Obamacare 2023 Rates for Florence County

Obamacare > Rates > Wisconsin > Florence 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 Florence County, WI.

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, 128 Plans and 2023 Rates for Florence County, Wisconsin

Below, you’ll find a summary of the 128 plans for Florence County, Wisconsin and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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

Florence County Resources

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HealthPartners

Local: 1-952-883-5900 | Toll Free: 1-855-813-3887 | TTY: 1-952-883-6060
Toc - Plan #1 HealthPartners
Gold

(PPO) Robin Oak $1,000 w/Copay P-S Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.04
$521.01
$586.65
$819.85
$1,245.83 		$810.21
$872.18
$937.82
$1,171.02 		$1,161.38
$1,223.35
$1,288.99
$1,522.19 		$1,512.55
$1,574.52
$1,640.16
$1,873.36 		$351.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.08
$1,042.02
$1,173.30
$1,639.70
$2,491.66 		$1,269.25
$1,393.19
$1,524.47
$1,990.87 		$1,620.42
$1,744.36
$1,875.64
$2,342.04 		$1,971.59
$2,095.53
$2,226.81
$2,693.21 		$351.17
Toc - Plan #2 HealthPartners
Expanded Bronze

(PPO) Robin Oak $6,250 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 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 		$322.53
$366.07
$412.19
$576.04
$875.35 		$569.27
$612.81
$658.93
$822.78 		$816.01
$859.55
$905.67
$1,069.52 		$1,062.75
$1,106.29
$1,152.41
$1,316.26 		$246.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.06
$732.14
$824.38
$1,152.08
$1,750.70 		$891.80
$978.88
$1,071.12
$1,398.82 		$1,138.54
$1,225.62
$1,317.86
$1,645.56 		$1,385.28
$1,472.36
$1,564.60
$1,892.30 		$246.74
Toc - Plan #3 HealthPartners
Catastrophic

(PPO) Robin Oak $9,100 Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.13
$275.95
$310.72
$434.23
$659.85 		$429.12
$461.94
$496.71
$620.22 		$615.11
$647.93
$682.70
$806.21 		$801.10
$833.92
$868.69
$992.20 		$185.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.26
$551.90
$621.44
$868.46
$1,319.70 		$672.25
$737.89
$807.43
$1,054.45 		$858.24
$923.88
$993.42
$1,240.44 		$1,044.23
$1,109.87
$1,179.41
$1,426.43 		$185.99
Toc - Plan #4 HealthPartners
Silver

(PPO) Robin Oak $3,800 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.40
$466.94
$525.77
$734.76
$1,116.54 		$726.12
$781.66
$840.49
$1,049.48 		$1,040.84
$1,096.38
$1,155.21
$1,364.20 		$1,355.56
$1,411.10
$1,469.93
$1,678.92 		$314.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.80
$933.88
$1,051.54
$1,469.52
$2,233.08 		$1,137.52
$1,248.60
$1,366.26
$1,784.24 		$1,452.24
$1,563.32
$1,680.98
$2,098.96 		$1,766.96
$1,878.04
$1,995.70
$2,413.68 		$314.72
Toc - Plan #5 HealthPartners
Expanded Bronze

(PPO) Robin Oak $7,500 HSA Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312.16
$354.30
$398.94
$557.52
$847.20 		$550.96
$593.10
$637.74
$796.32 		$789.76
$831.90
$876.54
$1,035.12 		$1,028.56
$1,070.70
$1,115.34
$1,273.92 		$238.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.32
$708.60
$797.88
$1,115.04
$1,694.40 		$863.12
$947.40
$1,036.68
$1,353.84 		$1,101.92
$1,186.20
$1,275.48
$1,592.64 		$1,340.72
$1,425.00
$1,514.28
$1,831.44 		$238.80
Toc - Plan #6 HealthPartners
Gold

(PPO) Robin Oak $2,000 w/Copay P-S Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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 		$443.24
$503.08
$566.46
$791.63
$1,202.95 		$782.32
$842.16
$905.54
$1,130.71 		$1,121.40
$1,181.24
$1,244.62
$1,469.79 		$1,460.48
$1,520.32
$1,583.70
$1,808.87 		$339.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.48
$1,006.16
$1,132.92
$1,583.26
$2,405.90 		$1,225.56
$1,345.24
$1,472.00
$1,922.34 		$1,564.64
$1,684.32
$1,811.08
$2,261.42 		$1,903.72
$2,023.40
$2,150.16
$2,600.50 		$339.08
Toc - Plan #7 HealthPartners
Silver

(PPO) Robin Oak $5,800 w/Copay P-S Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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 		$412.61
$468.31
$527.32
$736.92
$1,119.82 		$728.26
$783.96
$842.97
$1,052.57 		$1,043.91
$1,099.61
$1,158.62
$1,368.22 		$1,359.56
$1,415.26
$1,474.27
$1,683.87 		$315.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.22
$936.62
$1,054.64
$1,473.84
$2,239.64 		$1,140.87
$1,252.27
$1,370.29
$1,789.49 		$1,456.52
$1,567.92
$1,685.94
$2,105.14 		$1,772.17
$1,883.57
$2,001.59
$2,420.79 		$315.65
Toc - Plan #8 HealthPartners
Expanded Bronze

(PPO) Robin Oak $7,500 w/Copay P-S Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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 		$324.82
$368.67
$415.12
$580.13
$881.56 		$573.31
$617.16
$663.61
$828.62 		$821.80
$865.65
$912.10
$1,077.11 		$1,070.29
$1,114.14
$1,160.59
$1,325.60 		$248.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.64
$737.34
$830.24
$1,160.26
$1,763.12 		$898.13
$985.83
$1,078.73
$1,408.75 		$1,146.62
$1,234.32
$1,327.22
$1,657.24 		$1,395.11
$1,482.81
$1,575.71
$1,905.73 		$248.49
Toc - Plan #9 HealthPartners
Silver

(PPO) Robin Oak $3,500 HSA Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,300 $14,600 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 		$407.83
$462.89
$521.21
$728.38
$1,106.85 		$719.82
$774.88
$833.20
$1,040.37 		$1,031.81
$1,086.87
$1,145.19
$1,352.36 		$1,343.80
$1,398.86
$1,457.18
$1,664.35 		$311.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.66
$925.78
$1,042.42
$1,456.76
$2,213.70 		$1,127.65
$1,237.77
$1,354.41
$1,768.75 		$1,439.64
$1,549.76
$1,666.40
$2,080.74 		$1,751.63
$1,861.75
$1,978.39
$2,392.73 		$311.99
Toc - Plan #10 HealthPartners
Silver

(PPO) Robin Select $3,800 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.17
$415.60
$467.97
$653.98
$993.79 		$646.29
$695.72
$748.09
$934.10 		$926.41
$975.84
$1,028.21
$1,214.22 		$1,206.53
$1,255.96
$1,308.33
$1,494.34 		$280.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.34
$831.20
$935.94
$1,307.96
$1,987.58 		$1,012.46
$1,111.32
$1,216.06
$1,588.08 		$1,292.58
$1,391.44
$1,496.18
$1,868.20 		$1,572.70
$1,671.56
$1,776.30
$2,148.32 		$280.12
Toc - Plan #11 HealthPartners
Silver

(PPO) Robin Select $5,800 w/Copay P-S Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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 		$367.22
$416.79
$469.31
$655.85
$996.64 		$648.14
$697.71
$750.23
$936.77 		$929.06
$978.63
$1,031.15
$1,217.69 		$1,209.98
$1,259.55
$1,312.07
$1,498.61 		$280.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.44
$833.58
$938.62
$1,311.70
$1,993.28 		$1,015.36
$1,114.50
$1,219.54
$1,592.62 		$1,296.28
$1,395.42
$1,500.46
$1,873.54 		$1,577.20
$1,676.34
$1,781.38
$2,154.46 		$280.92
Toc - Plan #12 HealthPartners
Expanded Bronze

(PPO) Robin Select $6,250 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 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 		$287.04
$325.79
$366.84
$512.65
$779.03 		$506.63
$545.38
$586.43
$732.24 		$726.22
$764.97
$806.02
$951.83 		$945.81
$984.56
$1,025.61
$1,171.42 		$219.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.08
$651.58
$733.68
$1,025.30
$1,558.06 		$793.67
$871.17
$953.27
$1,244.89 		$1,013.26
$1,090.76
$1,172.86
$1,464.48 		$1,232.85
$1,310.35
$1,392.45
$1,684.07 		$219.59
Toc - Plan #13 HealthPartners
Expanded Bronze

(PPO) Robin Select $7,500 w/Copay P-S Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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 		$289.10
$328.13
$369.47
$516.33
$784.62 		$510.26
$549.29
$590.63
$737.49 		$731.42
$770.45
$811.79
$958.65 		$952.58
$991.61
$1,032.95
$1,179.81 		$221.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.20
$656.26
$738.94
$1,032.66
$1,569.24 		$799.36
$877.42
$960.10
$1,253.82 		$1,020.52
$1,098.58
$1,181.26
$1,474.98 		$1,241.68
$1,319.74
$1,402.42
$1,696.14 		$221.16
Toc - Plan #14 HealthPartners
Silver

(PPO) Robin Select $3,500 HSA Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,300 $14,600 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 		$362.95
$411.95
$463.85
$648.23
$985.05 		$640.61
$689.61
$741.51
$925.89 		$918.27
$967.27
$1,019.17
$1,203.55 		$1,195.93
$1,244.93
$1,296.83
$1,481.21 		$277.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.90
$823.90
$927.70
$1,296.46
$1,970.10 		$1,003.56
$1,101.56
$1,205.36
$1,574.12 		$1,281.22
$1,379.22
$1,483.02
$1,851.78 		$1,558.88
$1,656.88
$1,760.68
$2,129.44 		$277.66
Toc - Plan #15 HealthPartners
Expanded Bronze

