Obamacare 2023 Rates for Tuscarawas County

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

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, 110 Plans and 2023 Rates for Tuscarawas County, Ohio

Below, you’ll find a summary of the 110 plans for Tuscarawas County, Ohio and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Tuscarawas County Resources

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AultCare Insurance Company

Local: 1-330-363-6360 | Toll Free: 1-800-344-8858 | TTY: 1-171-1-
Toc - Plan #1 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$484.39
$549.78
$619.04
$865.11
$1,314.62 		$854.94
$920.33
$989.59
$1,235.66 		$1,225.49
$1,290.88
$1,360.14
$1,606.21 		$1,596.04
$1,661.43
$1,730.69
$1,976.76 		$370.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$968.78
$1,099.56
$1,238.08
$1,730.22
$2,629.24 		$1,339.33
$1,470.11
$1,608.63
$2,100.77 		$1,709.88
$1,840.66
$1,979.18
$2,471.32 		$2,080.43
$2,211.21
$2,349.73
$2,841.87 		$370.55
Toc - Plan #2 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$601.84
$683.08
$769.15
$1,074.88
$1,633.38 		$1,062.25
$1,143.49
$1,229.56
$1,535.29 		$1,522.66
$1,603.90
$1,689.97
$1,995.70 		$1,983.07
$2,064.31
$2,150.38
$2,456.11 		$460.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,203.68
$1,366.16
$1,538.30
$2,149.76
$3,266.76 		$1,664.09
$1,826.57
$1,998.71
$2,610.17 		$2,124.50
$2,286.98
$2,459.12
$3,070.58 		$2,584.91
$2,747.39
$2,919.53
$3,530.99 		$460.41
Toc - Plan #3 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1100 No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 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 		$757.97
$860.29
$968.68
$1,353.72
$2,057.11 		$1,337.81
$1,440.13
$1,548.52
$1,933.56 		$1,917.65
$2,019.97
$2,128.36
$2,513.40 		$2,497.49
$2,599.81
$2,708.20
$3,093.24 		$579.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,515.94
$1,720.58
$1,937.36
$2,707.44
$4,114.22 		$2,095.78
$2,300.42
$2,517.20
$3,287.28 		$2,675.62
$2,880.26
$3,097.04
$3,867.12 		$3,255.46
$3,460.10
$3,676.88
$4,446.96 		$579.84
Toc - Plan #4 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic Select

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$234.90
$266.60
$300.19
$419.52
$637.49 		$414.59
$446.29
$479.88
$599.21 		$594.28
$625.98
$659.57
$778.90 		$773.97
$805.67
$839.26
$958.59 		$179.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$469.80
$533.20
$600.38
$839.04
$1,274.98 		$649.49
$712.89
$780.07
$1,018.73 		$829.18
$892.58
$959.76
$1,198.42 		$1,008.87
$1,072.27
$1,139.45
$1,378.11 		$179.69
Toc - Plan #5 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 Select

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.02
$421.10
$474.16
$662.64
$1,006.94 		$654.85
$704.93
$757.99
$946.47 		$938.68
$988.76
$1,041.82
$1,230.30 		$1,222.51
$1,272.59
$1,325.65
$1,514.13 		$283.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.04
$842.20
$948.32
$1,325.28
$2,013.88 		$1,025.87
$1,126.03
$1,232.15
$1,609.11 		$1,309.70
$1,409.86
$1,515.98
$1,892.94 		$1,593.53
$1,693.69
$1,799.81
$2,176.77 		$283.83
Toc - Plan #6 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 Select

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.92
$522.01
$587.78
$821.42
$1,248.22 		$811.76
$873.85
$939.62
$1,173.26 		$1,163.60
$1,225.69
$1,291.46
$1,525.10 		$1,515.44
$1,577.53
$1,643.30
$1,876.94 		$351.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919.84
$1,044.02
$1,175.56
$1,642.84
$2,496.44 		$1,271.68
$1,395.86
$1,527.40
$1,994.68 		$1,623.52
$1,747.70
$1,879.24
$2,346.52 		$1,975.36
$2,099.54
$2,231.08
$2,698.36 		$351.84
Toc - Plan #7 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1100 Select

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 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 		$580.21
$658.54
$741.51
$1,036.25
$1,574.68 		$1,024.07
$1,102.40
$1,185.37
$1,480.11 		$1,467.93
$1,546.26
$1,629.23
$1,923.97 		$1,911.79
$1,990.12
$2,073.09
$2,367.83 		$443.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,160.42
$1,317.08
$1,483.02
$2,072.50
$3,149.36 		$1,604.28
$1,760.94
$1,926.88
$2,516.36 		$2,048.14
$2,204.80
$2,370.74
$2,960.22 		$2,492.00
$2,648.66
$2,814.60
$3,404.08 		$443.86
Toc - Plan #8 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$310.06
$351.91
$396.25
$553.76
$841.49 		$547.25
$589.10
$633.44
$790.95 		$784.44
$826.29
$870.63
$1,028.14 		$1,021.63
$1,063.48
$1,107.82
$1,265.33 		$237.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620.12
$703.82
$792.50
$1,107.52
$1,682.98 		$857.31
$941.01
$1,029.69
$1,344.71 		$1,094.50
$1,178.20
$1,266.88
$1,581.90 		$1,331.69
$1,415.39
$1,504.07
$1,819.09 		$237.19
Toc - Plan #9 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$489.75
$555.86
$625.89
$874.68
$1,329.16 		$864.40
$930.51
$1,000.54
$1,249.33 		$1,239.05
$1,305.16
$1,375.19
$1,623.98 		$1,613.70
$1,679.81
$1,749.84
$1,998.63 		$374.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$979.50
$1,111.72
$1,251.78
$1,749.36
$2,658.32 		$1,354.15
$1,486.37
$1,626.43
$2,124.01 		$1,728.80
$1,861.02
$2,001.08
$2,498.66 		$2,103.45
$2,235.67
$2,375.73
$2,873.31 		$374.65
Toc - Plan #10 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$607.10
$689.05
$775.87
$1,084.27
$1,647.65 		$1,071.53
$1,153.48
$1,240.30
$1,548.70 		$1,535.96
$1,617.91
$1,704.73
$2,013.13 		$2,000.39
$2,082.34
$2,169.16
$2,477.56 		$464.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,214.20
$1,378.10
$1,551.74
$2,168.54
$3,295.30 		$1,678.63
$1,842.53
$2,016.17
$2,632.97 		$2,143.06
$2,306.96
$2,480.60
$3,097.40 		$2,607.49
$2,771.39
$2,945.03
$3,561.83 		$464.43
Toc - Plan #11 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1100

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 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 		$765.88
$869.27
$978.79
$1,367.85
$2,078.58 		$1,351.77
$1,455.16
$1,564.68
$1,953.74 		$1,937.66
$2,041.05
$2,150.57
$2,539.63 		$2,523.55
$2,626.94
$2,736.46
$3,125.52 		$585.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,531.76
$1,738.54
$1,957.58
$2,735.70
$4,157.16 		$2,117.65
$2,324.43
$2,543.47
$3,321.59 		$2,703.54
$2,910.32
$3,129.36
$3,907.48 		$3,289.43
$3,496.21
$3,715.25
$4,493.37 		$585.89
Toc - Plan #12 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$306.69
$348.09
$391.95
$547.75
$832.35 		$541.31
$582.71
$626.57
$782.37 		$775.93
$817.33
$861.19
$1,016.99 		$1,010.55
$1,051.95
$1,095.81
$1,251.61 		$234.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.38
$696.18
$783.90
$1,095.50
$1,664.70 		$848.00
$930.80
$1,018.52
$1,330.12 		$1,082.62
$1,165.42
$1,253.14
$1,564.74 		$1,317.24
$1,400.04
$1,487.76
$1,799.36 		$234.62
Toc - Plan #13 AultCare Insurance Company
Gold

(PPO) AultCare Gold 1100 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 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 		$574.22
$651.73
$733.84
$1,025.55
$1,558.42 		$1,013.49
$1,091.00
$1,173.11
$1,464.82 		$1,452.76
$1,530.27
$1,612.38
$1,904.09 		$1,892.03
$1,969.54
$2,051.65
$2,343.36 		$439.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,148.44
$1,303.46
$1,467.68
$2,051.10
$3,116.84 		$1,587.71
$1,742.73
$1,906.95
$2,490.37 		$2,026.98
$2,182.00
$2,346.22
$2,929.64 		$2,466.25
$2,621.27
$2,785.49
$3,368.91 		$439.27
Toc - Plan #14 AultCare Insurance Company
Silver

