Obamacare 2023 Rates for Monroe County

Obamacare > Rates > Wisconsin > Monroe County

ADVERTISEMENT

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 Monroe 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, 70 Plans and 2023 Rates for Monroe County, Wisconsin

Below, you’ll find a summary of the 70 plans for Monroe 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 |

Monroe County Resources

ADVERTISEMENT

ADVERTISEMENT

Quartz

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

(HMO) QUARTZ ONE 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 		$484.96
$550.42
$619.77
$866.12
$1,316.16 		$855.95
$921.41
$990.76
$1,237.11 		$1,226.94
$1,292.40
$1,361.75
$1,608.10 		$1,597.93
$1,663.39
$1,732.74
$1,979.09 		$370.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.92
$1,100.84
$1,239.54
$1,732.24
$2,632.32 		$1,340.91
$1,471.83
$1,610.53
$2,103.23 		$1,711.90
$1,842.82
$1,981.52
$2,474.22 		$2,082.89
$2,213.81
$2,352.51
$2,845.21 		$370.99
Toc - Plan #2 Quartz
Silver

(HMO) QUARTZ ONE 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 		$508.81
$577.49
$650.25
$908.72
$1,380.89 		$898.05
$966.73
$1,039.49
$1,297.96 		$1,287.29
$1,355.97
$1,428.73
$1,687.20 		$1,676.53
$1,745.21
$1,817.97
$2,076.44 		$389.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,017.62
$1,154.98
$1,300.50
$1,817.44
$2,761.78 		$1,406.86
$1,544.22
$1,689.74
$2,206.68 		$1,796.10
$1,933.46
$2,078.98
$2,595.92 		$2,185.34
$2,322.70
$2,468.22
$2,985.16 		$389.24
Toc - Plan #3 Quartz
Silver

(HMO) Quartz One 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 		$532.90
$604.84
$681.04
$951.75
$1,446.28 		$940.56
$1,012.50
$1,088.70
$1,359.41 		$1,348.22
$1,420.16
$1,496.36
$1,767.07 		$1,755.88
$1,827.82
$1,904.02
$2,174.73 		$407.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,065.80
$1,209.68
$1,362.08
$1,903.50
$2,892.56 		$1,473.46
$1,617.34
$1,769.74
$2,311.16 		$1,881.12
$2,025.00
$2,177.40
$2,718.82 		$2,288.78
$2,432.66
$2,585.06
$3,126.48 		$407.66
Toc - Plan #4 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$360.69
$409.38
$460.95
$644.18
$978.89 		$636.61
$685.30
$736.87
$920.10 		$912.53
$961.22
$1,012.79
$1,196.02 		$1,188.45
$1,237.14
$1,288.71
$1,471.94 		$275.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.38
$818.76
$921.90
$1,288.36
$1,957.78 		$997.30
$1,094.68
$1,197.82
$1,564.28 		$1,273.22
$1,370.60
$1,473.74
$1,840.20 		$1,549.14
$1,646.52
$1,749.66
$2,116.12 		$275.92
Toc - Plan #5 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$364.26
$413.43
$465.51
$650.56
$988.58 		$642.91
$692.08
$744.16
$929.21 		$921.56
$970.73
$1,022.81
$1,207.86 		$1,200.21
$1,249.38
$1,301.46
$1,486.51 		$278.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.52
$826.86
$931.02
$1,301.12
$1,977.16 		$1,007.17
$1,105.51
$1,209.67
$1,579.77 		$1,285.82
$1,384.16
$1,488.32
$1,858.42 		$1,564.47
$1,662.81
$1,766.97
$2,137.07 		$278.65
Toc - Plan #6 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$381.82
$433.36
$487.96
$681.92
$1,036.24 		$673.91
$725.45
$780.05
$974.01 		$966.00
$1,017.54
$1,072.14
$1,266.10 		$1,258.09
$1,309.63
$1,364.23
$1,558.19 		$292.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.64
$866.72
$975.92
$1,363.84
$2,072.48 		$1,055.73
$1,158.81
$1,268.01
$1,655.93 		$1,347.82
$1,450.90
$1,560.10
$1,948.02 		$1,639.91
$1,742.99
$1,852.19
$2,240.11 		$292.09
Toc - Plan #7 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$377.92
$428.93
$482.97
$674.95
$1,025.65 		$667.02
$718.03
$772.07
$964.05 		$956.12
$1,007.13
$1,061.17
$1,253.15 		$1,245.22
$1,296.23
$1,350.27
$1,542.25 		$289.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.84
$857.86
$965.94
$1,349.90
$2,051.30 		$1,044.94
$1,146.96
$1,255.04
$1,639.00 		$1,334.04
$1,436.06
$1,544.14
$1,928.10 		$1,623.14
$1,725.16
$1,833.24
$2,217.20 		$289.10
Toc - Plan #8 Quartz
Expanded Bronze