(PPO) Robin Select $7,500 HSA Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277.84
$315.35
$355.08
$496.22
$754.06 		$490.39
$527.90
$567.63
$708.77 		$702.94
$740.45
$780.18
$921.32 		$915.49
$953.00
$992.73
$1,133.87 		$212.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.68
$630.70
$710.16
$992.44
$1,508.12 		$768.23
$843.25
$922.71
$1,204.99 		$980.78
$1,055.80
$1,135.26
$1,417.54 		$1,193.33
$1,268.35
$1,347.81
$1,630.09 		$212.55
Toc - Plan #16 HealthPartners
Catastrophic

(PPO) Robin Select $9,100 Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$216.38
$245.59
$276.53
$386.45
$587.26 		$381.91
$411.12
$442.06
$551.98 		$547.44
$576.65
$607.59
$717.51 		$712.97
$742.18
$773.12
$883.04 		$165.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432.76
$491.18
$553.06
$772.90
$1,174.52 		$598.29
$656.71
$718.59
$938.43 		$763.82
$822.24
$884.12
$1,103.96 		$929.35
$987.77
$1,049.65
$1,269.49 		$165.53

ADVERTISEMENT

Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973
Toc - Plan #17 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$445.18
$505.27
$568.93
$795.08
$1,208.20 		$785.74
$845.83
$909.49
$1,135.64 		$1,126.30
$1,186.39
$1,250.05
$1,476.20 		$1,466.86
$1,526.95
$1,590.61
$1,816.76 		$340.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.36
$1,010.54
$1,137.86
$1,590.16
$2,416.40 		$1,230.92
$1,351.10
$1,478.42
$1,930.72 		$1,571.48
$1,691.66
$1,818.98
$2,271.28 		$1,912.04
$2,032.22
$2,159.54
$2,611.84 		$340.56
Toc - Plan #18 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.00
$500.53
$563.60
$787.62
$1,196.87 		$778.36
$837.89
$900.96
$1,124.98 		$1,115.72
$1,175.25
$1,238.32
$1,462.34 		$1,453.08
$1,512.61
$1,575.68
$1,799.70 		$337.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.00
$1,001.06
$1,127.20
$1,575.24
$2,393.74 		$1,219.36
$1,338.42
$1,464.56
$1,912.60 		$1,556.72
$1,675.78
$1,801.92
$2,249.96 		$1,894.08
$2,013.14
$2,139.28
$2,587.32 		$337.36
Toc - Plan #19 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$444.67
$504.69
$568.28
$794.17
$1,206.82 		$784.84
$844.86
$908.45
$1,134.34 		$1,125.01
$1,185.03
$1,248.62
$1,474.51 		$1,465.18
$1,525.20
$1,588.79
$1,814.68 		$340.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.34
$1,009.38
$1,136.56
$1,588.34
$2,413.64 		$1,229.51
$1,349.55
$1,476.73
$1,928.51 		$1,569.68
$1,689.72
$1,816.90
$2,268.68 		$1,909.85
$2,029.89
$2,157.07
$2,608.85 		$340.17
Toc - Plan #20 Quartz
Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$456.06
$517.62
$582.83
$814.51
$1,237.72 		$804.94
$866.50
$931.71
$1,163.39 		$1,153.82
$1,215.38
$1,280.59
$1,512.27 		$1,502.70
$1,564.26
$1,629.47
$1,861.15 		$348.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912.12
$1,035.24
$1,165.66
$1,629.02
$2,475.44 		$1,261.00
$1,384.12
$1,514.54
$1,977.90 		$1,609.88
$1,733.00
$1,863.42
$2,326.78 		$1,958.76
$2,081.88
$2,212.30
$2,675.66 		$348.88
Toc - Plan #21 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$458.22
$520.08
$585.61
$818.38
$1,243.61 		$808.76
$870.62
$936.15
$1,168.92 		$1,159.30
$1,221.16
$1,286.69
$1,519.46 		$1,509.84
$1,571.70
$1,637.23
$1,870.00 		$350.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$916.44
$1,040.16
$1,171.22
$1,636.76
$2,487.22 		$1,266.98
$1,390.70
$1,521.76
$1,987.30 		$1,617.52
$1,741.24
$1,872.30
$2,337.84 		$1,968.06
$2,091.78
$2,222.84
$2,688.38 		$350.54
Toc - Plan #22 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$454.35
$515.68
$580.65
$811.45
$1,233.08 		$801.92
$863.25
$928.22
$1,159.02 		$1,149.49
$1,210.82
$1,275.79
$1,506.59 		$1,497.06
$1,558.39
$1,623.36
$1,854.16 		$347.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.70
$1,031.36
$1,161.30
$1,622.90
$2,466.16 		$1,256.27
$1,378.93
$1,508.87
$1,970.47 		$1,603.84
$1,726.50
$1,856.44
$2,318.04 		$1,951.41
$2,074.07
$2,204.01
$2,665.61 		$347.57
Toc - Plan #23 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$476.69
$541.04
$609.21
$851.37
$1,293.73 		$841.36
$905.71
$973.88
$1,216.04 		$1,206.03
$1,270.38
$1,338.55
$1,580.71 		$1,570.70
$1,635.05
$1,703.22
$1,945.38 		$364.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.38
$1,082.08
$1,218.42
$1,702.74
$2,587.46 		$1,318.05
$1,446.75
$1,583.09
$2,067.41 		$1,682.72
$1,811.42
$1,947.76
$2,432.08 		$2,047.39
$2,176.09
$2,312.43
$2,796.75 		$364.67
Toc - Plan #24 Quartz
Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$499.26
$566.66
$638.05
$891.68
$1,354.99 		$881.19
$948.59
$1,019.98
$1,273.61 		$1,263.12
$1,330.52
$1,401.91
$1,655.54 		$1,645.05
$1,712.45
$1,783.84
$2,037.47 		$381.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.52
$1,133.32
$1,276.10
$1,783.36
$2,709.98 		$1,380.45
$1,515.25
$1,658.03
$2,165.29 		$1,762.38
$1,897.18
$2,039.96
$2,547.22 		$2,144.31
$2,279.11
$2,421.89
$2,929.15 		$381.93
Toc - Plan #25 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$337.92
$383.54
$431.86
$603.52
$917.11 		$596.43
$642.05
$690.37
$862.03 		$854.94
$900.56
$948.88
$1,120.54 		$1,113.45
$1,159.07
$1,207.39
$1,379.05 		$258.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.84
$767.08
$863.72
$1,207.04
$1,834.22 		$934.35
$1,025.59
$1,122.23
$1,465.55 		$1,192.86
$1,284.10
$1,380.74
$1,724.06 		$1,451.37
$1,542.61
$1,639.25
$1,982.57 		$258.51
Toc - Plan #26 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$341.27
$387.33
$436.13
$609.49
$926.18 		$602.34
$648.40
$697.20
$870.56 		$863.41
$909.47
$958.27
$1,131.63 		$1,124.48
$1,170.54
$1,219.34
$1,392.70 		$261.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.54
$774.66
$872.26
$1,218.98
$1,852.36 		$943.61
$1,035.73
$1,133.33
$1,480.05 		$1,204.68
$1,296.80
$1,394.40
$1,741.12 		$1,465.75
$1,557.87
$1,655.47
$2,002.19 		$261.07
Toc - Plan #27 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$357.72
$406.01
$457.16
$638.88
$970.83 		$631.37
$679.66
$730.81
$912.53 		$905.02
$953.31
$1,004.46
$1,186.18 		$1,178.67
$1,226.96
$1,278.11
$1,459.83 		$273.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.44
$812.02
$914.32
$1,277.76
$1,941.66 		$989.09
$1,085.67
$1,187.97
$1,551.41 		$1,262.74
$1,359.32
$1,461.62
$1,825.06 		$1,536.39
$1,632.97
$1,735.27
$2,098.71 		$273.65
Toc - Plan #28 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$354.06
$401.86
$452.49
$632.35
$960.91 		$624.91
$672.71
$723.34
$903.20 		$895.76
$943.56
$994.19
$1,174.05 		$1,166.61
$1,214.41
$1,265.04
$1,444.90 		$270.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.12
$803.72
$904.98
$1,264.70
$1,921.82 		$978.97
$1,074.57
$1,175.83
$1,535.55 		$1,249.82
$1,345.42
$1,446.68
$1,806.40 		$1,520.67
$1,616.27
$1,717.53
$2,077.25 		$270.85
Toc - Plan #29 Quartz
Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$368.64
$418.40
$471.11
$658.38
$1,000.47 		$650.64
$700.40
$753.11
$940.38 		$932.64
$982.40
$1,035.11
$1,222.38 		$1,214.64
$1,264.40
$1,317.11
$1,504.38 		$282.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.28
$836.80
$942.22
$1,316.76
$2,000.94 		$1,019.28
$1,118.80
$1,224.22
$1,598.76 		$1,301.28
$1,400.80
$1,506.22
$1,880.76 		$1,583.28
$1,682.80
$1,788.22
$2,162.76 		$282.00
Toc - Plan #30 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$425.44
$482.87
$543.71
$759.83
$1,154.63 		$750.90
$808.33
$869.17
$1,085.29 		$1,076.36
$1,133.79
$1,194.63
$1,410.75 		$1,401.82
$1,459.25
$1,520.09
$1,736.21 		$325.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.88
$965.74
$1,087.42
$1,519.66
$2,309.26 		$1,176.34
$1,291.20
$1,412.88
$1,845.12 		$1,501.80
$1,616.66
$1,738.34
$2,170.58 		$1,827.26
$1,942.12
$2,063.80
$2,496.04 		$325.46
Toc - Plan #31 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.45
$478.34
$538.61
$752.70
$1,143.81 		$743.86
$800.75
$861.02
$1,075.11 		$1,066.27
$1,123.16
$1,183.43
$1,397.52 		$1,388.68
$1,445.57
$1,505.84
$1,719.93 		$322.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.90
$956.68
$1,077.22
$1,505.40
$2,287.62 		$1,165.31
$1,279.09
$1,399.63
$1,827.81 		$1,487.72
$1,601.50
$1,722.04
$2,150.22 		$1,810.13
$1,923.91
$2,044.45
$2,472.63 		$322.41
Toc - Plan #32 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424.95
$482.32
$543.09
$758.96
$1,153.31 		$750.04
$807.41
$868.18
$1,084.05 		$1,075.13
$1,132.50
$1,193.27
$1,409.14 		$1,400.22
$1,457.59
$1,518.36
$1,734.23 		$325.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.90
$964.64
$1,086.18
$1,517.92
$2,306.62 		$1,174.99
$1,289.73
$1,411.27
$1,843.01 		$1,500.08
$1,614.82
$1,736.36
$2,168.10 		$1,825.17
$1,939.91
$2,061.45
$2,493.19 		$325.09
Toc - Plan #33 Quartz
Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$435.84
$494.67
$556.99
$778.40
$1,182.85 		$769.25
$828.08
$890.40
$1,111.81 		$1,102.66
$1,161.49
$1,223.81
$1,445.22 		$1,436.07
$1,494.90
$1,557.22
$1,778.63 		$333.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.68
$989.34
$1,113.98
$1,556.80
$2,365.70 		$1,205.09
$1,322.75
$1,447.39
$1,890.21 		$1,538.50
$1,656.16
$1,780.80
$2,223.62 		$1,871.91
$1,989.57
$2,114.21
$2,557.03 		$333.41
Toc - Plan #34 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$437.91
$497.02
$559.64
$782.10
$1,188.47 		$772.91
$832.02
$894.64
$1,117.10 		$1,107.91
$1,167.02
$1,229.64
$1,452.10 		$1,442.91
$1,502.02
$1,564.64
$1,787.10 		$335.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$875.82
$994.04
$1,119.28
$1,564.20
$2,376.94 		$1,210.82
$1,329.04
$1,454.28
$1,899.20 		$1,545.82
$1,664.04
$1,789.28
$2,234.20 		$1,880.82
$1,999.04
$2,124.28
$2,569.20 		$335.00
Toc - Plan #35 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$434.20
$492.82
$554.91
$775.48
$1,178.41 		$766.36
$824.98
$887.07
$1,107.64 		$1,098.52
$1,157.14
$1,219.23
$1,439.80 		$1,430.68
$1,489.30
$1,551.39
$1,771.96 		$332.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.40
$985.64
$1,109.82
$1,550.96
$2,356.82 		$1,200.56
$1,317.80
$1,441.98
$1,883.12 		$1,532.72
$1,649.96
$1,774.14
$2,215.28 		$1,864.88
$1,982.12
$2,106.30
$2,547.44 		$332.16
Toc - Plan #36 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$455.56
$517.05
$582.20
$813.62
$1,236.38 		$804.06
$865.55
$930.70
$1,162.12 		$1,152.56
$1,214.05
$1,279.20
$1,510.62 		$1,501.06
$1,562.55
$1,627.70
$1,859.12 		$348.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.12
$1,034.10
$1,164.40
$1,627.24
$2,472.76 		$1,259.62
$1,382.60
$1,512.90
$1,975.74 		$1,608.12
$1,731.10
$1,861.40
$2,324.24 		$1,956.62
$2,079.60
$2,209.90
$2,672.74 		$348.50
Toc - Plan #37 Quartz
Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$477.13
$541.54
$609.76
$852.14
$1,294.91 		$842.13
$906.54
$974.76
$1,217.14 		$1,207.13
$1,271.54
$1,339.76
$1,582.14 		$1,572.13
$1,636.54
$1,704.76
$1,947.14 		$365.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.26
$1,083.08
$1,219.52
$1,704.28
$2,589.82 		$1,319.26
$1,448.08
$1,584.52
$2,069.28 		$1,684.26
$1,813.08
$1,949.52
$2,434.28 		$2,049.26
$2,178.08
$2,314.52
$2,799.28 		$365.00
Toc - Plan #38 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$322.94
$366.53
$412.71
$576.76
$876.45 		$569.99
$613.58
$659.76
$823.81 		$817.04
$860.63
$906.81
$1,070.86 		$1,064.09
$1,107.68
$1,153.86
$1,317.91 		$247.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.88
$733.06
$825.42
$1,153.52
$1,752.90 		$892.93
$980.11
$1,072.47
$1,400.57 		$1,139.98
$1,227.16
$1,319.52
$1,647.62 		$1,387.03
$1,474.21
$1,566.57
$1,894.67 		$247.05
Toc - Plan #39 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$326.14
$370.16
$416.80
$582.47
$885.12 		$575.63
$619.65
$666.29
$831.96 		$825.12
$869.14
$915.78
$1,081.45 		$1,074.61
$1,118.63
$1,165.27
$1,330.94 		$249.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.28
$740.32
$833.60
$1,164.94
$1,770.24 		$901.77
$989.81
$1,083.09
$1,414.43 		$1,151.26
$1,239.30
$1,332.58
$1,663.92 		$1,400.75
$1,488.79
$1,582.07
$1,913.41 		$249.49
Toc - Plan #40 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$341.86
$388.00
$436.89
$610.55
$927.79 		$603.38
$649.52
$698.41
$872.07 		$864.90
$911.04
$959.93
$1,133.59 		$1,126.42
$1,172.56
$1,221.45
$1,395.11 		$261.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.72
$776.00
$873.78
$1,221.10
$1,855.58 		$945.24
$1,037.52
$1,135.30
$1,482.62 		$1,206.76
$1,299.04
$1,396.82
$1,744.14 		$1,468.28
$1,560.56
$1,658.34
$2,005.66 		$261.52
Toc - Plan #41 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$338.37
$384.04
$432.42
$604.31
$918.31 		$597.22
$642.89
$691.27
$863.16 		$856.07
$901.74
$950.12
$1,122.01 		$1,114.92
$1,160.59
$1,208.97
$1,380.86 		$258.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$676.74
$768.08
$864.84
$1,208.62
$1,836.62 		$935.59
$1,026.93
$1,123.69
$1,467.47 		$1,194.44
$1,285.78
$1,382.54
$1,726.32 		$1,453.29
$1,544.63
$1,641.39
$1,985.17 		$258.85
Toc - Plan #42 Quartz
Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$352.30
$399.85
$450.23
$629.19
$956.12 		$621.80
$669.35
$719.73
$898.69 		$891.30
$938.85
$989.23
$1,168.19 		$1,160.80
$1,208.35
$1,258.73
$1,437.69 		$269.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.60
$799.70
$900.46
$1,258.38
$1,912.24 		$974.10
$1,069.20
$1,169.96
$1,527.88 		$1,243.60
$1,338.70
$1,439.46
$1,797.38 		$1,513.10
$1,608.20
$1,708.96
$2,066.88 		$269.50
Toc - Plan #43 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$451.51
$512.46
$577.03
$806.40
$1,225.40 		$796.91
$857.86
$922.43
$1,151.80 		$1,142.31
$1,203.26
$1,267.83
$1,497.20 		$1,487.71
$1,548.66
$1,613.23
$1,842.60 		$345.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.02
$1,024.92
$1,154.06
$1,612.80
$2,450.80 		$1,248.42
$1,370.32
$1,499.46
$1,958.20 		$1,593.82
$1,715.72
$1,844.86
$2,303.60 		$1,939.22
$2,061.12
$2,190.26
$2,649.00 		$345.40
Toc - Plan #44 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$479.71
$544.46
$613.06
$856.75
$1,301.92 		$846.68
$911.43
$980.03
$1,223.72 		$1,213.65
$1,278.40
$1,347.00
$1,590.69 		$1,580.62
$1,645.37
$1,713.97
$1,957.66 		$366.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$959.42
$1,088.92
$1,226.12
$1,713.50
$2,603.84 		$1,326.39
$1,455.89
$1,593.09
$2,080.47 		$1,693.36
$1,822.86
$1,960.06
$2,447.44 		$2,060.33
$2,189.83
$2,327.03
$2,814.41 		$366.97
Toc - Plan #45 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$339.38
$385.19
$433.72
$606.12
$921.05 		$599.00
$644.81
$693.34
$865.74 		$858.62
$904.43
$952.96
$1,125.36 		$1,118.24
$1,164.05
$1,212.58
$1,384.98 		$259.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.76
$770.38
$867.44
$1,212.24
$1,842.10 		$938.38
$1,030.00
$1,127.06
$1,471.86 		$1,198.00
$1,289.62
$1,386.68
$1,731.48 		$1,457.62
$1,549.24
$1,646.30
$1,991.10 		$259.62
Toc - Plan #46 Quartz
Catastrophic

