
$1,270.02
$1,389.70
$1,814.86 		$1,477.16
$1,590.14
$1,709.82
$2,134.98 		$1,797.28
$1,910.26
$2,029.94
$2,455.10 		$320.12
Toc - Plan #69 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 		$274.67
$311.75
$351.02
$490.56
$745.45 		$484.79
$521.87
$561.14
$700.68 		$694.91
$731.99
$771.26
$910.80 		$905.03
$942.11
$981.38
$1,120.92 		$210.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.34
$623.50
$702.04
$981.12
$1,490.90 		$759.46
$833.62
$912.16
$1,191.24 		$969.58
$1,043.74
$1,122.28
$1,401.36 		$1,179.70
$1,253.86
$1,332.40
$1,611.48 		$210.12
Toc - Plan #70 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 		$277.43
$314.89
$354.56
$495.49
$752.95 		$489.67
$527.13
$566.80
$707.73 		$701.91
$739.37
$779.04
$919.97 		$914.15
$951.61
$991.28
$1,132.21 		$212.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.86
$629.78
$709.12
$990.98
$1,505.90 		$767.10
$842.02
$921.36
$1,203.22 		$979.34
$1,054.26
$1,133.60
$1,415.46 		$1,191.58
$1,266.50
$1,345.84
$1,627.70 		$212.24
Toc - Plan #71 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 		$274.47
$311.52
$350.77
$490.20
$744.91 		$484.44
$521.49
$560.74
$700.17 		$694.41
$731.46
$770.71
$910.14 		$904.38
$941.43
$980.68
$1,120.11 		$209.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.94
$623.04
$701.54
$980.40
$1,489.82 		$758.91
$833.01
$911.51
$1,190.37 		$968.88
$1,042.98
$1,121.48
$1,400.34 		$1,178.85
$1,252.95
$1,331.45
$1,610.31 		$209.97
Toc - Plan #72 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 		$382.79
$434.46
$489.20
$683.65
$1,038.88 		$675.62
$727.29
$782.03
$976.48 		$968.45
$1,020.12
$1,074.86
$1,269.31 		$1,261.28
$1,312.95
$1,367.69
$1,562.14 		$292.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.58
$868.92
$978.40
$1,367.30
$2,077.76 		$1,058.41
$1,161.75
$1,271.23
$1,660.13 		$1,351.24
$1,454.58
$1,564.06
$1,952.96 		$1,644.07
$1,747.41
$1,856.89
$2,245.79 		$292.83
Toc - Plan #73 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 		$387.44
$439.75
$495.15
$691.97
$1,051.52 		$683.83
$736.14
$791.54
$988.36 		$980.22
$1,032.53
$1,087.93
$1,284.75 		$1,276.61
$1,328.92
$1,384.32
$1,581.14 		$296.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.88
$879.50
$990.30
$1,383.94
$2,103.04 		$1,071.27
$1,175.89
$1,286.69
$1,680.33 		$1,367.66
$1,472.28
$1,583.08
$1,976.72 		$1,664.05
$1,768.67
$1,879.47
$2,273.11 		$296.39
Toc - Plan #74 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 		$395.43
$448.82
$505.36
$706.24
$1,073.21 		$697.94
$751.33
$807.87
$1,008.75 		$1,000.45
$1,053.84
$1,110.38
$1,311.26 		$1,302.96
$1,356.35
$1,412.89
$1,613.77 		$302.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.86
$897.64
$1,010.72
$1,412.48
$2,146.42 		$1,093.37
$1,200.15
$1,313.23
$1,714.99 		$1,395.88
$1,502.66
$1,615.74
$2,017.50 		$1,698.39
$1,805.17
$1,918.25
$2,320.01 		$302.51
Toc - Plan #75 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 		$392.93
$445.97
$502.16
$701.77
$1,066.41 		$693.52
$746.56
$802.75
$1,002.36 		$994.11
$1,047.15
$1,103.34
$1,302.95 		$1,294.70
$1,347.74
$1,403.93
$1,603.54 		$300.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.86
$891.94
$1,004.32
$1,403.54
$2,132.82 		$1,086.45
$1,192.53