(HMO) Quartz One 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 		$393.47
$446.59
$502.85
$702.74
$1,067.87 		$694.47
$747.59
$803.85
$1,003.74 		$995.47
$1,048.59
$1,104.85
$1,304.74 		$1,296.47
$1,349.59
$1,405.85
$1,605.74 		$301.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.94
$893.18
$1,005.70
$1,405.48
$2,135.74 		$1,087.94
$1,194.18
$1,306.70
$1,706.48 		$1,388.94
$1,495.18
$1,607.70
$2,007.48 		$1,689.94
$1,796.18
$1,908.70
$2,308.48 		$301.00
Toc - Plan #9 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$493.28
$559.87
$630.41
$881.00
$1,338.76 		$870.64
$937.23
$1,007.77
$1,258.36 		$1,248.00
$1,314.59
$1,385.13
$1,635.72 		$1,625.36
$1,691.95
$1,762.49
$2,013.08 		$377.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$986.56
$1,119.74
$1,260.82
$1,762.00
$2,677.52 		$1,363.92
$1,497.10
$1,638.18
$2,139.36 		$1,741.28
$1,874.46
$2,015.54
$2,516.72 		$2,118.64
$2,251.82
$2,392.90
$2,894.08 		$377.36
Toc - Plan #10 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406 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
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$431.70
$489.98
$551.71
$771.01
$1,171.62 		$761.95
$820.23
$881.96
$1,101.26 		$1,092.20
$1,150.48
$1,212.21
$1,431.51 		$1,422.45
$1,480.73
$1,542.46
$1,761.76 		$330.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.40
$979.96
$1,103.42
$1,542.02
$2,343.24 		$1,193.65
$1,310.21
$1,433.67
$1,872.27 		$1,523.90
$1,640.46
$1,763.92
$2,202.52 		$1,854.15
$1,970.71
$2,094.17
$2,532.77 		$330.25
Toc - Plan #11 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409 with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$3,600 $7,200 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 		$440.27
$499.70
$562.65
$786.31
$1,194.87 		$777.07
$836.50
$899.45
$1,123.11 		$1,113.87
$1,173.30
$1,236.25
$1,459.91 		$1,450.67
$1,510.10
$1,573.05
$1,796.71 		$336.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.54
$999.40
$1,125.30
$1,572.62
$2,389.74 		$1,217.34
$1,336.20
$1,462.10
$1,909.42 		$1,554.14
$1,673.00
$1,798.90
$2,246.22 		$1,890.94
$2,009.80
$2,135.70
$2,583.02 		$336.80
Toc - Plan #12 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305 with Dental & Vision

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$463.80
$526.41
$592.74
$828.34
$1,258.75 		$818.61
$881.22
$947.55
$1,183.15 		$1,173.42
$1,236.03
$1,302.36
$1,537.96 		$1,528.23
$1,590.84
$1,657.17
$1,892.77 		$354.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.60
$1,052.82
$1,185.48
$1,656.68
$2,517.50 		$1,282.41
$1,407.63
$1,540.29
$2,011.49 		$1,637.22
$1,762.44
$1,895.10
$2,366.30 		$1,992.03
$2,117.25
$2,249.91
$2,721.11 		$354.81
Toc - Plan #13 Quartz
Gold

(HMO) Quartz One 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 		$486.78
$552.49
$622.10
$869.38
$1,321.11 		$859.16
$924.87
$994.48
$1,241.76 		$1,231.54
$1,297.25
$1,366.86
$1,614.14 		$1,603.92
$1,669.63
$1,739.24
$1,986.52 		$372.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.56
$1,104.98
$1,244.20
$1,738.76
$2,642.22 		$1,345.94
$1,477.36
$1,616.58
$2,111.14 		$1,718.32
$1,849.74
$1,988.96
$2,483.52 		$2,090.70
$2,222.12
$2,361.34
$2,855.90 		$372.38
Toc - Plan #14 Quartz
Silver