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE CATASTROPHIC I101

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$250.18
$283.95
$319.73
$446.82
$678.98 		$441.57
$475.34
$511.12
$638.21 		$632.96
$666.73
$702.51
$829.60 		$824.35
$858.12
$893.90
$1,020.99 		$191.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500.36
$567.90
$639.46
$893.64
$1,357.96 		$691.75
$759.29
$830.85
$1,085.03 		$883.14
$950.68
$1,022.24
$1,276.42 		$1,074.53
$1,142.07
$1,213.63
$1,467.81 		$191.39
Toc - Plan #47 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$481.80
$546.84
$615.73
$860.49
$1,307.59 		$850.37
$915.41
$984.30
$1,229.06 		$1,218.94
$1,283.98
$1,352.87
$1,597.63 		$1,587.51
$1,652.55
$1,721.44
$1,966.20 		$368.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$963.60
$1,093.68
$1,231.46
$1,720.98
$2,615.18 		$1,332.17
$1,462.25
$1,600.03
$2,089.55 		$1,700.74
$1,830.82
$1,968.60
$2,458.12 		$2,069.31
$2,199.39
$2,337.17
$2,826.69 		$368.57
Toc - Plan #48 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I401 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$430.38
$488.48
$550.02
$768.66
$1,168.05 		$759.62
$817.72
$879.26
$1,097.90 		$1,088.86
$1,146.96
$1,208.50
$1,427.14 		$1,418.10
$1,476.20
$1,537.74
$1,756.38 		$329.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.76
$976.96
$1,100.04
$1,537.32
$2,336.10 		$1,190.00
$1,306.20
$1,429.28
$1,866.56 		$1,519.24
$1,635.44
$1,758.52
$2,195.80 		$1,848.48
$1,964.68
$2,087.76
$2,525.04 		$329.24
Toc - Plan #49 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I402 Maintenance with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.35
$483.90
$544.86
$761.45
$1,157.09 		$752.50
$810.05
$871.01
$1,087.60 		$1,078.65
$1,136.20
$1,197.16
$1,413.75 		$1,404.80
$1,462.35
$1,523.31
$1,739.90 		$326.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.70
$967.80
$1,089.72
$1,522.90
$2,314.18 		$1,178.85
$1,293.95
$1,415.87
$1,849.05 		$1,505.00
$1,620.10
$1,742.02
$2,175.20 		$1,831.15
$1,946.25
$2,068.17
$2,501.35 		$326.15
Toc - Plan #50 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I405 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.89
$487.92
$549.39
$767.78
$1,166.71 		$758.75
$816.78
$878.25
$1,096.64 		$1,087.61
$1,145.64
$1,207.11
$1,425.50 		$1,416.47
$1,474.50
$1,535.97
$1,754.36 		$328.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.78
$975.84
$1,098.78
$1,535.56
$2,333.42 		$1,188.64
$1,304.70
$1,427.64
$1,864.42 		$1,517.50
$1,633.56
$1,756.50
$2,193.28 		$1,846.36
$1,962.42
$2,085.36
$2,522.14 		$328.86
Toc - Plan #51 Quartz
Gold