(PPO) AultCare Silver 5000 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$455.94
$517.49
$582.69
$814.30
$1,237.41 		$804.73
$866.28
$931.48
$1,163.09 		$1,153.52
$1,215.07
$1,280.27
$1,511.88 		$1,502.31
$1,563.86
$1,629.06
$1,860.67 		$348.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.88
$1,034.98
$1,165.38
$1,628.60
$2,474.82 		$1,260.67
$1,383.77
$1,514.17
$1,977.39 		$1,609.46
$1,732.56
$1,862.96
$2,326.18 		$1,958.25
$2,081.35
$2,211.75
$2,674.97 		$348.79
Toc - Plan #15 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 5750 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.96
$416.50
$468.97
$655.39
$995.93 		$647.68
$697.22
$749.69
$936.11 		$928.40
$977.94
$1,030.41
$1,216.83 		$1,209.12
$1,258.66
$1,311.13
$1,497.55 		$280.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.92
$833.00
$937.94
$1,310.78
$1,991.86 		$1,014.64
$1,113.72
$1,218.66
$1,591.50 		$1,295.36
$1,394.44
$1,499.38
$1,872.22 		$1,576.08
$1,675.16
$1,780.10
$2,152.94 		$280.72
Toc - Plan #16 AultCare Insurance Company
Catastrophic

(PPO) AultCare Catastrophic Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$232.35
$263.71
$296.93
$414.96
$630.57 		$410.09
$441.45
$474.67
$592.70 		$587.83
$619.19
$652.41
$770.44 		$765.57
$796.93
$830.15
$948.18 		$177.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$464.70
$527.42
$593.86
$829.92
$1,261.14 		$642.44
$705.16
$771.60
$1,007.66 		$820.18
$882.90
$949.34
$1,185.40 		$997.92
$1,060.64
$1,127.08
$1,363.14 		$177.74
Toc - Plan #17 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$535.03
$607.25
$683.76
$955.55
$1,452.06 		$944.32
$1,016.54
$1,093.05
$1,364.84 		$1,353.61
$1,425.83
$1,502.34
$1,774.13 		$1,762.90
$1,835.12
$1,911.63
$2,183.42 		$409.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,070.06
$1,214.50
$1,367.52
$1,911.10
$2,904.12 		$1,479.35
$1,623.79
$1,776.81
$2,320.39 		$1,888.64
$2,033.08
$2,186.10
$2,729.68 		$2,297.93
$2,442.37
$2,595.39
$3,138.97 		$409.29
Toc - Plan #18 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 Select

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.33
$460.04
$518.00
$723.90
$1,100.04 		$715.40
$770.11
$828.07
$1,033.97 		$1,025.47
$1,080.18
$1,138.14
$1,344.04 		$1,335.54
$1,390.25
$1,448.21
$1,654.11 		$310.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.66
$920.08
$1,036.00
$1,447.80
$2,200.08 		$1,120.73
$1,230.15
$1,346.07
$1,757.87 		$1,430.80
$1,540.22
$1,656.14
$2,067.94 		$1,740.87
$1,850.29
$1,966.21
$2,378.01 		$310.07
Toc - Plan #19 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 No Pediatric Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$529.34
$600.79
$676.49
$945.39
$1,436.61 		$934.28
$1,005.73
$1,081.43
$1,350.33 		$1,339.22
$1,410.67
$1,486.37
$1,755.27 		$1,744.16
$1,815.61
$1,891.31
$2,160.21 		$404.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,058.68
$1,201.58
$1,352.98
$1,890.78
$2,873.22 		$1,463.62
$1,606.52
$1,757.92
$2,295.72 		$1,868.56
$2,011.46
$2,162.86
$2,700.66 		$2,273.50
$2,416.40
$2,567.80
$3,105.60 		$404.94
Toc - Plan #20 AultCare Insurance Company
Silver

(PPO) AultCare Silver 6850 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.02
$455.15
$512.49
$716.20
$1,088.34 		$707.79
$761.92
$819.26
$1,022.97 		$1,014.56
$1,068.69
$1,126.03
$1,329.74 		$1,321.33
$1,375.46
$1,432.80
$1,636.51 		$306.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.04
$910.30
$1,024.98
$1,432.40
$2,176.68 		$1,108.81
$1,217.07
$1,331.75
$1,739.17 		$1,415.58
$1,523.84
$1,638.52
$2,045.94 		$1,722.35
$1,830.61
$1,945.29
$2,352.71 		$306.77
Toc - Plan #21 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$499.80
$567.27
$638.74
$892.63
$1,356.44 		$882.14
$949.61
$1,021.08
$1,274.97 		$1,264.48
$1,331.95
$1,403.42
$1,657.31 		$1,646.82
$1,714.29
$1,785.76
$2,039.65 		$382.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$999.60
$1,134.54
$1,277.48
$1,785.26
$2,712.88 		$1,381.94
$1,516.88
$1,659.82
$2,167.60 		$1,764.28
$1,899.22
$2,042.16
$2,549.94 		$2,146.62
$2,281.56
$2,424.50
$2,932.28 		$382.34
Toc - Plan #22 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 Select

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.64
$429.75
$483.89
$676.24
$1,027.61 		$668.29
$719.40
$773.54
$965.89 		$957.94
$1,009.05
$1,063.19
$1,255.54 		$1,247.59
$1,298.70
$1,352.84
$1,545.19 		$289.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.28
$859.50
$967.78
$1,352.48
$2,055.22 		$1,046.93
$1,149.15
$1,257.43
$1,642.13 		$1,336.58
$1,438.80
$1,547.08
$1,931.78 		$1,626.23
$1,728.45
$1,836.73
$2,221.43 		$289.65
Toc - Plan #23 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 No Pediatric Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$494.41
$561.16
$631.86
$883.02
$1,341.83 		$872.63
$939.38
$1,010.08
$1,261.24 		$1,250.85
$1,317.60
$1,388.30
$1,639.46 		$1,629.07
$1,695.82
$1,766.52
$2,017.68 		$378.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$988.82
$1,122.32
$1,263.72
$1,766.04
$2,683.66 		$1,367.04
$1,500.54
$1,641.94
$2,144.26 		$1,745.26
$1,878.76
$2,020.16
$2,522.48 		$2,123.48
$2,256.98
$2,398.38
$2,900.70 		$378.22
Toc - Plan #24 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 6850 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.56
$425.12
$478.68
$668.95
$1,016.54 		$661.09
$711.65
$765.21
$955.48 		$947.62
$998.18
$1,051.74
$1,242.01 		$1,234.15
$1,284.71
$1,338.27
$1,528.54 		$286.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.12
$850.24
$957.36
$1,337.90
$2,033.08 		$1,035.65
$1,136.77
$1,243.89
$1,624.43 		$1,322.18
$1,423.30
$1,530.42
$1,910.96 		$1,608.71
$1,709.83
$1,816.95
$2,197.49 		$286.53
Toc - Plan #25 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Standard Bronze Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $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 		$312.24
$354.39
$399.04
$557.65
$847.41 		$551.10
$593.25
$637.90
$796.51 		$789.96
$832.11
$876.76
$1,035.37 		$1,028.82
$1,070.97
$1,115.62
$1,274.23 		$238.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.48
$708.78
$798.08
$1,115.30
$1,694.82 		$863.34
$947.64
$1,036.94
$1,354.16 		$1,102.20
$1,186.50
$1,275.80
$1,593.02 		$1,341.06
$1,425.36
$1,514.66
$1,831.88 		$238.86
Toc - Plan #26 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250

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

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.06
$475.63
$535.55
$748.43
$1,137.32 		$739.64
$796.21
$856.13
$1,069.01 		$1,060.22
$1,116.79
$1,176.71
$1,389.59 		$1,380.80
$1,437.37
$1,497.29
$1,710.17 		$320.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.12
$951.26
$1,071.10
$1,496.86
$2,274.64 		$1,158.70
$1,271.84
$1,391.68
$1,817.44 		$1,479.28
$1,592.42
$1,712.26
$2,138.02 		$1,799.86
$1,913.00
$2,032.84
$2,458.60 		$320.58
Toc - Plan #27 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 Select