(HMO) QUARTZ ONE 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 		$463.46
$526.02
$592.29
$827.72
$1,257.81 		$818.00
$880.56
$946.83
$1,182.26 		$1,172.54
$1,235.10
$1,301.37
$1,536.80 		$1,527.08
$1,589.64
$1,655.91
$1,891.34 		$354.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.92
$1,052.04
$1,184.58
$1,655.44
$2,515.62 		$1,281.46
$1,406.58
$1,539.12
$2,009.98 		$1,636.00
$1,761.12
$1,893.66
$2,364.52 		$1,990.54
$2,115.66
$2,248.20
$2,719.06 		$354.54
Toc - Plan #15 Quartz
Silver

(HMO) QUARTZ ONE 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 		$486.25
$551.89
$621.42
$868.43
$1,319.67 		$858.23
$923.87
$993.40
$1,240.41 		$1,230.21
$1,295.85
$1,365.38
$1,612.39 		$1,602.19
$1,667.83
$1,737.36
$1,984.37 		$371.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.50
$1,103.78
$1,242.84
$1,736.86
$2,639.34 		$1,344.48
$1,475.76
$1,614.82
$2,108.84 		$1,716.46
$1,847.74
$1,986.80
$2,480.82 		$2,088.44
$2,219.72
$2,358.78
$2,852.80 		$371.98
Toc - Plan #16 Quartz
Silver

(HMO) Quartz One 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 		$509.27
$578.02
$650.84
$909.55
$1,382.15 		$898.86
$967.61
$1,040.43
$1,299.14 		$1,288.45
$1,357.20
$1,430.02
$1,688.73 		$1,678.04
$1,746.79
$1,819.61
$2,078.32 		$389.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,018.54
$1,156.04
$1,301.68
$1,819.10
$2,764.30 		$1,408.13
$1,545.63
$1,691.27
$2,208.69 		$1,797.72
$1,935.22
$2,080.86
$2,598.28 		$2,187.31
$2,324.81
$2,470.45
$2,987.87 		$389.59
Toc - Plan #17 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$344.70
$391.23
$440.52
$615.62
$935.49 		$608.39
$654.92
$704.21
$879.31 		$872.08
$918.61
$967.90
$1,143.00 		$1,135.77
$1,182.30
$1,231.59
$1,406.69 		$263.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.40
$782.46
$881.04
$1,231.24
$1,870.98 		$953.09
$1,046.15
$1,144.73
$1,494.93 		$1,216.78
$1,309.84
$1,408.42
$1,758.62 		$1,480.47
$1,573.53
$1,672.11
$2,022.31 		$263.69
Toc - Plan #18 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$348.11
$395.10
$444.88
$621.71
$944.75 		$614.41
$661.40
$711.18
$888.01 		$880.71
$927.70
$977.48
$1,154.31 		$1,147.01
$1,194.00
$1,243.78
$1,420.61 		$266.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.22
$790.20
$889.76
$1,243.42
$1,889.50 		$962.52
$1,056.50
$1,156.06
$1,509.72 		$1,228.82
$1,322.80
$1,422.36
$1,776.02 		$1,495.12
$1,589.10
$1,688.66
$2,042.32 		$266.30
Toc - Plan #19 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$364.89
$414.14
$466.32
$651.68
$990.30 		$644.03
$693.28
$745.46
$930.82 		$923.17
$972.42
$1,024.60
$1,209.96 		$1,202.31
$1,251.56
$1,303.74
$1,489.10 		$279.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.78
$828.28
$932.64
$1,303.36
$1,980.60 		$1,008.92
$1,107.42
$1,211.78
$1,582.50 		$1,288.06
$1,386.56
$1,490.92
$1,861.64 		$1,567.20
$1,665.70
$1,770.06
$2,140.78 		$279.14
Toc - Plan #20 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$361.16
$409.91
$461.56
$645.02
$980.18 		$637.44
$686.19
$737.84
$921.30 		$913.72
$962.47
$1,014.12
$1,197.58 		$1,190.00
$1,238.75
$1,290.40
$1,473.86 		$276.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.32
$819.82
$923.12
$1,290.04
$1,960.36 		$998.60
$1,096.10
$1,199.40
$1,566.32 		$1,274.88
$1,372.38
$1,475.68
$1,842.60 		$1,551.16
$1,648.66
$1,751.96
$2,118.88 		$276.28
Toc - Plan #21 Quartz
Expanded Bronze