$1,304.91
$1,704.13 		$1,387.04
$1,493.12
$1,605.50
$2,004.72 		$1,687.63
$1,793.71
$1,906.09
$2,305.31 		$300.59
Toc - Plan #76 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 		$402.45
$456.78
$514.33
$718.77
$1,092.25 		$710.32
$764.65
$822.20
$1,026.64 		$1,018.19
$1,072.52
$1,130.07
$1,334.51 		$1,326.06
$1,380.39
$1,437.94
$1,642.38 		$307.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.90
$913.56
$1,028.66
$1,437.54
$2,184.50 		$1,112.77
$1,221.43
$1,336.53
$1,745.41 		$1,420.64
$1,529.30
$1,644.40
$2,053.28 		$1,728.51
$1,837.17
$1,952.27
$2,361.15 		$307.87
Toc - Plan #77 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 		$418.11
$474.56
$534.35
$746.75
$1,134.76 		$737.97
$794.42
$854.21
$1,066.61 		$1,057.83
$1,114.28
$1,174.07
$1,386.47 		$1,377.69
$1,434.14
$1,493.93
$1,706.33 		$319.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.22
$949.12
$1,068.70
$1,493.50
$2,269.52 		$1,156.08
$1,268.98
$1,388.56
$1,813.36 		$1,475.94
$1,588.84
$1,708.42
$2,133.22 		$1,795.80
$1,908.70
$2,028.28
$2,453.08 		$319.86
Toc - Plan #78 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 		$274.67
$311.75
$351.02
$490.56
$745.45 		$484.79
$521.87
$561.14
$700.68 		$694.91
$731.99
$771.26
$910.80 		$905.03
$942.11
$981.38
$1,120.92 		$210.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.34
$623.50
$702.04
$981.12
$1,490.90 		$759.46
$833.62
$912.16
$1,191.24 		$969.58
$1,043.74
$1,122.28
$1,401.36 		$1,179.70
$1,253.86
$1,332.40
$1,611.48 		$210.12
Toc - Plan #79 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 		$273.17
$310.05
$349.11
$487.88
$741.38 		$482.14
$519.02
$558.08
$696.85 		$691.11
$727.99
$767.05
$905.82 		$900.08
$936.96
$976.02
$1,114.79 		$208.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.34
$620.10
$698.22
$975.76
$1,482.76 		$755.31
$829.07
$907.19
$1,184.73 		$964.28
$1,038.04
$1,116.16
$1,393.70 		$1,173.25
$1,247.01
$1,325.13
$1,602.67 		$208.97
Toc - Plan #80 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 		$379.76
$431.02
$485.33
$678.24
$1,030.66 		$670.27
$721.53
$775.84
$968.75 		$960.78
$1,012.04
$1,066.35
$1,259.26 		$1,251.29
$1,302.55
$1,356.86
$1,549.77 		$290.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.52
$862.04
$970.66
$1,356.48
$2,061.32 		$1,050.03
$1,152.55
$1,261.17
$1,646.99 		$1,340.54
$1,443.06
$1,551.68
$1,937.50 		$1,631.05
$1,733.57
$1,842.19
$2,228.01 		$290.51
Toc - Plan #81 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 		$416.36
$472.57
$532.11
$743.62
$1,130.01 		$734.88
$791.09
$850.63
$1,062.14 		$1,053.40
$1,109.61
$1,169.15
$1,380.66 		$1,371.92
$1,428.13
$1,487.67
$1,699.18 		$318.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.72
$945.14
$1,064.22
$1,487.24
$2,260.02 		$1,151.24
$1,263.66
$1,382.74
$1,805.76 		$1,469.76
$1,582.18
$1,701.26
$2,124.28 		$1,788.28
$1,900.70
$2,019.78
$2,442.80 		$318.52

‡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 Nash County here.

Nash County is in “Rating Area 14” of North Carolina.

Currently, there are 81 plans offered in Rating Area 14.

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2023 Obamacare Plans for Nash County, NC

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