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

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.47
$360.32
$405.72
$566.99
$861.60 		$560.33
$603.18
$648.58
$809.85 		$803.19
$846.04
$891.44
$1,052.71 		$1,046.05
$1,088.90
$1,134.30
$1,295.57 		$242.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.94
$720.64
$811.44
$1,133.98
$1,723.20 		$877.80
$963.50
$1,054.30
$1,376.84 		$1,120.66
$1,206.36
$1,297.16
$1,619.70 		$1,363.52
$1,449.22
$1,540.02
$1,862.56 		$242.86
Toc - Plan #28 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.39
$470.32
$529.58
$740.08
$1,124.63 		$731.39
$787.32
$846.58
$1,057.08 		$1,048.39
$1,104.32
$1,163.58
$1,374.08 		$1,365.39
$1,421.32
$1,480.58
$1,691.08 		$317.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.78
$940.64
$1,059.16
$1,480.16
$2,249.26 		$1,145.78
$1,257.64
$1,376.16
$1,797.16 		$1,462.78
$1,574.64
$1,693.16
$2,114.16 		$1,779.78
$1,891.64
$2,010.16
$2,431.16 		$317.00
Toc - Plan #29 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8250 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.93
$356.30
$401.20
$560.67
$851.99 		$554.08
$596.45
$641.35
$800.82 		$794.23
$836.60
$881.50
$1,040.97 		$1,034.38
$1,076.75
$1,121.65
$1,281.12 		$240.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.86
$712.60
$802.40
$1,121.34
$1,703.98 		$868.01
$952.75
$1,042.55
$1,361.49 		$1,108.16
$1,192.90
$1,282.70
$1,601.64 		$1,348.31
$1,433.05
$1,522.85
$1,841.79 		$240.15
Toc - Plan #30 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.95
$463.02
$521.36
$728.60
$1,107.17 		$720.03
$775.10
$833.44
$1,040.68 		$1,032.11
$1,087.18
$1,145.52
$1,352.76 		$1,344.19
$1,399.26
$1,457.60
$1,664.84 		$312.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.90
$926.04
$1,042.72
$1,457.20
$2,214.34 		$1,127.98
$1,238.12
$1,354.80
$1,769.28 		$1,440.06
$1,550.20
$1,666.88
$2,081.36 		$1,752.14
$1,862.28
$1,978.96
$2,393.44 		$312.08
Toc - Plan #31 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 Select

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.06
$350.77
$394.97
$551.97
$838.77 		$545.48
$587.19
$631.39
$788.39 		$781.90
$823.61
$867.81
$1,024.81 		$1,018.32
$1,060.03
$1,104.23
$1,261.23 		$236.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.12
$701.54
$789.94
$1,103.94
$1,677.54 		$854.54
$937.96
$1,026.36
$1,340.36 		$1,090.96
$1,174.38
$1,262.78
$1,576.78 		$1,327.38
$1,410.80
$1,499.20
$1,813.20 		$236.42
Toc - Plan #32 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.42
$457.88
$515.57
$720.50
$1,094.87 		$712.03
$766.49
$824.18
$1,029.11 		$1,020.64
$1,075.10
$1,132.79
$1,337.72 		$1,329.25
$1,383.71
$1,441.40
$1,646.33 		$308.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.84
$915.76
$1,031.14
$1,441.00
$2,189.74 		$1,115.45
$1,224.37
$1,339.75
$1,749.61 		$1,424.06
$1,532.98
$1,648.36
$2,058.22 		$1,732.67
$1,841.59
$1,956.97
$2,366.83 		$308.61
Toc - Plan #33 AultCare Insurance Company
Bronze

(PPO) AultCare Bronze 8550 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.62
$346.88
$390.58
$545.84
$829.45 		$539.42
$580.68
$624.38
$779.64 		$773.22
$814.48
$858.18
$1,013.44 		$1,007.02
$1,048.28
$1,091.98
$1,247.24 		$233.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.24
$693.76
$781.16
$1,091.68
$1,658.90 		$845.04
$927.56
$1,014.96
$1,325.48 		$1,078.84
$1,161.36
$1,248.76
$1,559.28 		$1,312.64
$1,395.16
$1,482.56
$1,793.08 		$233.80
Toc - Plan #34 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$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 		$411.28
$466.80
$525.61
$734.53
$1,116.20 		$725.90
$781.42
$840.23
$1,049.15 		$1,040.52
$1,096.04
$1,154.85
$1,363.77 		$1,355.14
$1,410.66
$1,469.47
$1,678.39 		$314.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.56
$933.60
$1,051.22
$1,469.06
$2,232.40 		$1,137.18
$1,248.22
$1,365.84
$1,783.68 		$1,451.80
$1,562.84
$1,680.46
$2,098.30 		$1,766.42
$1,877.46
$1,995.08
$2,412.92 		$314.62
Toc - Plan #35 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 Select

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$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 		$311.58
$353.63
$398.19
$556.47
$845.60 		$549.93
$591.98
$636.54
$794.82 		$788.28
$830.33
$874.89
$1,033.17 		$1,026.63
$1,068.68
$1,113.24
$1,271.52 		$238.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.16
$707.26
$796.38
$1,112.94
$1,691.20 		$861.51
$945.61
$1,034.73
$1,351.29 		$1,099.86
$1,183.96
$1,273.08
$1,589.64 		$1,338.21
$1,422.31
$1,511.43
$1,827.99 		$238.35
Toc - Plan #36 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$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 		$406.77
$461.68
$519.85
$726.49
$1,103.97 		$717.95
$772.86
$831.03
$1,037.67 		$1,029.13
$1,084.04
$1,142.21
$1,348.85 		$1,340.31
$1,395.22
$1,453.39
$1,660.03 		$311.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.54
$923.36
$1,039.70
$1,452.98
$2,207.94 		$1,124.72
$1,234.54
$1,350.88
$1,764.16 		$1,435.90
$1,545.72
$1,662.06
$2,075.34 		$1,747.08
$1,856.90
$1,973.24
$2,386.52 		$311.18
Toc - Plan #37 AultCare Insurance Company
Expanded Bronze

(PPO) AultCare Bronze 7000 Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$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 		$308.16
$349.76
$393.83
$550.37
$836.34 		$543.90
$585.50
$629.57
$786.11 		$779.64
$821.24
$865.31
$1,021.85 		$1,015.38
$1,056.98
$1,101.05
$1,257.59 		$235.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.32
$699.52
$787.66
$1,100.74
$1,672.68 		$852.06
$935.26
$1,023.40
$1,336.48 		$1,087.80
$1,171.00
$1,259.14
$1,572.22 		$1,323.54
$1,406.74
$1,494.88
$1,807.96 		$235.74
Toc - Plan #38 AultCare Insurance Company
Gold

(PPO) AultCare Standard Gold Select No Pediatric Dental

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

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 		$556.91
$632.09
$711.73
$994.64
$1,511.45 		$982.95
$1,058.13
$1,137.77
$1,420.68 		$1,408.99
$1,484.17
$1,563.81
$1,846.72 		$1,835.03
$1,910.21
$1,989.85
$2,272.76 		$426.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,113.82
$1,264.18
$1,423.46
$1,989.28
$3,022.90 		$1,539.86
$1,690.22
$1,849.50
$2,415.32 		$1,965.90
$2,116.26
$2,275.54
$2,841.36 		$2,391.94
$2,542.30
$2,701.58
$3,267.40 		$426.04
Toc - Plan #39 AultCare Insurance Company
Silver

(PPO) AultCare Standard Silver Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $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 		$382.54
$434.18
$488.88
$683.21
$1,038.21 		$675.18
$726.82
$781.52
$975.85 		$967.82
$1,019.46
$1,074.16
$1,268.49 		$1,260.46
$1,312.10
$1,366.80
$1,561.13 		$292.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.08
$868.36
$977.76
$1,366.42
$2,076.42 		$1,057.72
$1,161.00
$1,270.40
$1,659.06 		$1,350.36
$1,453.64
$1,563.04
$1,951.70 		$1,643.00
$1,746.28
$1,855.68
$2,244.34 		$292.64
Toc - Plan #40 AultCare Insurance Company
Silver

(PPO) AultCare Standard Silver Premier Select No Pediatric Dental

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$360.74
$409.43
$461.02
$644.27
$979.03 		$636.70
$685.39
$736.98
$920.23 		$912.66
$961.35
$1,012.94
$1,196.19 		$1,188.62
$1,237.31
$1,288.90
$1,472.15 		$275.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.48
$818.86
$922.04
$1,288.54
$1,958.06 		$997.44
$1,094.82
$1,198.00
$1,564.50 		$1,273.40
$1,370.78
$1,473.96
$1,840.46 		$1,549.36
$1,646.74
$1,749.92
$2,116.42 		$275.96

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

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

Toc - Plan #41 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$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 		$401.52
$455.73
$513.14
$717.11
$1,089.73 		$708.68
$762.89
$820.30
$1,024.27 		$1,015.84
$1,070.05
$1,127.46
$1,331.43 		$1,323.00
$1,377.21
$1,434.62
$1,638.59 		$307.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.04
$911.46
$1,026.28
$1,434.22
$2,179.46 		$1,110.20
$1,218.62
$1,333.44
$1,741.38 		$1,417.36
$1,525.78
$1,640.60
$2,048.54 		$1,724.52
$1,832.94
$1,947.76
$2,355.70 		$307.16
Toc - Plan #42 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