(HMO) Quartz One 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 		$376.03
$426.79
$480.56
$671.58
$1,020.53 		$663.69
$714.45
$768.22
$959.24 		$951.35
$1,002.11
$1,055.88
$1,246.90 		$1,239.01
$1,289.77
$1,343.54
$1,534.56 		$287.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.06
$853.58
$961.12
$1,343.16
$2,041.06 		$1,039.72
$1,141.24
$1,248.78
$1,630.82 		$1,327.38
$1,428.90
$1,536.44
$1,918.48 		$1,615.04
$1,716.56
$1,824.10
$2,206.14 		$287.66
Toc - Plan #22 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$471.41
$535.05
$602.46
$841.94
$1,279.41 		$832.04
$895.68
$963.09
$1,202.57 		$1,192.67
$1,256.31
$1,323.72
$1,563.20 		$1,553.30
$1,616.94
$1,684.35
$1,923.83 		$360.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.82
$1,070.10
$1,204.92
$1,683.88
$2,558.82 		$1,303.45
$1,430.73
$1,565.55
$2,044.51 		$1,664.08
$1,791.36
$1,926.18
$2,405.14 		$2,024.71
$2,151.99
$2,286.81
$2,765.77 		$360.63
Toc - Plan #23 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406

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
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.56
$468.25
$527.25
$736.83
$1,119.68 		$728.17
$783.86
$842.86
$1,052.44 		$1,043.78
$1,099.47
$1,158.47
$1,368.05 		$1,359.39
$1,415.08
$1,474.08
$1,683.66 		$315.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.12
$936.50
$1,054.50
$1,473.66
$2,239.36 		$1,140.73
$1,252.11
$1,370.11
$1,789.27 		$1,456.34
$1,567.72
$1,685.72
$2,104.88 		$1,771.95
$1,883.33
$2,001.33
$2,420.49 		$315.61
Toc - Plan #24 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$3,600 $7,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.75
$477.54
$537.71
$751.45
$1,141.90 		$742.62
$799.41
$859.58
$1,073.32 		$1,064.49
$1,121.28
$1,181.45
$1,395.19 		$1,386.36
$1,443.15
$1,503.32
$1,717.06 		$321.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.50
$955.08
$1,075.42
$1,502.90
$2,283.80 		$1,163.37
$1,276.95
$1,397.29
$1,824.77 		$1,485.24
$1,598.82
$1,719.16
$2,146.64 		$1,807.11
$1,920.69
$2,041.03
$2,468.51 		$321.87
Toc - Plan #25 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$443.24
$503.07
$566.46
$791.62
$1,202.94 		$782.32
$842.15
$905.54
$1,130.70 		$1,121.40
$1,181.23
$1,244.62
$1,469.78 		$1,460.48
$1,520.31
$1,583.70
$1,808.86 		$339.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.48
$1,006.14
$1,132.92
$1,583.24
$2,405.88 		$1,225.56
$1,345.22
$1,472.00
$1,922.32 		$1,564.64
$1,684.30
$1,811.08
$2,261.40 		$1,903.72
$2,023.38
$2,150.16
$2,600.48 		$339.08
Toc - Plan #26 Quartz
Gold

(HMO) Quartz One 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 		$465.20
$528.00
$594.52
$830.84
$1,262.54 		$821.07
$883.87
$950.39
$1,186.71 		$1,176.94
$1,239.74
$1,306.26
$1,542.58 		$1,532.81
$1,595.61
$1,662.13
$1,898.45 		$355.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$930.40
$1,056.00
$1,189.04
$1,661.68
$2,525.08 		$1,286.27
$1,411.87
$1,544.91
$2,017.55 		$1,642.14
$1,767.74
$1,900.78
$2,373.42 		$1,998.01
$2,123.61
$2,256.65
$2,729.29 		$355.87
Toc - Plan #27 Quartz
Gold

(HMO) Tiered Choice Plus Gold I408 HSA

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
$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 		$436.80
$495.76
$558.22
$780.11
$1,185.46 		$770.95
$829.91
$892.37
$1,114.26 		$1,105.10
$1,164.06
$1,226.52
$1,448.41 		$1,439.25
$1,498.21
$1,560.67
$1,782.56 		$334.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.60
$991.52
$1,116.44
$1,560.22
$2,370.92 		$1,207.75
$1,325.67
$1,450.59
$1,894.37 		$1,541.90
$1,659.82
$1,784.74
$2,228.52 		$1,876.05
$1,993.97
$2,118.89
$2,562.67 		$334.15
Toc - Plan #28 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$362.24
$411.14
$462.94
$646.95
$983.11 		$639.35
$688.25
$740.05
$924.06 		$916.46
$965.36
$1,017.16
$1,201.17 		$1,193.57
$1,242.47
$1,294.27
$1,478.28 		$277.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.48
$822.28
$925.88
$1,293.90
$1,966.22 		$1,001.59
$1,099.39
$1,202.99
$1,571.01 		$1,278.70
$1,376.50
$1,480.10
$1,848.12 		$1,555.81
$1,653.61
$1,757.21
$2,125.23 		$277.11
Toc - Plan #29 Quartz
Catastrophic