(HMO) Quartz One with Aurora Health Care Gold I410 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$440.90
$500.42
$563.46
$787.44
$1,196.59 		$778.18
$837.70
$900.74
$1,124.72 		$1,115.46
$1,174.98
$1,238.02
$1,462.00 		$1,452.74
$1,512.26
$1,575.30
$1,799.28 		$337.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.80
$1,000.84
$1,126.92
$1,574.88
$2,393.18 		$1,219.08
$1,338.12
$1,464.20
$1,912.16 		$1,556.36
$1,675.40
$1,801.48
$2,249.44 		$1,893.64
$2,012.68
$2,138.76
$2,586.72 		$337.28
Toc - Plan #52 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I301 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$443.00
$502.79
$566.14
$791.18
$1,202.28 		$781.89
$841.68
$905.03
$1,130.07 		$1,120.78
$1,180.57
$1,243.92
$1,468.96 		$1,459.67
$1,519.46
$1,582.81
$1,807.85 		$338.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.00
$1,005.58
$1,132.28
$1,582.36
$2,404.56 		$1,224.89
$1,344.47
$1,471.17
$1,921.25 		$1,563.78
$1,683.36
$1,810.06
$2,260.14 		$1,902.67
$2,022.25
$2,148.95
$2,599.03 		$338.89
Toc - Plan #53 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I303 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$439.25
$498.54
$561.35
$784.49
$1,192.10 		$775.27
$834.56
$897.37
$1,120.51 		$1,111.29
$1,170.58
$1,233.39
$1,456.53 		$1,447.31
$1,506.60
$1,569.41
$1,792.55 		$336.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.50
$997.08
$1,122.70
$1,568.98
$2,384.20 		$1,214.52
$1,333.10
$1,458.72
$1,905.00 		$1,550.54
$1,669.12
$1,794.74
$2,241.02 		$1,886.56
$2,005.14
$2,130.76
$2,577.04 		$336.02
Toc - Plan #54 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I308 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$460.85
$523.06
$588.96
$823.07
$1,250.74 		$813.40
$875.61
$941.51
$1,175.62 		$1,165.95
$1,228.16
$1,294.06
$1,528.17 		$1,518.50
$1,580.71
$1,646.61
$1,880.72 		$352.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.70
$1,046.12
$1,177.92
$1,646.14
$2,501.48 		$1,274.25
$1,398.67
$1,530.47
$1,998.69 		$1,626.80
$1,751.22
$1,883.02
$2,351.24 		$1,979.35
$2,103.77
$2,235.57
$2,703.79 		$352.55
Toc - Plan #55 Quartz
Silver

(HMO) Quartz One with Aurora Health Care Silver I309 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$482.67
$547.83
$616.85
$862.04
$1,309.96 		$851.91
$917.07
$986.09
$1,231.28 		$1,221.15
$1,286.31
$1,355.33
$1,600.52 		$1,590.39
$1,655.55
$1,724.57
$1,969.76 		$369.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$965.34
$1,095.66
$1,233.70
$1,724.08
$2,619.92 		$1,334.58
$1,464.90
$1,602.94
$2,093.32 		$1,703.82
$1,834.14
$1,972.18
$2,462.56 		$2,073.06
$2,203.38
$2,341.42
$2,831.80 		$369.24
Toc - Plan #56 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I201 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$326.69
$370.79
$417.51
$583.46
$886.63 		$576.61
$620.71
$667.43
$833.38 		$826.53
$870.63
$917.35
$1,083.30 		$1,076.45
$1,120.55
$1,167.27
$1,333.22 		$249.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.38
$741.58
$835.02
$1,166.92
$1,773.26 		$903.30
$991.50
$1,084.94
$1,416.84 		$1,153.22
$1,241.42
$1,334.86
$1,666.76 		$1,403.14
$1,491.34
$1,584.78
$1,916.68 		$249.92
Toc - Plan #57 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$329.92
$374.46
$421.64
$589.24
$895.40 		$582.31
$626.85
$674.03
$841.63 		$834.70
$879.24
$926.42
$1,094.02 		$1,087.09
$1,131.63
$1,178.81
$1,346.41 		$252.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.84
$748.92
$843.28
$1,178.48
$1,790.80 		$912.23
$1,001.31
$1,095.67
$1,430.87 		$1,164.62
$1,253.70
$1,348.06
$1,683.26 		$1,417.01
$1,506.09
$1,600.45
$1,935.65 		$252.39
Toc - Plan #58 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I204 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$345.83
$392.51
$441.96
$617.64
$938.57 		$610.39
$657.07
$706.52
$882.20 		$874.95
$921.63
$971.08
$1,146.76 		$1,139.51
$1,186.19
$1,235.64
$1,411.32 		$264.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.66
$785.02
$883.92
$1,235.28
$1,877.14 		$956.22
$1,049.58
$1,148.48
$1,499.84 		$1,220.78
$1,314.14
$1,413.04
$1,764.40 		$1,485.34
$1,578.70
$1,677.60
$2,028.96 		$264.56
Toc - Plan #59 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I205 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$342.30
$388.50
$437.45
$611.33
$928.98 		$604.15
$650.35
$699.30
$873.18 		$866.00
$912.20
$961.15
$1,135.03 		$1,127.85
$1,174.05
$1,223.00
$1,396.88 		$261.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.60
$777.00
$874.90
$1,222.66
$1,857.96 		$946.45
$1,038.85
$1,136.75
$1,484.51 		$1,208.30
$1,300.70
$1,398.60
$1,746.36 		$1,470.15
$1,562.55
$1,660.45
$2,008.21 		$261.85
Toc - Plan #60 Quartz
Expanded Bronze

(HMO) Quartz One with Aurora Health Care Bronze I206 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$356.39
$404.49
$455.46
$636.50
$967.22 		$629.02
$677.12
$728.09
$909.13 		$901.65
$949.75
$1,000.72
$1,181.76 		$1,174.28
$1,222.38
$1,273.35
$1,454.39 		$272.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.78
$808.98
$910.92
$1,273.00
$1,934.44 		$985.41
$1,081.61
$1,183.55
$1,545.63 		$1,258.04
$1,354.24
$1,456.18
$1,818.26 		$1,530.67
$1,626.87
$1,728.81
$2,090.89 		$272.63
Toc - Plan #61 Quartz
Gold

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE GOLD I403 HSA with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$456.76
$518.42
$583.73
$815.76
$1,239.63 		$806.18
$867.84
$933.15
$1,165.18 		$1,155.60
$1,217.26
$1,282.57
$1,514.60 		$1,505.02
$1,566.68
$1,631.99
$1,864.02 		$349.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$913.52
$1,036.84
$1,167.46
$1,631.52
$2,479.26 		$1,262.94
$1,386.26
$1,516.88
$1,980.94 		$1,612.36
$1,735.68
$1,866.30
$2,330.36 		$1,961.78
$2,085.10
$2,215.72
$2,679.78 		$349.42
Toc - Plan #62 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I304 HSA with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$485.28
$550.79
$620.18
$866.70
$1,317.04 		$856.52
$922.03
$991.42
$1,237.94 		$1,227.76
$1,293.27
$1,362.66
$1,609.18 		$1,599.00
$1,664.51
$1,733.90
$1,980.42 		$371.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$970.56
$1,101.58
$1,240.36
$1,733.40
$2,634.08 		$1,341.80
$1,472.82
$1,611.60
$2,104.64 		$1,713.04
$1,844.06
$1,982.84
$2,475.88 		$2,084.28
$2,215.30
$2,354.08
$2,847.12 		$371.24
Toc - Plan #63 Quartz
Silver

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE SILVER I307 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$487.40
$553.19
$622.89
$870.48
$1,322.78 		$860.25
$926.04
$995.74
$1,243.33 		$1,233.10
$1,298.89
$1,368.59
$1,616.18 		$1,605.95
$1,671.74
$1,741.44
$1,989.03 		$372.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$974.80
$1,106.38
$1,245.78
$1,740.96
$2,645.56 		$1,347.65
$1,479.23
$1,618.63
$2,113.81 		$1,720.50
$1,852.08
$1,991.48
$2,486.66 		$2,093.35
$2,224.93
$2,364.33
$2,859.51 		$372.85
Toc - Plan #64 Quartz
Expanded Bronze

(HMO) QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I203 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$343.32
$389.66
$438.75
$613.16
$931.75 		$605.95
$652.29
$701.38
$875.79 		$868.58
$914.92
$964.01
$1,138.42 		$1,131.21
$1,177.55
$1,226.64
$1,401.05 		$262.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.64
$779.32
$877.50
$1,226.32
$1,863.50 		$949.27
$1,041.95
$1,140.13
$1,488.95 		$1,211.90
$1,304.58
$1,402.76
$1,751.58 		$1,474.53
$1,567.21
$1,665.39
$2,014.21 		$262.63

ADVERTISEMENT

Security Health Plan

Local: 1-715-221-9258x19258 | Toll Free: 1-844-293-9624 | TTY: 1-877-727-2232
Toc - Plan #65 Security Health Plan
Gold