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 		$379.24
$430.44
$484.67
$677.32
$1,029.26 		$669.36
$720.56
$774.79
$967.44 		$959.48
$1,010.68
$1,064.91
$1,257.56 		$1,249.60
$1,300.80
$1,355.03
$1,547.68 		$290.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.48
$860.88
$969.34
$1,354.64
$2,058.52 		$1,048.60
$1,151.00
$1,259.46
$1,644.76 		$1,338.72
$1,441.12
$1,549.58
$1,934.88 		$1,628.84
$1,731.24
$1,839.70
$2,225.00 		$290.12
Toc - Plan #43 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,600 $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 		$505.88
$574.17
$646.51
$903.50
$1,372.96 		$892.88
$961.17
$1,033.51
$1,290.50 		$1,279.88
$1,348.17
$1,420.51
$1,677.50 		$1,666.88
$1,735.17
$1,807.51
$2,064.50 		$387.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.76
$1,148.34
$1,293.02
$1,807.00
$2,745.92 		$1,398.76
$1,535.34
$1,680.02
$2,194.00 		$1,785.76
$1,922.34
$2,067.02
$2,581.00 		$2,172.76
$2,309.34
$2,454.02
$2,968.00 		$387.00
Toc - Plan #44 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 7450/0% for HSA (+ Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.35
$462.34
$520.59
$727.53
$1,105.55 		$718.97
$773.96
$832.21
$1,039.15 		$1,030.59
$1,085.58
$1,143.83
$1,350.77 		$1,342.21
$1,397.20
$1,455.45
$1,662.39 		$311.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.70
$924.68
$1,041.18
$1,455.06
$2,211.10 		$1,126.32
$1,236.30
$1,352.80
$1,766.68 		$1,437.94
$1,547.92
$1,664.42
$2,078.30 		$1,749.56
$1,859.54
$1,976.04
$2,389.92 		$311.62
Toc - Plan #45 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3200/10% for HSA (+ Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$509.06
$577.78
$650.58
$909.18
$1,381.59 		$898.49
$967.21
$1,040.01
$1,298.61 		$1,287.92
$1,356.64
$1,429.44
$1,688.04 		$1,677.35
$1,746.07
$1,818.87
$2,077.47 		$389.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,018.12
$1,155.56
$1,301.16
$1,818.36
$2,763.18 		$1,407.55
$1,544.99
$1,690.59
$2,207.79 		$1,796.98
$1,934.42
$2,080.02
$2,597.22 		$2,186.41
$2,323.85
$2,469.45
$2,986.65 		$389.43
Toc - Plan #46 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000/20% for HSA (+ Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.68
$468.39
$527.41
$737.05
$1,120.01 		$728.38
$784.09
$843.11
$1,052.75 		$1,044.08
$1,099.79
$1,158.81
$1,368.45 		$1,359.78
$1,415.49
$1,474.51
$1,684.15 		$315.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.36
$936.78
$1,054.82
$1,474.10
$2,240.02 		$1,141.06
$1,252.48
$1,370.52
$1,789.80 		$1,456.76
$1,568.18
$1,686.22
$2,105.50 		$1,772.46
$1,883.88
$2,001.92
$2,421.20 		$315.70
Toc - Plan #47 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5400/0% for HSA ( + Incentives)

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

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 		$517.94
$587.86
$661.93
$925.04
$1,405.69 		$914.16
$984.08
$1,058.15
$1,321.26 		$1,310.38
$1,380.30
$1,454.37
$1,717.48 		$1,706.60
$1,776.52
$1,850.59
$2,113.70 		$396.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,035.88
$1,175.72
$1,323.86
$1,850.08
$2,811.38 		$1,432.10
$1,571.94
$1,720.08
$2,246.30 		$1,828.32
$1,968.16
$2,116.30
$2,642.52 		$2,224.54
$2,364.38
$2,512.52
$3,038.74 		$396.22
Toc - Plan #48 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$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 		$518.21
$588.17
$662.27
$925.52
$1,406.42 		$914.64
$984.60
$1,058.70
$1,321.95 		$1,311.07
$1,381.03
$1,455.13
$1,718.38 		$1,707.50
$1,777.46
$1,851.56
$2,114.81 		$396.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,036.42
$1,176.34
$1,324.54
$1,851.04
$2,812.84 		$1,432.85
$1,572.77
$1,720.97
$2,247.47 		$1,829.28
$1,969.20
$2,117.40
$2,643.90 		$2,225.71
$2,365.63
$2,513.83
$3,040.33 		$396.43
Toc - Plan #49 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,950 $15,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$499.02
$566.39
$637.75
$891.25
$1,354.34 		$880.77
$948.14
$1,019.50
$1,273.00 		$1,262.52
$1,329.89
$1,401.25
$1,654.75 		$1,644.27
$1,711.64
$1,783.00
$2,036.50 		$381.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.04
$1,132.78
$1,275.50
$1,782.50
$2,708.68 		$1,379.79
$1,514.53
$1,657.25
$2,164.25 		$1,761.54
$1,896.28
$2,039.00
$2,546.00 		$2,143.29
$2,278.03
$2,420.75
$2,927.75 		$381.75
Toc - Plan #50 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway X HMO 9100 ( + Incentives)

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

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 		$300.12
$340.64
$383.55
$536.01
$814.53 		$529.71
$570.23
$613.14
$765.60 		$759.30
$799.82
$842.73
$995.19 		$988.89
$1,029.41
$1,072.32
$1,224.78 		$229.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.24
$681.28
$767.10
$1,072.02
$1,629.06 		$829.83
$910.87
$996.69
$1,301.61 		$1,059.42
$1,140.46
$1,226.28
$1,531.20 		$1,289.01
$1,370.05
$1,455.87
$1,760.79 		$229.59
Toc - Plan #51 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 6000/25% ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$502.25
$570.05
$641.88
$897.02
$1,363.11 		$886.47
$954.27
$1,026.10
$1,281.24 		$1,270.69
$1,338.49
$1,410.32
$1,665.46 		$1,654.91
$1,722.71
$1,794.54
$2,049.68 		$384.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,004.50
$1,140.10
$1,283.76
$1,794.04
$2,726.22 		$1,388.72
$1,524.32
$1,667.98
$2,178.26 		$1,772.94
$1,908.54
$2,052.20
$2,562.48 		$2,157.16
$2,292.76
$2,436.42
$2,946.70 		$384.22
Toc - Plan #52 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$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 		$406.95
$461.89
$520.08
$726.81
$1,104.46 		$718.27
$773.21
$831.40
$1,038.13 		$1,029.59
$1,084.53
$1,142.72
$1,349.45 		$1,340.91
$1,395.85
$1,454.04
$1,660.77 		$311.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.90
$923.78
$1,040.16
$1,453.62
$2,208.92 		$1,125.22
$1,235.10
$1,351.48
$1,764.94 		$1,436.54
$1,546.42
$1,662.80
$2,076.26 		$1,747.86
$1,857.74
$1,974.12
$2,387.58 		$311.32
Toc - Plan #53 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$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 		$386.68
$438.88
$494.18
$690.61
$1,049.45 		$682.49
$734.69
$789.99
$986.42 		$978.30
$1,030.50
$1,085.80
$1,282.23 		$1,274.11
$1,326.31
$1,381.61
$1,578.04 		$295.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.36
$877.76
$988.36
$1,381.22
$2,098.90 		$1,069.17
$1,173.57
$1,284.17
$1,677.03 		$1,364.98
$1,469.38
$1,579.98
$1,972.84 		$1,660.79
$1,765.19
$1,875.79
$2,268.65 		$295.81
Toc - Plan #54 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 9100/0% Standard

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

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 		$380.09
$431.40
$485.76
$678.84
$1,031.56 		$670.86
$722.17
$776.53
$969.61 		$961.63
$1,012.94
$1,067.30
$1,260.38 		$1,252.40
$1,303.71
$1,358.07
$1,551.15 		$290.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.18
$862.80
$971.52
$1,357.68
$2,063.12 		$1,050.95
$1,153.57
$1,262.29
$1,648.45 		$1,341.72
$1,444.34
$1,553.06
$1,939.22 		$1,632.49
$1,735.11
$1,843.83
$2,229.99 		$290.77
Toc - Plan #55 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 7500/50% Standard

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

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 		$416.14
$472.32
$531.83
$743.23
$1,129.40 		$734.49
$790.67
$850.18
$1,061.58 		$1,052.84
$1,109.02
$1,168.53
$1,379.93 		$1,371.19
$1,427.37
$1,486.88
$1,698.28 		$318.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.28
$944.64
$1,063.66
$1,486.46
$2,258.80 		$1,150.63
$1,262.99
$1,382.01
$1,804.81 		$1,468.98
$1,581.34
$1,700.36
$2,123.16 		$1,787.33
$1,899.69
$2,018.71
$2,441.51 		$318.35
Toc - Plan #56 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5800/40% Standard