(HMO) QUARTZ ONE 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 		$267.04
$303.08
$341.27
$476.92
$724.73 		$471.32
$507.36
$545.55
$681.20 		$675.60
$711.64
$749.83
$885.48 		$879.88
$915.92
$954.11
$1,089.76 		$204.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.08
$606.16
$682.54
$953.84
$1,449.46 		$738.36
$810.44
$886.82
$1,158.12 		$942.64
$1,014.72
$1,091.10
$1,362.40 		$1,146.92
$1,219.00
$1,295.38
$1,566.68 		$204.28
Toc - Plan #30 Quartz
Silver

(HMO) Tiered Choice Plus Silver I310 HSA

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
$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 		$487.43
$553.23
$622.93
$870.54
$1,322.88 		$860.31
$926.11
$995.81
$1,243.42 		$1,233.19
$1,298.99
$1,368.69
$1,616.30 		$1,606.07
$1,671.87
$1,741.57
$1,989.18 		$372.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$974.86
$1,106.46
$1,245.86
$1,741.08
$2,645.76 		$1,347.74
$1,479.34
$1,618.74
$2,113.96 		$1,720.62
$1,852.22
$1,991.62
$2,486.84 		$2,093.50
$2,225.10
$2,364.50
$2,859.72 		$372.88
Toc - Plan #31 Quartz
Silver

(HMO) Tiered Choice Plus Silver I311 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 Annual Deductible
$4,400 $8,800 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 		$477.83
$542.33
$610.66
$853.39
$1,296.81 		$843.36
$907.86
$976.19
$1,218.92 		$1,208.89
$1,273.39
$1,341.72
$1,584.45 		$1,574.42
$1,638.92
$1,707.25
$1,949.98 		$365.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.66
$1,084.66
$1,221.32
$1,706.78
$2,593.62 		$1,321.19
$1,450.19
$1,586.85
$2,072.31 		$1,686.72
$1,815.72
$1,952.38
$2,437.84 		$2,052.25
$2,181.25
$2,317.91
$2,803.37 		$365.53
Toc - Plan #32 Quartz
Silver

(HMO) QUARTZ ONE 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 		$468.84
$532.13
$599.17
$837.34
$1,272.42 		$827.50
$890.79
$957.83
$1,196.00 		$1,186.16
$1,249.45
$1,316.49
$1,554.66 		$1,544.82
$1,608.11
$1,675.15
$1,913.32 		$358.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$937.68
$1,064.26
$1,198.34
$1,674.68
$2,544.84 		$1,296.34
$1,422.92
$1,557.00
$2,033.34 		$1,655.00
$1,781.58
$1,915.66
$2,392.00 		$2,013.66
$2,140.24
$2,274.32
$2,750.66 		$358.66
Toc - Plan #33 Quartz
Silver

(HMO) QUARTZ ONE 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 		$491.90
$558.30
$628.64
$878.52
$1,335.00 		$868.20
$934.60
$1,004.94
$1,254.82 		$1,244.50
$1,310.90
$1,381.24
$1,631.12 		$1,620.80
$1,687.20
$1,757.54
$2,007.42 		$376.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.80
$1,116.60
$1,257.28
$1,757.04
$2,670.00 		$1,360.10
$1,492.90
$1,633.58
$2,133.34 		$1,736.40
$1,869.20
$2,009.88
$2,509.64 		$2,112.70
$2,245.50
$2,386.18
$2,885.94 		$376.30
Toc - Plan #34 Quartz
Silver