(EPO) SimplyOne $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$393.87
$447.03
$503.35
$703.43
$1,068.92 		$695.17
$748.33
$804.65
$1,004.73 		$996.47
$1,049.63
$1,105.95
$1,306.03 		$1,297.77
$1,350.93
$1,407.25
$1,607.33 		$301.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.74
$894.06
$1,006.70
$1,406.86
$2,137.84 		$1,089.04
$1,195.36
$1,308.00
$1,708.16 		$1,390.34
$1,496.66
$1,609.30
$2,009.46 		$1,691.64
$1,797.96
$1,910.60
$2,310.76 		$301.30
Toc - Plan #66 Security Health Plan
Silver

(EPO) SimplyOne $4,100 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$478.36
$542.93
$611.33
$854.33
$1,298.24 		$844.30
$908.87
$977.27
$1,220.27 		$1,210.24
$1,274.81
$1,343.21
$1,586.21 		$1,576.18
$1,640.75
$1,709.15
$1,952.15 		$365.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.72
$1,085.86
$1,222.66
$1,708.66
$2,596.48 		$1,322.66
$1,451.80
$1,588.60
$2,074.60 		$1,688.60
$1,817.74
$1,954.54
$2,440.54 		$2,054.54
$2,183.68
$2,320.48
$2,806.48 		$365.94
Toc - Plan #67 Security Health Plan
Expanded Bronze

(EPO) SimplyOne $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$326.07
$370.08
$416.71
$582.35
$884.94 		$575.51
$619.52
$666.15
$831.79 		$824.95
$868.96
$915.59
$1,081.23 		$1,074.39
$1,118.40
$1,165.03
$1,330.67 		$249.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.14
$740.16
$833.42
$1,164.70
$1,769.88 		$901.58
$989.60
$1,082.86
$1,414.14 		$1,151.02
$1,239.04
$1,332.30
$1,663.58 		$1,400.46
$1,488.48
$1,581.74
$1,913.02 		$249.44
Toc - Plan #68 Security Health Plan
Bronze

(EPO) SimplyOne $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$280.88
$318.79
$358.95
$501.63
$762.28 		$495.74
$533.65
$573.81
$716.49 		$710.60
$748.51
$788.67
$931.35 		$925.46
$963.37
$1,003.53
$1,146.21 		$214.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.76
$637.58
$717.90
$1,003.26
$1,524.56 		$776.62
$852.44
$932.76
$1,218.12 		$991.48
$1,067.30
$1,147.62
$1,432.98 		$1,206.34
$1,282.16
$1,362.48
$1,647.84 		$214.86
Toc - Plan #69 Security Health Plan
Catastrophic

(EPO) SimplyOne Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$192.15
$218.08
$245.56
$343.17
$521.47 		$339.14
$365.07
$392.55
$490.16 		$486.13
$512.06
$539.54
$637.15 		$633.12
$659.05
$686.53
$784.14 		$146.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$384.30
$436.16
$491.12
$686.34
$1,042.94 		$531.29
$583.15
$638.11
$833.33 		$678.28
$730.14
$785.10
$980.32 		$825.27
$877.13
$932.09
$1,127.31 		$146.99
Toc - Plan #70 Security Health Plan
Gold

(EPO) SimplyOne $2,000 - 25%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$418.18
$474.63
$534.42
$746.85
$1,134.92 		$738.08
$794.53
$854.32
$1,066.75 		$1,057.98
$1,114.43
$1,174.22
$1,386.65 		$1,377.88
$1,434.33
$1,494.12
$1,706.55 		$319.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.36
$949.26
$1,068.84
$1,493.70
$2,269.84 		$1,156.26
$1,269.16
$1,388.74
$1,813.60 		$1,476.16
$1,589.06
$1,708.64
$2,133.50 		$1,796.06
$1,908.96
$2,028.54
$2,453.40 		$319.90
Toc - Plan #71 Security Health Plan
Silver

(EPO) SimplyOne $5,800 - 40%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$414.58
$470.54
$529.82
$740.42
$1,125.14 		$731.73
$787.69
$846.97
$1,057.57 		$1,048.88
$1,104.84
$1,164.12
$1,374.72 		$1,366.03
$1,421.99
$1,481.27
$1,691.87 		$317.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.16
$941.08
$1,059.64
$1,480.84
$2,250.28 		$1,146.31
$1,258.23
$1,376.79
$1,797.99 		$1,463.46
$1,575.38
$1,693.94
$2,115.14 		$1,780.61
$1,892.53
$2,011.09
$2,432.29 		$317.15
Toc - Plan #72 Security Health Plan
Expanded Bronze

(EPO) SimplyOne $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$287.06
$325.80
$366.85
$512.67
$779.06 		$506.65
$545.39
$586.44
$732.26 		$726.24
$764.98
$806.03
$951.85 		$945.83
$984.57
$1,025.62
$1,171.44 		$219.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.12
$651.60
$733.70
$1,025.34
$1,558.12 		$793.71
$871.19
$953.29
$1,244.93 		$1,013.30
$1,090.78
$1,172.88
$1,464.52 		$1,232.89
$1,310.37
$1,392.47
$1,684.11 		$219.59
Toc - Plan #73 Security Health Plan
Gold

(HMO) Premier $2,000 - 25%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$519.71
$589.85
$664.17
$928.18
$1,410.45 		$917.28
$987.42
$1,061.74
$1,325.75 		$1,314.85
$1,384.99
$1,459.31
$1,723.32 		$1,712.42
$1,782.56
$1,856.88
$2,120.89 		$397.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,039.42
$1,179.70
$1,328.34
$1,856.36
$2,820.90 		$1,436.99
$1,577.27
$1,725.91
$2,253.93 		$1,834.56
$1,974.84
$2,123.48
$2,651.50 		$2,232.13
$2,372.41
$2,521.05
$3,049.07 		$397.57
Toc - Plan #74 Security Health Plan
Gold

(HMO) Premier $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$489.49
$555.55
$625.55
$874.20
$1,328.44 		$863.94
$930.00
$1,000.00
$1,248.65 		$1,238.39
$1,304.45
$1,374.45
$1,623.10 		$1,612.84
$1,678.90
$1,748.90
$1,997.55 		$374.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$978.98
$1,111.10
$1,251.10
$1,748.40
$2,656.88 		$1,353.43
$1,485.55
$1,625.55
$2,122.85 		$1,727.88
$1,860.00
$2,000.00
$2,497.30 		$2,102.33
$2,234.45
$2,374.45
$2,871.75 		$374.45
Toc - Plan #75 Security Health Plan
Silver

(HMO) Premier $5,800 - 40%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$515.23
$584.77
$658.45
$920.18
$1,398.30 		$909.37
$978.91
$1,052.59
$1,314.32 		$1,303.51
$1,373.05
$1,446.73
$1,708.46 		$1,697.65
$1,767.19
$1,840.87
$2,102.60 		$394.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,030.46
$1,169.54
$1,316.90
$1,840.36
$2,796.60 		$1,424.60
$1,563.68
$1,711.04
$2,234.50 		$1,818.74
$1,957.82
$2,105.18
$2,628.64 		$2,212.88
$2,351.96
$2,499.32
$3,022.78 		$394.14
Toc - Plan #76 Security Health Plan
Silver

(HMO) Premier $4,100 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$594.49
$674.74
$759.75
$1,061.75
$1,613.43 		$1,049.27
$1,129.52
$1,214.53
$1,516.53 		$1,504.05
$1,584.30
$1,669.31
$1,971.31 		$1,958.83
$2,039.08
$2,124.09
$2,426.09 		$454.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,188.98
$1,349.48
$1,519.50
$2,123.50
$3,226.86 		$1,643.76
$1,804.26
$1,974.28
$2,578.28 		$2,098.54
$2,259.04
$2,429.06
$3,033.06 		$2,553.32
$2,713.82
$2,883.84
$3,487.84 		$454.78
Toc - Plan #77 Security Health Plan
Expanded Bronze

(HMO) Premier $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.24
$459.93
$517.88
$723.73
$1,099.78 		$715.24
$769.93
$827.88
$1,033.73 		$1,025.24
$1,079.93
$1,137.88
$1,343.73 		$1,335.24
$1,389.93
$1,447.88
$1,653.73 		$310.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.48
$919.86
$1,035.76
$1,447.46
$2,199.56 		$1,120.48
$1,229.86
$1,345.76
$1,757.46 		$1,430.48
$1,539.86
$1,655.76
$2,067.46 		$1,740.48
$1,849.86
$1,965.76
$2,377.46 		$310.00
Toc - Plan #78 Security Health Plan
Expanded Bronze

(HMO) Premier $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$356.75
$404.90
$455.91
$637.14
$968.19 		$629.66
$677.81
$728.82
$910.05 		$902.57
$950.72
$1,001.73
$1,182.96 		$1,175.48
$1,223.63
$1,274.64
$1,455.87 		$272.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.50
$809.80
$911.82
$1,274.28
$1,936.38 		$986.41
$1,082.71
$1,184.73
$1,547.19 		$1,259.32
$1,355.62
$1,457.64
$1,820.10 		$1,532.23
$1,628.53
$1,730.55
$2,093.01 		$272.91
Toc - Plan #79 Security Health Plan
Bronze

(HMO) Premier $9,100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$349.07
$396.18
$446.10
$623.42
$947.35 		$616.10
$663.21
$713.13
$890.45 		$883.13
$930.24
$980.16
$1,157.48 		$1,150.16
$1,197.27
$1,247.19
$1,424.51 		$267.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.14
$792.36
$892.20
$1,246.84
$1,894.70 		$965.17
$1,059.39
$1,159.23
$1,513.87 		$1,232.20
$1,326.42
$1,426.26
$1,780.90 		$1,499.23
$1,593.45
$1,693.29
$2,047.93 		$267.03
Toc - Plan #80 Security Health Plan
Catastrophic