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

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 		$496.24
$563.23
$634.19
$886.28
$1,346.80 		$875.86
$942.85
$1,013.81
$1,265.90 		$1,255.48
$1,322.47
$1,393.43
$1,645.52 		$1,635.10
$1,702.09
$1,773.05
$2,025.14 		$379.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$992.48
$1,126.46
$1,268.38
$1,772.56
$2,693.60 		$1,372.10
$1,506.08
$1,648.00
$2,152.18 		$1,751.72
$1,885.70
$2,027.62
$2,531.80 		$2,131.34
$2,265.32
$2,407.24
$2,911.42 		$379.62
Toc - Plan #57 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X HMO 2000/25% Standard

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

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 		$720.34
$817.59
$920.59
$1,286.53
$1,955.00 		$1,271.40
$1,368.65
$1,471.65
$1,837.59 		$1,822.46
$1,919.71
$2,022.71
$2,388.65 		$2,373.52
$2,470.77
$2,573.77
$2,939.71 		$551.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,440.68
$1,635.18
$1,841.18
$2,573.06
$3,910.00 		$1,991.74
$2,186.24
$2,392.24
$3,124.12 		$2,542.80
$2,737.30
$2,943.30
$3,675.18 		$3,093.86
$3,288.36
$3,494.36
$4,226.24 		$551.06

ADVERTISEMENT

Oscar Insurance Corporation of Ohio

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

Toc - Plan #58 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$353.32
$401.01
$451.53
$631.02
$958.89 		$623.60
$671.29
$721.81
$901.30 		$893.88
$941.57
$992.09
$1,171.58 		$1,164.16
$1,211.85
$1,262.37
$1,441.86 		$270.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.64
$802.02
$903.06
$1,262.04
$1,917.78 		$976.92
$1,072.30
$1,173.34
$1,532.32 		$1,247.20
$1,342.58
$1,443.62
$1,802.60 		$1,517.48
$1,612.86
$1,713.90
$2,072.88 		$270.28
Toc - Plan #59 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 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 		$359.93
$408.51
$459.98
$642.82
$976.83 		$635.27
$683.85
$735.32
$918.16 		$910.61
$959.19
$1,010.66
$1,193.50 		$1,185.95
$1,234.53
$1,286.00
$1,468.84 		$275.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.86
$817.02
$919.96
$1,285.64
$1,953.66 		$995.20
$1,092.36
$1,195.30
$1,560.98 		$1,270.54
$1,367.70
$1,470.64
$1,836.32 		$1,545.88
$1,643.04
$1,745.98
$2,111.66 		$275.34
Toc - Plan #60 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 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 		$355.44
$403.41
$454.24
$634.79
$964.63 		$627.34
$675.31
$726.14
$906.69 		$899.24
$947.21
$998.04
$1,178.59 		$1,171.14
$1,219.11
$1,269.94
$1,450.49 		$271.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.88
$806.82
$908.48
$1,269.58
$1,929.26 		$982.78
$1,078.72
$1,180.38
$1,541.48 		$1,254.68
$1,350.62
$1,452.28
$1,813.38 		$1,526.58
$1,622.52
$1,724.18
$2,085.28 		$271.90
Toc - Plan #61 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Elite- Deductible+PCP Saver Plus

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

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 		$411.28
$466.80
$525.61
$734.53
$1,116.20 		$725.90
$781.42
$840.23
$1,049.15 		$1,040.52
$1,096.04
$1,154.85
$1,363.77 		$1,355.14
$1,410.66
$1,469.47
$1,678.39 		$314.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.56
$933.60
$1,051.22
$1,469.06
$2,232.40 		$1,137.18
$1,248.22
$1,365.84
$1,783.68 		$1,451.80
$1,562.84
$1,680.46
$2,098.30 		$1,766.42
$1,877.46
$1,995.08
$2,412.92 		$314.62
Toc - Plan #62 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433.02
$491.47
$553.39
$773.35
$1,175.19 		$764.27
$822.72
$884.64
$1,104.60 		$1,095.52
$1,153.97
$1,215.89
$1,435.85 		$1,426.77
$1,485.22
$1,547.14
$1,767.10 		$331.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.04
$982.94
$1,106.78
$1,546.70
$2,350.38 		$1,197.29
$1,314.19
$1,438.03
$1,877.95 		$1,528.54
$1,645.44
$1,769.28
$2,209.20 		$1,859.79
$1,976.69
$2,100.53
$2,540.45 		$331.25
Toc - Plan #63 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$424.65
$481.96
$542.69
$758.40
$1,152.47 		$749.50
$806.81
$867.54
$1,083.25 		$1,074.35
$1,131.66
$1,192.39
$1,408.10 		$1,399.20
$1,456.51
$1,517.24
$1,732.95 		$324.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.30
$963.92
$1,085.38
$1,516.80
$2,304.94 		$1,174.15
$1,288.77
$1,410.23
$1,841.65 		$1,499.00
$1,613.62
$1,735.08
$2,166.50 		$1,823.85
$1,938.47
$2,059.93
$2,491.35 		$324.85
Toc - Plan #64 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$432.94
$491.37
$553.28
$773.21
$1,174.97 		$764.13
$822.56
$884.47
$1,104.40 		$1,095.32
$1,153.75
$1,215.66
$1,435.59 		$1,426.51
$1,484.94
$1,546.85
$1,766.78 		$331.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$865.88
$982.74
$1,106.56
$1,546.42
$2,349.94 		$1,197.07
$1,313.93
$1,437.75
$1,877.61 		$1,528.26
$1,645.12
$1,768.94
$2,208.80 		$1,859.45
$1,976.31
$2,100.13
$2,539.99 		$331.19
Toc - Plan #65 Oscar Insurance Corporation of Ohio
Catastrophic

(HMO) Secure

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$256.15
$290.72
$327.35
$457.47
$695.17 		$452.10
$486.67
$523.30
$653.42 		$648.05
$682.62
$719.25
$849.37 		$844.00
$878.57
$915.20
$1,045.32 		$195.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512.30
$581.44
$654.70
$914.94
$1,390.34 		$708.25
$777.39
$850.65
$1,110.89 		$904.20
$973.34
$1,046.60
$1,306.84 		$1,100.15
$1,169.29
$1,242.55
$1,502.79 		$195.95
Toc - Plan #66 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Elite- Deductible+Specialist Saver Plus

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

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 		$411.74
$467.31
$526.19
$735.35
$1,117.43 		$726.71
$782.28
$841.16
$1,050.32 		$1,041.68
$1,097.25
$1,156.13
$1,365.29 		$1,356.65
$1,412.22
$1,471.10
$1,680.26 		$314.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.48
$934.62
$1,052.38
$1,470.70
$2,234.86 		$1,138.45
$1,249.59
$1,367.35
$1,785.67 		$1,453.42
$1,564.56
$1,682.32
$2,100.64 		$1,768.39
$1,879.53
$1,997.29
$2,415.61 		$314.97
Toc - Plan #67 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$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 		$491.72
$558.09
$628.41
$878.20
$1,334.50 		$867.88
$934.25
$1,004.57
$1,254.36 		$1,244.04
$1,310.41
$1,380.73
$1,630.52 		$1,620.20
$1,686.57
$1,756.89
$2,006.68 		$376.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.44
$1,116.18
$1,256.82
$1,756.40
$2,669.00 		$1,359.60
$1,492.34
$1,632.98
$2,132.56 		$1,735.76
$1,868.50
$2,009.14
$2,508.72 		$2,111.92
$2,244.66
$2,385.30
$2,884.88 		$376.16
Toc - Plan #68 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$386.93
$439.15
$494.48
$691.04
$1,050.10 		$682.92
$735.14
$790.47
$987.03 		$978.91
$1,031.13
$1,086.46
$1,283.02 		$1,274.90
$1,327.12
$1,382.45
$1,579.01 		$295.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.86
$878.30
$988.96
$1,382.08
$2,100.20 		$1,069.85
$1,174.29
$1,284.95
$1,678.07 		$1,365.84
$1,470.28
$1,580.94
$1,974.06 		$1,661.83
$1,766.27
$1,876.93
$2,270.05 		$295.99
Toc - Plan #69 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$427.34
$485.02
$546.13
$763.21
$1,159.77 		$754.25
$811.93
$873.04
$1,090.12 		$1,081.16
$1,138.84
$1,199.95
$1,417.03 		$1,408.07
$1,465.75
$1,526.86
$1,743.94 		$326.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.68
$970.04
$1,092.26
$1,526.42
$2,319.54 		$1,181.59
$1,296.95
$1,419.17
$1,853.33 		$1,508.50
$1,623.86
$1,746.08
$2,180.24 		$1,835.41
$1,950.77
$2,072.99
$2,507.15 		$326.91
Toc - Plan #70 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$440.76
$500.25
$563.28
$787.18
$1,196.20 		$777.93
$837.42
$900.45
$1,124.35 		$1,115.10
$1,174.59
$1,237.62
$1,461.52 		$1,452.27
$1,511.76
$1,574.79
$1,798.69 		$337.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.52
$1,000.50
$1,126.56
$1,574.36
$2,392.40 		$1,218.69
$1,337.67
$1,463.73
$1,911.53 		$1,555.86
$1,674.84
$1,800.90
$2,248.70 		$1,893.03
$2,012.01
$2,138.07
$2,585.87 		$337.17
Toc - Plan #71 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$461.26
$523.52
$589.48
$823.80
$1,251.84 		$814.12
$876.38
$942.34
$1,176.66 		$1,166.98
$1,229.24
$1,295.20
$1,529.52 		$1,519.84
$1,582.10
$1,648.06
$1,882.38 		$352.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.52
$1,047.04
$1,178.96
$1,647.60
$2,503.68 		$1,275.38
$1,399.90
$1,531.82
$2,000.46 		$1,628.24
$1,752.76
$1,884.68
$2,353.32 		$1,981.10
$2,105.62
$2,237.54
$2,706.18 		$352.86
Toc - Plan #72 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$369.62
$419.51
$472.36
$660.13
$1,003.12 		$652.37
$702.26
$755.11
$942.88 		$935.12
$985.01
$1,037.86
$1,225.63 		$1,217.87
$1,267.76
$1,320.61
$1,508.38 		$282.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.24
$839.02
$944.72
$1,320.26
$2,006.24 		$1,021.99
$1,121.77
$1,227.47
$1,603.01 		$1,304.74
$1,404.52
$1,510.22
$1,885.76 		$1,587.49
$1,687.27
$1,792.97
$2,168.51 		$282.75
Toc - Plan #73 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$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 		$376.54
$427.36
$481.20
$672.48
$1,021.90 		$664.58
$715.40
$769.24
$960.52 		$952.62
$1,003.44
$1,057.28
$1,248.56 		$1,240.66
$1,291.48
$1,345.32
$1,536.60 		$288.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.08
$854.72
$962.40
$1,344.96
$2,043.80 		$1,041.12
$1,142.76
$1,250.44
$1,633.00 		$1,329.16
$1,430.80
$1,538.48
$1,921.04 		$1,617.20
$1,718.84
$1,826.52
$2,209.08 		$288.04
Toc - Plan #74 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,900 $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 		$418.98
$475.53
$535.44
$748.28
$1,137.09 		$739.49
$796.04
$855.95
$1,068.79 		$1,060.00
$1,116.55
$1,176.46
$1,389.30 		$1,380.51
$1,437.06
$1,496.97
$1,709.81 		$320.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.96
$951.06
$1,070.88
$1,496.56
$2,274.18 		$1,158.47
$1,271.57
$1,391.39
$1,817.07 		$1,478.98
$1,592.08
$1,711.90
$2,137.58 		$1,799.49
$1,912.59
$2,032.41
$2,458.09 		$320.51
Toc - Plan #75 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$4,850 $9,700 Annual Deductible
$4,850 $9,700 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 		$455.57
$517.06
$582.20
$813.63
$1,236.39 		$804.07
$865.56
$930.70
$1,162.13 		$1,152.57
$1,214.06
$1,279.20
$1,510.63 		$1,501.07
$1,562.56
$1,627.70
$1,859.13 		$348.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.14
$1,034.12
$1,164.40
$1,627.26
$2,472.78 		$1,259.64
$1,382.62
$1,512.90
$1,975.76 		$1,608.14
$1,731.12
$1,861.40
$2,324.26 		$1,956.64
$2,079.62
$2,209.90
$2,672.76 		$348.50
Toc - Plan #76 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite- Deductible Saver Plus

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

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 		$443.42
$503.27
$566.68
$791.93
$1,203.42 		$782.63
$842.48
$905.89
$1,131.14 		$1,121.84
$1,181.69
$1,245.10
$1,470.35 		$1,461.05
$1,520.90
$1,584.31
$1,809.56 		$339.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.84
$1,006.54
$1,133.36
$1,583.86
$2,406.84 		$1,226.05
$1,345.75
$1,472.57
$1,923.07 		$1,565.26
$1,684.96
$1,811.78
$2,262.28 		$1,904.47
$2,024.17
$2,150.99
$2,601.49 		$339.21
Toc - Plan #77 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$537.74
$610.32
$687.22
$960.38
$1,459.39 		$949.10
$1,021.68
$1,098.58
$1,371.74 		$1,360.46
$1,433.04
$1,509.94
$1,783.10 		$1,771.82
$1,844.40
$1,921.30
$2,194.46 		$411.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,075.48
$1,220.64
$1,374.44
$1,920.76
$2,918.78 		$1,486.84
$1,632.00
$1,785.80
$2,332.12 		$1,898.20
$2,043.36
$2,197.16
$2,743.48 		$2,309.56
$2,454.72
$2,608.52
$3,154.84 		$411.36
Toc - Plan #78 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$513.73
$583.07
$656.53
$917.51
$1,394.24 		$906.73
$976.07
$1,049.53
$1,310.51 		$1,299.73
$1,369.07
$1,442.53
$1,703.51 		$1,692.73
$1,762.07
$1,835.53
$2,096.51 		$393.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,027.46
$1,166.14
$1,313.06
$1,835.02
$2,788.48 		$1,420.46
$1,559.14
$1,706.06
$2,228.02 		$1,813.46
$1,952.14
$2,099.06
$2,621.02 		$2,206.46
$2,345.14
$2,492.06
$3,014.02 		$393.00
Toc - Plan #79 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,550 $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 		$424.22
$481.48
$542.14
$757.64
$1,151.30 		$748.74
$806.00
$866.66
$1,082.16 		$1,073.26
$1,130.52
$1,191.18
$1,406.68 		$1,397.78
$1,455.04
$1,515.70
$1,731.20 		$324.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.44
$962.96
$1,084.28
$1,515.28
$2,302.60 		$1,172.96
$1,287.48
$1,408.80
$1,839.80 		$1,497.48
$1,612.00
$1,733.32
$2,164.32 		$1,822.00
$1,936.52
$2,057.84
$2,488.84 		$324.52
Toc - Plan #80 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $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 		$425.97
$483.46
$544.37
$760.76
$1,156.05 		$751.83
$809.32
$870.23
$1,086.62 		$1,077.69
$1,135.18
$1,196.09
$1,412.48 		$1,403.55
$1,461.04
$1,521.95
$1,738.34 		$325.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.94
$966.92
$1,088.74
$1,521.52
$2,312.10 		$1,177.80
$1,292.78
$1,414.60
$1,847.38 		$1,503.66
$1,618.64
$1,740.46
$2,173.24 		$1,829.52
$1,944.50
$2,066.32
$2,499.10 		$325.86
Toc - Plan #81 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$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 		$370.31
$420.29
$473.24
$661.35
$1,004.99 		$653.59
$703.57
$756.52
$944.63 		$936.87
$986.85
$1,039.80
$1,227.91 		$1,220.15
$1,270.13
$1,323.08
$1,511.19 		$283.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.62
$840.58
$946.48
$1,322.70
$2,009.98 		$1,023.90
$1,123.86
$1,229.76
$1,605.98 		$1,307.18
$1,407.14
$1,513.04
$1,889.26 		$1,590.46
$1,690.42
$1,796.32
$2,172.54 		$283.28
Toc - Plan #82 Oscar Insurance Corporation of Ohio
Bronze

(HMO) Bronze Simple- Standard

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

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 		$345.34
$391.95
$441.33
$616.76
$937.23 		$609.52
$656.13
$705.51
$880.94 		$873.70
$920.31
$969.69
$1,145.12 		$1,137.88
$1,184.49
$1,233.87
$1,409.30 		$264.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.68
$783.90
$882.66
$1,233.52
$1,874.46 		$954.86
$1,048.08
$1,146.84
$1,497.70 		$1,219.04
$1,312.26
$1,411.02
$1,761.88 		$1,483.22
$1,576.44
$1,675.20
$2,026.06 		$264.18
Toc - Plan #83 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Standard