(HMO) Premier Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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 		$238.80
$271.03
$305.17
$426.48
$648.08 		$421.48
$453.71
$487.85
$609.16 		$604.16
$636.39
$670.53
$791.84 		$786.84
$819.07
$853.21
$974.52 		$182.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$477.60
$542.06
$610.34
$852.96
$1,296.16 		$660.28
$724.74
$793.02
$1,035.64 		$842.96
$907.42
$975.70
$1,218.32 		$1,025.64
$1,090.10
$1,158.38
$1,401.00 		$182.68

ADVERTISEMENT

Aspirus Health Plan

Local: 1-866-631-4611 | Toll Free: 1-866-631-4611 | TTY: 1-866-631-8597
Toc - Plan #81 Aspirus Health Plan
Silver

(HMO) HMO Silver 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$505.56
$573.82
$646.11
$902.94
$1,372.10 		$892.32
$960.58
$1,032.87
$1,289.70 		$1,279.08
$1,347.34
$1,419.63
$1,676.46 		$1,665.84
$1,734.10
$1,806.39
$2,063.22 		$386.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.12
$1,147.64
$1,292.22
$1,805.88
$2,744.20 		$1,397.88
$1,534.40
$1,678.98
$2,192.64 		$1,784.64
$1,921.16
$2,065.74
$2,579.40 		$2,171.40
$2,307.92
$2,452.50
$2,966.16 		$386.76
Toc - Plan #82 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$6,950 $13,900 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 		$373.50
$423.93
$477.34
$667.08
$1,013.69 		$659.23
$709.66
$763.07
$952.81 		$944.96
$995.39
$1,048.80
$1,238.54 		$1,230.69
$1,281.12
$1,334.53
$1,524.27 		$285.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.00
$847.86
$954.68
$1,334.16
$2,027.38 		$1,032.73
$1,133.59
$1,240.41
$1,619.89 		$1,318.46
$1,419.32
$1,526.14
$1,905.62 		$1,604.19
$1,705.05
$1,811.87
$2,191.35 		$285.73
Toc - Plan #83 Aspirus Health Plan
Bronze

(HMO) HMO Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$343.45
$389.82
$438.93
$613.41
$932.14 		$606.19
$652.56
$701.67
$876.15 		$868.93
$915.30
$964.41
$1,138.89 		$1,131.67
$1,178.04
$1,227.15
$1,401.63 		$262.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.90
$779.64
$877.86
$1,226.82
$1,864.28 		$949.64
$1,042.38
$1,140.60
$1,489.56 		$1,212.38
$1,305.12
$1,403.34
$1,752.30 		$1,475.12
$1,567.86
$1,666.08
$2,015.04 		$262.74
Toc - Plan #84 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 6500 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369.55
$419.44
$472.29
$660.02
$1,002.97 		$652.26
$702.15
$755.00
$942.73 		$934.97
$984.86
$1,037.71
$1,225.44 		$1,217.68
$1,267.57
$1,320.42
$1,508.15 		$282.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.10
$838.88
$944.58
$1,320.04
$2,005.94 		$1,021.81
$1,121.59
$1,227.29
$1,602.75 		$1,304.52
$1,404.30
$1,510.00
$1,885.46 		$1,587.23
$1,687.01
$1,792.71
$2,168.17 		$282.71
Toc - Plan #85 Aspirus Health Plan
Gold

(HMO) HMO Gold 2800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$464.77
$527.52
$593.98
$830.09
$1,261.40 		$820.32
$883.07
$949.53
$1,185.64 		$1,175.87
$1,238.62
$1,305.08
$1,541.19 		$1,531.42
$1,594.17
$1,660.63
$1,896.74 		$355.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.54
$1,055.04
$1,187.96
$1,660.18
$2,522.80 		$1,285.09
$1,410.59
$1,543.51
$2,015.73 		$1,640.64
$1,766.14
$1,899.06
$2,371.28 		$1,996.19
$2,121.69
$2,254.61
$2,726.83 		$355.55
Toc - Plan #86 Aspirus Health Plan
Catastrophic

(HMO) HMO Catastrophic 9100 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$249.99
$283.74
$319.49
$446.49
$678.49 		$441.24
$474.99
$510.74
$637.74 		$632.49
$666.24
$701.99
$828.99 		$823.74
$857.49
$893.24
$1,020.24 		$191.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.98
$567.48
$638.98
$892.98
$1,356.98 		$691.23
$758.73
$830.23
$1,084.23 		$882.48
$949.98
$1,021.48
$1,275.48 		$1,073.73
$1,141.23
$1,212.73
$1,466.73 		$191.25
Toc - Plan #87 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.02
$422.25
$475.45
$664.43
$1,009.67 		$656.62
$706.85
$760.05
$949.03 		$941.22
$991.45
$1,044.65
$1,233.63 		$1,225.82
$1,276.05
$1,329.25
$1,518.23 		$284.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.04
$844.50
$950.90
$1,328.86
$2,019.34 		$1,028.64
$1,129.10
$1,235.50
$1,613.46 		$1,313.24
$1,413.70
$1,520.10
$1,898.06 		$1,597.84
$1,698.30
$1,804.70
$2,182.66 		$284.60
Toc - Plan #88 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$366.01
$415.42
$467.76
$653.69
$993.35 		$646.01
$695.42
$747.76
$933.69 		$926.01
$975.42
$1,027.76
$1,213.69 		$1,206.01
$1,255.42
$1,307.76
$1,493.69 		$280.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.02
$830.84
$935.52
$1,307.38
$1,986.70 		$1,012.02
$1,110.84
$1,215.52
$1,587.38 		$1,292.02
$1,390.84
$1,495.52
$1,867.38 		$1,572.02
$1,670.84
$1,775.52
$2,147.38 		$280.00
Toc - Plan #89 Aspirus Health Plan
Silver

(HMO) HMO Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$504.29
$572.36
$644.48
$900.65
$1,368.63 		$890.07
$958.14
$1,030.26
$1,286.43 		$1,275.85
$1,343.92
$1,416.04
$1,672.21 		$1,661.63
$1,729.70
$1,801.82
$2,057.99 		$385.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,008.58
$1,144.72
$1,288.96
$1,801.30
$2,737.26 		$1,394.36
$1,530.50
$1,674.74
$2,187.08 		$1,780.14
$1,916.28
$2,060.52
$2,572.86 		$2,165.92
$2,302.06
$2,446.30
$2,958.64 		$385.78
Toc - Plan #90 Aspirus Health Plan
Silver

(HMO) HMO HDHP Silver 5400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$512.87
$582.10
$655.44
$915.98
$1,391.92 		$905.21
$974.44
$1,047.78
$1,308.32 		$1,297.55
$1,366.78
$1,440.12
$1,700.66 		$1,689.89
$1,759.12
$1,832.46
$2,093.00 		$392.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,025.74
$1,164.20
$1,310.88
$1,831.96
$2,783.84 		$1,418.08
$1,556.54
$1,703.22
$2,224.30 		$1,810.42
$1,948.88
$2,095.56
$2,616.64 		$2,202.76
$2,341.22
$2,487.90
$3,008.98 		$392.34
Toc - Plan #91 Aspirus Health Plan
Gold

(HMO) HMO Gold 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$464.23
$526.90
$593.28
$829.11
$1,259.91 		$819.36
$882.03
$948.41
$1,184.24 		$1,174.49
$1,237.16
$1,303.54
$1,539.37 		$1,529.62
$1,592.29
$1,658.67
$1,894.50 		$355.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$928.46
$1,053.80
$1,186.56
$1,658.22
$2,519.82 		$1,283.59
$1,408.93
$1,541.69
$2,013.35 		$1,638.72
$1,764.06
$1,896.82
$2,368.48 		$1,993.85
$2,119.19
$2,251.95
$2,723.61 		$355.13
Toc - Plan #92 Aspirus Health Plan
Silver

(POS) POS Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$577.34
$655.28
$737.84
$1,031.13
$1,566.90 		$1,019.00
$1,096.94
$1,179.50
$1,472.79 		$1,460.66
$1,538.60
$1,621.16
$1,914.45 		$1,902.32
$1,980.26
$2,062.82
$2,356.11 		$441.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,154.68
$1,310.56
$1,475.68
$2,062.26
$3,133.80 		$1,596.34
$1,752.22
$1,917.34
$2,503.92 		$2,038.00
$2,193.88
$2,359.00
$2,945.58 		$2,479.66
$2,635.54
$2,800.66
$3,387.24 		$441.66
Toc - Plan #93 Aspirus Health Plan
Expanded Bronze

(POS) POS HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$6,950 $13,900 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 		$411.07
$466.57
$525.35
$734.18
$1,115.65 		$725.54
$781.04
$839.82
$1,048.65 		$1,040.01
$1,095.51
$1,154.29
$1,363.12 		$1,354.48
$1,409.98
$1,468.76
$1,677.59 		$314.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.14
$933.14
$1,050.70
$1,468.36
$2,231.30 		$1,136.61
$1,247.61
$1,365.17
$1,782.83 		$1,451.08
$1,562.08
$1,679.64
$2,097.30 		$1,765.55
$1,876.55
$1,994.11
$2,411.77 		$314.47
Toc - Plan #94 Aspirus Health Plan
Expanded Bronze

(POS) POS Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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 		$528.61
$599.97
$675.57
$944.10
$1,434.65 		$933.00
$1,004.36
$1,079.96
$1,348.49 		$1,337.39
$1,408.75
$1,484.35
$1,752.88 		$1,741.78
$1,813.14
$1,888.74
$2,157.27 		$404.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,057.22
$1,199.94
$1,351.14
$1,888.20
$2,869.30 		$1,461.61
$1,604.33
$1,755.53
$2,292.59 		$1,866.00
$2,008.72
$2,159.92
$2,696.98 		$2,270.39
$2,413.11
$2,564.31
$3,101.37 		$404.39