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

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 		$419.20
$475.78
$535.72
$748.66
$1,137.67 		$739.88
$796.46
$856.40
$1,069.34 		$1,060.56
$1,117.14
$1,177.08
$1,390.02 		$1,381.24
$1,437.82
$1,497.76
$1,710.70 		$320.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.40
$951.56
$1,071.44
$1,497.32
$2,275.34 		$1,159.08
$1,272.24
$1,392.12
$1,818.00 		$1,479.76
$1,592.92
$1,712.80
$2,138.68 		$1,800.44
$1,913.60
$2,033.48
$2,459.36 		$320.68
Toc - Plan #84 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$473.58
$537.50
$605.22
$845.79
$1,285.27 		$835.86
$899.78
$967.50
$1,208.07 		$1,198.14
$1,262.06
$1,329.78
$1,570.35 		$1,560.42
$1,624.34
$1,692.06
$1,932.63 		$362.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.16
$1,075.00
$1,210.44
$1,691.58
$2,570.54 		$1,309.44
$1,437.28
$1,572.72
$2,053.86 		$1,671.72
$1,799.56
$1,935.00
$2,416.14 		$2,034.00
$2,161.84
$2,297.28
$2,778.42 		$362.28

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-750-0750
Toc - Plan #85 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$395.11
$448.44
$504.94
$705.66
$1,072.31 		$697.37
$750.70
$807.20
$1,007.92 		$999.63
$1,052.96
$1,109.46
$1,310.18 		$1,301.89
$1,355.22
$1,411.72
$1,612.44 		$302.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.22
$896.88
$1,009.88
$1,411.32
$2,144.62 		$1,092.48
$1,199.14
$1,312.14
$1,713.58 		$1,394.74
$1,501.40
$1,614.40
$2,015.84 		$1,697.00
$1,803.66
$1,916.66
$2,318.10 		$302.26
Toc - Plan #86 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$558.91
$634.36
$714.29
$998.21
$1,516.88 		$986.48
$1,061.93
$1,141.86
$1,425.78 		$1,414.05
$1,489.50
$1,569.43
$1,853.35 		$1,841.62
$1,917.07
$1,997.00
$2,280.92 		$427.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,117.82
$1,268.72
$1,428.58
$1,996.42
$3,033.76 		$1,545.39
$1,696.29
$1,856.15
$2,423.99 		$1,972.96
$2,123.86
$2,283.72
$2,851.56 		$2,400.53
$2,551.43
$2,711.29
$3,279.13 		$427.57
Toc - Plan #87 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$403.54
$458.01
$515.72
$720.71
$1,095.19 		$712.24
$766.71
$824.42
$1,029.41 		$1,020.94
$1,075.41
$1,133.12
$1,338.11 		$1,329.64
$1,384.11
$1,441.82
$1,646.81 		$308.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.08
$916.02
$1,031.44
$1,441.42
$2,190.38 		$1,115.78
$1,224.72
$1,340.14
$1,750.12 		$1,424.48
$1,533.42
$1,648.84
$2,058.82 		$1,733.18
$1,842.12
$1,957.54
$2,367.52 		$308.70
Toc - Plan #88 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$293.05
$332.61
$374.51
$523.38
$795.32 		$517.23
$556.79
$598.69
$747.56 		$741.41
$780.97
$822.87
$971.74 		$965.59
$1,005.15
$1,047.05
$1,195.92 		$224.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.10
$665.22
$749.02
$1,046.76
$1,590.64 		$810.28
$889.40
$973.20
$1,270.94 		$1,034.46
$1,113.58
$1,197.38
$1,495.12 		$1,258.64
$1,337.76
$1,421.56
$1,719.30 		$224.18
Toc - Plan #89 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$286.65
$325.35
$366.34
$511.96
$777.97 		$505.94
$544.64
$585.63
$731.25 		$725.23
$763.93
$804.92
$950.54 		$944.52
$983.22
$1,024.21
$1,169.83 		$219.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.30
$650.70
$732.68
$1,023.92
$1,555.94 		$792.59
$869.99
$951.97
$1,243.21 		$1,011.88
$1,089.28
$1,171.26
$1,462.50 		$1,231.17
$1,308.57
$1,390.55
$1,681.79 		$219.29
Toc - Plan #90 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$451.76
$512.74
$577.34
$806.84
$1,226.06 		$797.35
$858.33
$922.93
$1,152.43 		$1,142.94
$1,203.92
$1,268.52
$1,498.02 		$1,488.53
$1,549.51
$1,614.11
$1,843.61 		$345.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.52
$1,025.48
$1,154.68
$1,613.68
$2,452.12 		$1,249.11
$1,371.07
$1,500.27
$1,959.27 		$1,594.70
$1,716.66
$1,845.86
$2,304.86 		$1,940.29
$2,062.25
$2,191.45
$2,650.45 		$345.59
Toc - Plan #91 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$401.46
$455.66
$513.07
$717.01
$1,089.56 		$708.58
$762.78
$820.19
$1,024.13 		$1,015.70
$1,069.90
$1,127.31
$1,331.25 		$1,322.82
$1,377.02
$1,434.43
$1,638.37 		$307.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.92
$911.32
$1,026.14
$1,434.02
$2,179.12 		$1,110.04
$1,218.44
$1,333.26
$1,741.14 		$1,417.16
$1,525.56
$1,640.38
$2,048.26 		$1,724.28
$1,832.68
$1,947.50
$2,355.38 		$307.12
Toc - Plan #92 CareSource
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$566.61
$643.10
$724.12
$1,011.96
$1,537.77 		$1,000.06
$1,076.55
$1,157.57
$1,445.41 		$1,433.51
$1,510.00
$1,591.02
$1,878.86 		$1,866.96
$1,943.45
$2,024.47
$2,312.31 		$433.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,133.22
$1,286.20
$1,448.24
$2,023.92
$3,075.54 		$1,566.67
$1,719.65
$1,881.69
$2,457.37 		$2,000.12
$2,153.10
$2,315.14
$2,890.82 		$2,433.57
$2,586.55
$2,748.59
$3,324.27 		$433.45
Toc - Plan #93 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$409.88
$465.21
$523.83
$732.05
$1,112.42 		$723.44
$778.77
$837.39
$1,045.61 		$1,037.00
$1,092.33
$1,150.95
$1,359.17 		$1,350.56
$1,405.89
$1,464.51
$1,672.73 		$313.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.76
$930.42
$1,047.66
$1,464.10
$2,224.84 		$1,133.32
$1,243.98
$1,361.22
$1,777.66 		$1,446.88
$1,557.54
$1,674.78
$2,091.22 		$1,760.44
$1,871.10
$1,988.34
$2,404.78 		$313.56
Toc - Plan #94 CareSource
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$298.74
$339.06
$381.78
$533.54
$810.76 		$527.27
$567.59
$610.31
$762.07 		$755.80
$796.12
$838.84
$990.60 		$984.33
$1,024.65
$1,067.37
$1,219.13 		$228.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.48
$678.12
$763.56
$1,067.08
$1,621.52 		$826.01
$906.65
$992.09
$1,295.61 		$1,054.54
$1,135.18
$1,220.62
$1,524.14 		$1,283.07
$1,363.71
$1,449.15
$1,752.67 		$228.53
Toc - Plan #95 CareSource
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$292.01
$331.43
$373.19
$521.53
$792.52 		$515.40
$554.82
$596.58
$744.92 		$738.79
$778.21
$819.97
$968.31 		$962.18
$1,001.60
$1,043.36
$1,191.70 		$223.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.02
$662.86
$746.38
$1,043.06
$1,585.04 		$807.41
$886.25
$969.77
$1,266.45 		$1,030.80
$1,109.64
$1,193.16
$1,489.84 		$1,254.19
$1,333.03
$1,416.55
$1,713.23 		$223.39
Toc - Plan #96 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$457.90
$519.71
$585.19
$817.80
$1,242.72 		$808.19
$870.00
$935.48
$1,168.09 		$1,158.48
$1,220.29
$1,285.77
$1,518.38 		$1,508.77
$1,570.58
$1,636.06
$1,868.67 		$350.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.80
$1,039.42
$1,170.38
$1,635.60
$2,485.44 		$1,266.09
$1,389.71
$1,520.67
$1,985.89 		$1,616.38
$1,740.00
$1,870.96
$2,336.18 		$1,966.67
$2,090.29
$2,221.25
$2,686.47 		$350.29

ADVERTISEMENT

MedMutual

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

Toc - Plan #97 MedMutual
Silver

(HMO) Market HMO 3500 - Northern Ohio

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

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 		$429.54
$487.53
$548.95
$767.16
$1,165.77 		$758.14
$816.13
$877.55
$1,095.76 		$1,086.74
$1,144.73
$1,206.15
$1,424.36 		$1,415.34
$1,473.33
$1,534.75
$1,752.96 		$328.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.08
$975.06
$1,097.90
$1,534.32
$2,331.54 		$1,187.68
$1,303.66
$1,426.50
$1,862.92 		$1,516.28
$1,632.26
$1,755.10
$2,191.52 		$1,844.88
$1,960.86
$2,083.70
$2,520.12 		$328.60
Toc - Plan #98 MedMutual
Silver

(HMO) Market HMO 4000 HSA - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$5,850 $11,700 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 		$429.54
$487.53
$548.95
$767.16
$1,165.77 		$758.14
$816.13
$877.55
$1,095.76 		$1,086.74
$1,144.73
$1,206.15
$1,424.36 		$1,415.34
$1,473.33
$1,534.75
$1,752.96 		$328.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.08
$975.06
$1,097.90
$1,534.32
$2,331.54 		$1,187.68
$1,303.66
$1,426.50
$1,862.92 		$1,516.28
$1,632.26
$1,755.10
$2,191.52 		$1,844.88
$1,960.86
$2,083.70
$2,520.12 		$328.60
Toc - Plan #99 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$326.91
$371.05
$417.79
$583.87
$887.24 		$577.00
$621.14
$667.88
$833.96 		$827.09
$871.23
$917.97
$1,084.05 		$1,077.18
$1,121.32
$1,168.06
$1,334.14 		$250.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.82
$742.10
$835.58
$1,167.74
$1,774.48 		$903.91
$992.19
$1,085.67
$1,417.83 		$1,154.00
$1,242.28
$1,335.76
$1,667.92 		$1,404.09
$1,492.37
$1,585.85
$1,918.01 		$250.09
Toc - Plan #100 MedMutual
Bronze

(HMO) Market HMO 9100 - Northern Ohio

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

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 		$309.24
$350.99
$395.21
$552.31
$839.28 		$545.81
$587.56
$631.78
$788.88 		$782.38
$824.13
$868.35
$1,025.45 		$1,018.95
$1,060.70
$1,104.92
$1,262.02 		$236.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.48
$701.98
$790.42
$1,104.62
$1,678.56 		$855.05
$938.55
$1,026.99
$1,341.19 		$1,091.62
$1,175.12
$1,263.56
$1,577.76 		$1,328.19
$1,411.69
$1,500.13
$1,814.33 		$236.57
Toc - Plan #101 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$204.24
$231.81
$261.01
$364.76
$554.30 		$360.48
$388.05
$417.25
$521.00 		$516.72
$544.29
$573.49
$677.24 		$672.96
$700.53
$729.73
$833.48 		$156.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$408.48
$463.62
$522.02
$729.52
$1,108.60 		$564.72
$619.86
$678.26
$885.76 		$720.96
$776.10
$834.50
$1,042.00 		$877.20
$932.34
$990.74
$1,198.24 		$156.24
Toc - Plan #102 MedMutual
Silver

(HMO) Market HMO 6500 - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$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 		$428.18
$485.99
$547.22
$764.73
$1,162.08 		$755.74
$813.55
$874.78
$1,092.29 		$1,083.30
$1,141.11
$1,202.34
$1,419.85 		$1,410.86
$1,468.67
$1,529.90
$1,747.41 		$327.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.36
$971.98
$1,094.44
$1,529.46
$2,324.16 		$1,183.92
$1,299.54
$1,422.00
$1,857.02 		$1,511.48
$1,627.10
$1,749.56
$2,184.58 		$1,839.04
$1,954.66
$2,077.12
$2,512.14 		$327.56
Toc - Plan #103 MedMutual
Expanded Bronze

(HMO) Market HMO Select Bronze - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$369.05
$418.87
$471.65
$659.13
$1,001.61 		$651.37
$701.19
$753.97
$941.45 		$933.69
$983.51
$1,036.29
$1,223.77 		$1,216.01
$1,265.83
$1,318.61
$1,506.09 		$282.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.10
$837.74
$943.30
$1,318.26
$2,003.22 		$1,020.42
$1,120.06
$1,225.62
$1,600.58 		$1,302.74
$1,402.38
$1,507.94
$1,882.90 		$1,585.06
$1,684.70
$1,790.26
$2,165.22 		$282.32
Toc - Plan #104 MedMutual
Silver

(HMO) Market HMO Select Silver - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,250 $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 		$461.82
$524.17
$590.21
$824.82
$1,253.39 		$815.12
$877.47
$943.51
$1,178.12 		$1,168.42
$1,230.77
$1,296.81
$1,531.42 		$1,521.72
$1,584.07
$1,650.11
$1,884.72 		$353.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$923.64
$1,048.34
$1,180.42
$1,649.64
$2,506.78 		$1,276.94
$1,401.64
$1,533.72
$2,002.94 		$1,630.24
$1,754.94
$1,887.02
$2,356.24 		$1,983.54
$2,108.24
$2,240.32
$2,709.54 		$353.30
Toc - Plan #105 MedMutual
Expanded Bronze

(HMO) Market HMO 8000 - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$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 		$313.32
$355.62
$400.42
$559.59
$850.35 		$553.01
$595.31
$640.11
$799.28 		$792.70
$835.00
$879.80
$1,038.97 		$1,032.39
$1,074.69
$1,119.49
$1,278.66 		$239.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.64
$711.24
$800.84
$1,119.18
$1,700.70 		$866.33
$950.93
$1,040.53
$1,358.87 		$1,106.02
$1,190.62
$1,280.22
$1,598.56 		$1,345.71
$1,430.31
$1,519.91
$1,838.25 		$239.69
Toc - Plan #106 MedMutual
Gold

(HMO) Market HMO 2500 - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,750 $11,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$571.93
$649.14
$730.92
$1,021.46
$1,552.21 		$1,009.45
$1,086.66
$1,168.44
$1,458.98 		$1,446.97
$1,524.18
$1,605.96
$1,896.50 		$1,884.49
$1,961.70
$2,043.48
$2,334.02 		$437.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,143.86
$1,298.28
$1,461.84
$2,042.92
$3,104.42 		$1,581.38
$1,735.80
$1,899.36
$2,480.44 		$2,018.90
$2,173.32
$2,336.88
$2,917.96 		$2,456.42
$2,610.84
$2,774.40
$3,355.48 		$437.52
Toc - Plan #107 MedMutual
Gold

(HMO) Market HMO Standard Gold - Northern Ohio

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

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 		$550.18
$624.45
$703.13
$982.62
$1,493.19 		$971.07
$1,045.34
$1,124.02
$1,403.51 		$1,391.96
$1,466.23
$1,544.91
$1,824.40 		$1,812.85
$1,887.12
$1,965.80
$2,245.29 		$420.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,100.36
$1,248.90
$1,406.26
$1,965.24
$2,986.38 		$1,521.25
$1,669.79
$1,827.15
$2,386.13 		$1,942.14
$2,090.68
$2,248.04
$2,807.02 		$2,363.03
$2,511.57
$2,668.93
$3,227.91 		$420.89
Toc - Plan #108 MedMutual
Silver

(HMO) Market HMO Standard Silver - Northern Ohio

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

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 		$426.14
$483.67
$544.61
$761.09
$1,156.55 		$752.14
$809.67
$870.61
$1,087.09 		$1,078.14
$1,135.67
$1,196.61
$1,413.09 		$1,404.14
$1,461.67
$1,522.61
$1,739.09 		$326.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.28
$967.34
$1,089.22
$1,522.18
$2,313.10 		$1,178.28
$1,293.34
$1,415.22
$1,848.18 		$1,504.28
$1,619.34
$1,741.22
$2,174.18 		$1,830.28
$1,945.34
$2,067.22
$2,500.18 		$326.00
Toc - Plan #109 MedMutual
Expanded Bronze

(HMO) Market HMO Standard Expanded Bronze - Northern Ohio

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

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 		$334.73
$379.92
$427.78
$597.83
$908.45 		$590.80
$635.99
$683.85
$853.90 		$846.87
$892.06
$939.92
$1,109.97 		$1,102.94
$1,148.13
$1,195.99
$1,366.04 		$256.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.46
$759.84
$855.56
$1,195.66
$1,816.90 		$925.53
$1,015.91
$1,111.63
$1,451.73 		$1,181.60
$1,271.98
$1,367.70
$1,707.80 		$1,437.67
$1,528.05
$1,623.77
$1,963.87 		$256.07
Toc - Plan #110 MedMutual
Bronze

(HMO) Market HMO Standard Bronze - Northern Ohio

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

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 		$312.98
$355.23
$399.99
$558.98
$849.43 		$552.41
$594.66
$639.42
$798.41 		$791.84
$834.09
$878.85
$1,037.84 		$1,031.27
$1,073.52
$1,118.28
$1,277.27 		$239.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.96
$710.46
$799.98
$1,117.96
$1,698.86 		$865.39
$949.89
$1,039.41
$1,357.39 		$1,104.82
$1,189.32
$1,278.84
$1,596.82 		$1,344.25
$1,428.75
$1,518.27
$1,836.25 		$239.43

‡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 Tuscarawas County here.

Tuscarawas County is in “Rating Area 16” of Ohio.

Currently, there are 110 plans offered in Rating Area 16.

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