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442
Toc - Plan #95 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$309.12
$350.85
$395.05
$552.08
$838.94 		$545.59
$587.32
$631.52
$788.55 		$782.06
$823.79
$867.99
$1,025.02 		$1,018.53
$1,060.26
$1,104.46
$1,261.49 		$236.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.24
$701.70
$790.10
$1,104.16
$1,677.88 		$854.71
$938.17
$1,026.57
$1,340.63 		$1,091.18
$1,174.64
$1,263.04
$1,577.10 		$1,327.65
$1,411.11
$1,499.51
$1,813.57 		$236.47
Toc - Plan #96 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Copay Silver $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$438.89
$498.13
$560.89
$783.84
$1,191.12 		$774.63
$833.87
$896.63
$1,119.58 		$1,110.37
$1,169.61
$1,232.37
$1,455.32 		$1,446.11
$1,505.35
$1,568.11
$1,791.06 		$335.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.78
$996.26
$1,121.78
$1,567.68
$2,382.24 		$1,213.52
$1,332.00
$1,457.52
$1,903.42 		$1,549.26
$1,667.74
$1,793.26
$2,239.16 		$1,885.00
$2,003.48
$2,129.00
$2,574.90 		$335.74
Toc - Plan #97 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$473.01
$536.85
$604.49
$844.77
$1,283.71 		$834.85
$898.69
$966.33
$1,206.61 		$1,196.69
$1,260.53
$1,328.17
$1,568.45 		$1,558.53
$1,622.37
$1,690.01
$1,930.29 		$361.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946.02
$1,073.70
$1,208.98
$1,689.54
$2,567.42 		$1,307.86
$1,435.54
$1,570.82
$2,051.38 		$1,669.70
$1,797.38
$1,932.66
$2,413.22 		$2,031.54
$2,159.22
$2,294.50
$2,775.06 		$361.84
Toc - Plan #98 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$408.01
$463.08
$521.43
$728.69
$1,107.32 		$720.13
$775.20
$833.55
$1,040.81 		$1,032.25
$1,087.32
$1,145.67
$1,352.93 		$1,344.37
$1,399.44
$1,457.79
$1,665.05 		$312.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.02
$926.16
$1,042.86
$1,457.38
$2,214.64 		$1,128.14
$1,238.28
$1,354.98
$1,769.50 		$1,440.26
$1,550.40
$1,667.10
$2,081.62 		$1,752.38
$1,862.52
$1,979.22
$2,393.74 		$312.12
Toc - Plan #99 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.90
$507.22
$571.12
$798.14
$1,212.85 		$788.77
$849.09
$912.99
$1,140.01 		$1,130.64
$1,190.96
$1,254.86
$1,481.88 		$1,472.51
$1,532.83
$1,596.73
$1,823.75 		$341.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893.80
$1,014.44
$1,142.24
$1,596.28
$2,425.70 		$1,235.67
$1,356.31
$1,484.11
$1,938.15 		$1,577.54
$1,698.18
$1,825.98
$2,280.02 		$1,919.41
$2,040.05
$2,167.85
$2,621.89 		$341.87
Toc - Plan #100 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$402.61
$456.96
$514.53
$719.05
$1,092.67 		$710.60
$764.95
$822.52
$1,027.04 		$1,018.59
$1,072.94
$1,130.51
$1,335.03 		$1,326.58
$1,380.93
$1,438.50
$1,643.02 		$307.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.22
$913.92
$1,029.06
$1,438.10
$2,185.34 		$1,113.21
$1,221.91
$1,337.05
$1,746.09 		$1,421.20
$1,529.90
$1,645.04
$2,054.08 		$1,729.19
$1,837.89
$1,953.03
$2,362.07 		$307.99
Toc - Plan #101 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$344.44
$390.93
$440.18
$615.15
$934.78 		$607.93
$654.42
$703.67
$878.64 		$871.42
$917.91
$967.16
$1,142.13 		$1,134.91
$1,181.40
$1,230.65
$1,405.62 		$263.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.88
$781.86
$880.36
$1,230.30
$1,869.56 		$952.37
$1,045.35
$1,143.85
$1,493.79 		$1,215.86
$1,308.84
$1,407.34
$1,757.28 		$1,479.35
$1,572.33
$1,670.83
$2,020.77 		$263.49
Toc - Plan #102 Common Ground Healthcare Cooperative
Catastrophic

(EPO) CGHC Catastrophic $9100 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$202.59
$229.93
$258.90
$361.81
$549.81 		$357.56
$384.90
$413.87
$516.78 		$512.53
$539.87
$568.84
$671.75 		$667.50
$694.84
$723.81
$826.72 		$154.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$405.18
$459.86
$517.80
$723.62
$1,099.62 		$560.15
$614.83
$672.77
$878.59 		$715.12
$769.80
$827.74
$1,033.56 		$870.09
$924.77
$982.71
$1,188.53 		$154.97
Toc - Plan #103 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9100 ($35 PCP Copay) - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$289.59
$328.67
$370.08
$517.19
$785.92 		$511.12
$550.20
$591.61
$738.72 		$732.65
$771.73
$813.14
$960.25 		$954.18
$993.26
$1,034.67
$1,181.78 		$221.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.18
$657.34
$740.16
$1,034.38
$1,571.84 		$800.71
$878.87
$961.69
$1,255.91 		$1,022.24
$1,100.40
$1,183.22
$1,477.44 		$1,243.77
$1,321.93
$1,404.75
$1,698.97 		$221.53
Toc - Plan #104 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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 		$300.55
$341.11
$384.09
$536.76
$815.66 		$530.46
$571.02
$614.00
$766.67 		$760.37
$800.93
$843.91
$996.58 		$990.28
$1,030.84
$1,073.82
$1,226.49 		$229.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.10
$682.22
$768.18
$1,073.52
$1,631.32 		$831.01
$912.13
$998.09
$1,303.43 		$1,060.92
$1,142.04
$1,228.00
$1,533.34 		$1,290.83
$1,371.95
$1,457.91
$1,763.25 		$229.91
Toc - Plan #105 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$298.97
$339.32
$382.07
$533.94
$811.38 		$527.67
$568.02
$610.77
$762.64 		$756.37
$796.72
$839.47
$991.34 		$985.07
$1,025.42
$1,068.17
$1,220.04 		$228.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.94
$678.64
$764.14
$1,067.88
$1,622.76 		$826.64
$907.34
$992.84
$1,296.58 		$1,055.34
$1,136.04
$1,221.54
$1,525.28 		$1,284.04
$1,364.74
$1,450.24
$1,753.98 		$228.70
Toc - Plan #106 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$475.10
$539.23
$607.17
$848.51
$1,289.40 		$838.55
$902.68
$970.62
$1,211.96 		$1,202.00
$1,266.13
$1,334.07
$1,575.41 		$1,565.45
$1,629.58
$1,697.52
$1,938.86 		$363.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$950.20
$1,078.46
$1,214.34
$1,697.02
$2,578.80 		$1,313.65
$1,441.91
$1,577.79
$2,060.47 		$1,677.10
$1,805.36
$1,941.24
$2,423.92 		$2,040.55
$2,168.81
$2,304.69
$2,787.37 		$363.45
Toc - Plan #107 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.74
$522.92
$588.81
$822.86
$1,250.41 		$813.20
$875.38
$941.27
$1,175.32 		$1,165.66
$1,227.84
$1,293.73
$1,527.78 		$1,518.12
$1,580.30
$1,646.19
$1,880.24 		$352.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.48
$1,045.84
$1,177.62
$1,645.72
$2,500.82 		$1,273.94
$1,398.30
$1,530.08
$1,998.18 		$1,626.40
$1,750.76
$1,882.54
$2,350.64 		$1,978.86
$2,103.22
$2,235.00
$2,703.10 		$352.46
Toc - Plan #108 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$296.80
$336.86
$379.30
$530.07
$805.50 		$523.85
$563.91
$606.35
$757.12 		$750.90
$790.96
$833.40
$984.17 		$977.95
$1,018.01
$1,060.45
$1,211.22 		$227.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$593.60
$673.72
$758.60
$1,060.14
$1,611.00 		$820.65
$900.77
$985.65
$1,287.19 		$1,047.70
$1,127.82
$1,212.70
$1,514.24 		$1,274.75
$1,354.87
$1,439.75
$1,741.29 		$227.05
Toc - Plan #109 Common Ground Healthcare Cooperative
Bronze

(EPO) Bronze Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$287.49
$326.29
$367.40
$513.45
$780.23 		$507.42
$546.22
$587.33
$733.38 		$727.35
$766.15
$807.26
$953.31 		$947.28
$986.08
$1,027.19
$1,173.24 		$219.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.98
$652.58
$734.80
$1,026.90
$1,560.46 		$794.91
$872.51
$954.73
$1,246.83 		$1,014.84
$1,092.44
$1,174.66
$1,466.76 		$1,234.77
$1,312.37
$1,394.59
$1,686.69 		$219.93
Toc - Plan #110 Common Ground Healthcare Cooperative
Silver

(EPO) Silver Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$347.91
$394.86
$444.61
$621.34
$944.19 		$614.05
$661.00
$710.75
$887.48 		$880.19
$927.14
$976.89
$1,153.62 		$1,146.33
$1,193.28
$1,243.03
$1,419.76 		$266.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.82
$789.72
$889.22
$1,242.68
$1,888.38 		$961.96
$1,055.86
$1,155.36
$1,508.82 		$1,228.10
$1,322.00
$1,421.50
$1,774.96 		$1,494.24
$1,588.14
$1,687.64
$2,041.10 		$266.14
Toc - Plan #111 Common Ground Healthcare Cooperative
Gold

(EPO) Gold Standard Plan - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$415.95
$472.09
$531.57
$742.86
$1,128.85 		$734.14
$790.28
$849.76
$1,061.05 		$1,052.33
$1,108.47
$1,167.95
$1,379.24 		$1,370.52
$1,426.66
$1,486.14
$1,697.43 		$318.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.90
$944.18
$1,063.14
$1,485.72
$2,257.70 		$1,150.09
$1,262.37
$1,381.33
$1,803.91 		$1,468.28
$1,580.56
$1,699.52
$2,122.10 		$1,786.47
$1,898.75
$2,017.71
$2,440.29 		$318.19
Toc - Plan #112 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$344.21
$390.67
$439.89
$614.75
$934.17 		$607.53
$653.99
$703.21
$878.07 		$870.85
$917.31
$966.53
$1,141.39 		$1,134.17
$1,180.63
$1,229.85
$1,404.71 		$263.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.42
$781.34
$879.78
$1,229.50
$1,868.34 		$951.74
$1,044.66
$1,143.10
$1,492.82 		$1,215.06
$1,307.98
$1,406.42
$1,756.14 		$1,478.38
$1,571.30
$1,669.74
$2,019.46 		$263.32
Toc - Plan #113 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $1800 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$6,600 $13,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$450.08
$510.82
$575.18
$803.82
$1,221.48 		$794.38
$855.12
$919.48
$1,148.12 		$1,138.68
$1,199.42
$1,263.78
$1,492.42 		$1,482.98
$1,543.72
$1,608.08
$1,836.72 		$344.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.16
$1,021.64
$1,150.36
$1,607.64
$2,442.96 		$1,244.46
$1,365.94
$1,494.66
$1,951.94 		$1,588.76
$1,710.24
$1,838.96
$2,296.24 		$1,933.06
$2,054.54
$2,183.26
$2,640.54 		$344.30
Toc - Plan #114 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $2000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$418.70
$475.22
$535.09
$747.79
$1,136.33 		$739.00
$795.52
$855.39
$1,068.09 		$1,059.30
$1,115.82
$1,175.69
$1,388.39 		$1,379.60
$1,436.12
$1,495.99
$1,708.69 		$320.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.40
$950.44
$1,070.18
$1,495.58
$2,272.66 		$1,157.70
$1,270.74
$1,390.48
$1,815.88 		$1,478.00
$1,591.04
$1,710.78
$2,136.18 		$1,798.30
$1,911.34
$2,031.08
$2,456.48 		$320.30
Toc - Plan #115 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Gold $3000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$411.16
$466.65
$525.45
$734.31
$1,115.86 		$725.69
$781.18
$839.98
$1,048.84 		$1,040.22
$1,095.71
$1,154.51
$1,363.37 		$1,354.75
$1,410.24
$1,469.04
$1,677.90 		$314.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.32
$933.30
$1,050.90
$1,468.62
$2,231.72 		$1,136.85
$1,247.83
$1,365.43
$1,783.15 		$1,451.38
$1,562.36
$1,679.96
$2,097.68 		$1,765.91
$1,876.89
$1,994.49
$2,412.21 		$314.53
Toc - Plan #116 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $4000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.76
$460.53
$518.55
$724.67
$1,101.21 		$716.16
$770.93
$828.95
$1,035.07 		$1,026.56
$1,081.33
$1,139.35
$1,345.47 		$1,336.96
$1,391.73
$1,449.75
$1,655.87 		$310.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.52
$921.06
$1,037.10
$1,449.34
$2,202.42 		$1,121.92
$1,231.46
$1,347.50
$1,759.74 		$1,432.32
$1,541.86
$1,657.90
$2,070.14 		$1,742.72
$1,852.26
$1,968.30
$2,380.54 		$310.40
Toc - Plan #117 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5650 (Vision Exam + Allergy Test) - Envision Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$347.32
$394.20
$443.86
$620.29
$942.60 		$613.01
$659.89
$709.55
$885.98 		$878.70
$925.58
$975.24
$1,151.67 		$1,144.39
$1,191.27
$1,240.93
$1,417.36 		$265.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.64
$788.40
$887.72
$1,240.58
$1,885.20 		$960.33
$1,054.09
$1,153.41
$1,506.27 		$1,226.02
$1,319.78
$1,419.10
$1,771.96 		$1,491.71
$1,585.47
$1,684.79
$2,037.65 		$265.69
Toc - Plan #118 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Silver $5000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$347.55
$394.45
$444.15
$620.70
$943.21 		$613.42
$660.32
$710.02
$886.57 		$879.29
$926.19
$975.89
$1,152.44 		$1,145.16
$1,192.06
$1,241.76
$1,418.31 		$265.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.10
$788.90
$888.30
$1,241.40
$1,886.42 		$960.97
$1,054.77
$1,154.17
$1,507.27 		$1,226.84
$1,320.64
$1,420.04
$1,773.14 		$1,492.71
$1,586.51
$1,685.91
$2,039.01 		$265.87
Toc - Plan #119 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $9100 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$290.57
$329.79
$371.34
$518.94
$788.58 		$512.85
$552.07
$593.62
$741.22 		$735.13
$774.35
$815.90
$963.50 		$957.41
$996.63
$1,038.18
$1,185.78 		$222.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.14
$659.58
$742.68
$1,037.88
$1,577.16 		$803.42
$881.86
$964.96
$1,260.16 		$1,025.70
$1,104.14
$1,187.24
$1,482.44 		$1,247.98
$1,326.42
$1,409.52
$1,704.72 		$222.28
Toc - Plan #120 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $9100 ($35 PCP Copay) - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$292.66
$332.16
$374.01
$522.68
$794.26 		$516.54
$556.04
$597.89
$746.56 		$740.42
$779.92
$821.77
$970.44 		$964.30
$1,003.80
$1,045.65
$1,194.32 		$223.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.32
$664.32
$748.02
$1,045.36
$1,588.52 		$809.20
$888.20
$971.90
$1,269.24 		$1,033.08
$1,112.08
$1,195.78
$1,493.12 		$1,256.96
$1,335.96
$1,419.66
$1,717.00 		$223.88
Toc - Plan #121 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Bronze $8150 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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 		$303.63
$344.61
$388.03
$542.27
$824.04 		$535.90
$576.88
$620.30
$774.54 		$768.17
$809.15
$852.57
$1,006.81 		$1,000.44
$1,041.42
$1,084.84
$1,239.08 		$232.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.26
$689.22
$776.06
$1,084.54
$1,648.08 		$839.53
$921.49
$1,008.33
$1,316.81 		$1,071.80
$1,153.76
$1,240.60
$1,549.08 		$1,304.07
$1,386.03
$1,472.87
$1,781.35 		$232.27
Toc - Plan #122 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Bronze $6000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$299.88
$340.35
$383.23
$535.56
$813.84 		$529.28
$569.75
$612.63
$764.96 		$758.68
$799.15
$842.03
$994.36 		$988.08
$1,028.55
$1,071.43
$1,223.76 		$229.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.76
$680.70
$766.46
$1,071.12
$1,627.68 		$829.16
$910.10
$995.86
$1,300.52 		$1,058.56
$1,139.50
$1,225.26
$1,529.92 		$1,287.96
$1,368.90
$1,454.66
$1,759.32 		$229.40
Toc - Plan #123 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7500 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.05
$342.81
$386.00
$539.44
$819.72 		$533.11
$573.87
$617.06
$770.50 		$764.17
$804.93
$848.12
$1,001.56 		$995.23
$1,035.99
$1,079.18
$1,232.62 		$231.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.10
$685.62
$772.00
$1,078.88
$1,639.44 		$835.16
$916.68
$1,003.06
$1,309.94 		$1,066.22
$1,147.74
$1,234.12
$1,541.00 		$1,297.28
$1,378.80
$1,465.18
$1,772.06 		$231.06
Toc - Plan #124 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$463.92
$526.54
$592.88
$828.55
$1,259.07 		$818.81
$881.43
$947.77
$1,183.44 		$1,173.70
$1,236.32
$1,302.66
$1,538.33 		$1,528.59
$1,591.21
$1,657.55
$1,893.22 		$354.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.84
$1,053.08
$1,185.76
$1,657.10
$2,518.14 		$1,282.73
$1,407.97
$1,540.65
$2,011.99 		$1,637.62
$1,762.86
$1,895.54
$2,366.88 		$1,992.51
$2,117.75
$2,250.43
$2,721.77 		$354.89
Toc - Plan #125 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $3000 - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$478.30
$542.86
$611.26
$854.23
$1,298.08 		$844.19
$908.75
$977.15
$1,220.12 		$1,210.08
$1,274.64
$1,343.04
$1,586.01 		$1,575.97
$1,640.53
$1,708.93
$1,951.90 		$365.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.60
$1,085.72
$1,222.52
$1,708.46
$2,596.16 		$1,322.49
$1,451.61
$1,588.41
$2,074.35 		$1,688.38
$1,817.50
$1,954.30
$2,440.24 		$2,054.27
$2,183.39
$2,320.19
$2,806.13 		$365.89
Toc - Plan #126 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Copay Bronze $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$312.21
$354.35
$398.99
$557.59
$847.31 		$551.04
$593.18
$637.82
$796.42 		$789.87
$832.01
$876.65
$1,035.25 		$1,028.70
$1,070.84
$1,115.48
$1,274.08 		$238.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.42
$708.70
$797.98
$1,115.18
$1,694.62 		$863.25
$947.53
$1,036.81
$1,354.01 		$1,102.08
$1,186.36
$1,275.64
$1,592.84 		$1,340.91
$1,425.19
$1,514.47
$1,831.67 		$238.83
Toc - Plan #127 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Copay Silver $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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 		$442.06
$501.72
$564.94
$789.50
$1,199.72 		$780.23
$839.89
$903.11
$1,127.67 		$1,118.40
$1,178.06
$1,241.28
$1,465.84 		$1,456.57
$1,516.23
$1,579.45
$1,804.01 		$338.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.12
$1,003.44
$1,129.88
$1,579.00
$2,399.44 		$1,222.29
$1,341.61
$1,468.05
$1,917.17 		$1,560.46
$1,679.78
$1,806.22
$2,255.34 		$1,898.63
$2,017.95
$2,144.39
$2,593.51 		$338.17
Toc - Plan #128 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Copay Gold $0 Ded - Envision Network (Vision Exam + Allergy Test)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$476.20
$540.47
$608.56
$850.47
$1,292.37 		$840.48
$904.75
$972.84
$1,214.75 		$1,204.76
$1,269.03
$1,337.12
$1,579.03 		$1,569.04
$1,633.31
$1,701.40
$1,943.31 		$364.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.40
$1,080.94
$1,217.12
$1,700.94
$2,584.74 		$1,316.68
$1,445.22
$1,581.40
$2,065.22 		$1,680.96
$1,809.50
$1,945.68
$2,429.50 		$2,045.24
$2,173.78
$2,309.96
$2,793.78 		$364.28

‡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 Florence County here.

Florence County is in “Rating Area 13” of Wisconsin.

Currently, there are 128 plans offered in Rating Area 13.

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