(HMO) Quartz One 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 		$515.19
$584.73
$658.40
$920.12
$1,398.21 		$909.31
$978.85
$1,052.52
$1,314.24 		$1,303.43
$1,372.97
$1,446.64
$1,708.36 		$1,697.55
$1,767.09
$1,840.76
$2,102.48 		$394.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,030.38
$1,169.46
$1,316.80
$1,840.24
$2,796.42 		$1,424.50
$1,563.58
$1,710.92
$2,234.36 		$1,818.62
$1,957.70
$2,105.04
$2,628.48 		$2,212.74
$2,351.82
$2,499.16
$3,022.60 		$394.12
Toc - Plan #35 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$348.70
$395.77
$445.63
$622.77
$946.36 		$615.45
$662.52
$712.38
$889.52 		$882.20
$929.27
$979.13
$1,156.27 		$1,148.95
$1,196.02
$1,245.88
$1,423.02 		$266.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.40
$791.54
$891.26
$1,245.54
$1,892.72 		$964.15
$1,058.29
$1,158.01
$1,512.29 		$1,230.90
$1,325.04
$1,424.76
$1,779.04 		$1,497.65
$1,591.79
$1,691.51
$2,045.79 		$266.75
Toc - Plan #36 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$352.15
$399.69
$450.04
$628.93
$955.73 		$621.54
$669.08
$719.43
$898.32 		$890.93
$938.47
$988.82
$1,167.71 		$1,160.32
$1,207.86
$1,258.21
$1,437.10 		$269.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.30
$799.38
$900.08
$1,257.86
$1,911.46 		$973.69
$1,068.77
$1,169.47
$1,527.25 		$1,243.08
$1,338.16
$1,438.86
$1,796.64 		$1,512.47
$1,607.55
$1,708.25
$2,066.03 		$269.39
Toc - Plan #37 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$369.13
$418.96
$471.74
$659.25
$1,001.80 		$651.51
$701.34
$754.12
$941.63 		$933.89
$983.72
$1,036.50
$1,224.01 		$1,216.27
$1,266.10
$1,318.88
$1,506.39 		$282.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.26
$837.92
$943.48
$1,318.50
$2,003.60 		$1,020.64
$1,120.30
$1,225.86
$1,600.88 		$1,303.02
$1,402.68
$1,508.24
$1,883.26 		$1,585.40
$1,685.06
$1,790.62
$2,165.64 		$282.38
Toc - Plan #38 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$365.36
$414.67
$466.92
$652.52
$991.56 		$644.85
$694.16
$746.41
$932.01 		$924.34
$973.65
$1,025.90
$1,211.50 		$1,203.83
$1,253.14
$1,305.39
$1,490.99 		$279.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.72
$829.34
$933.84
$1,305.04
$1,983.12 		$1,010.21
$1,108.83
$1,213.33
$1,584.53 		$1,289.70
$1,388.32
$1,492.82
$1,864.02 		$1,569.19
$1,667.81
$1,772.31
$2,143.51 		$279.49
Toc - Plan #39 Quartz
Expanded Bronze

(HMO) Quartz One 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 		$380.40
$431.74
$486.14
$679.38
$1,032.38 		$671.40
$722.74
$777.14
$970.38 		$962.40
$1,013.74
$1,068.14
$1,261.38 		$1,253.40
$1,304.74
$1,359.14
$1,552.38 		$291.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.80
$863.48
$972.28
$1,358.76
$2,064.76 		$1,051.80
$1,154.48
$1,263.28
$1,649.76 		$1,342.80
$1,445.48
$1,554.28
$1,940.76 		$1,633.80
$1,736.48
$1,845.28
$2,231.76 		$291.00
Toc - Plan #40 Quartz
Expanded Bronze

(HMO) QUARTZ ONE 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 		$366.45
$415.91
$468.31
$654.47
$994.53 		$646.78
$696.24
$748.64
$934.80 		$927.11
$976.57
$1,028.97
$1,215.13 		$1,207.44
$1,256.90
$1,309.30
$1,495.46 		$280.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.90
$831.82
$936.62
$1,308.94
$1,989.06 		$1,013.23
$1,112.15
$1,216.95
$1,589.27 		$1,293.56
$1,392.48
$1,497.28
$1,869.60 		$1,573.89
$1,672.81
$1,777.61
$2,149.93 		$280.33
Toc - Plan #41 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$476.89
$541.27
$609.46
$851.72
$1,294.27 		$841.71
$906.09
$974.28
$1,216.54 		$1,206.53
$1,270.91
$1,339.10
$1,581.36 		$1,571.35
$1,635.73
$1,703.92
$1,946.18 		$364.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.78
$1,082.54
$1,218.92
$1,703.44
$2,588.54 		$1,318.60
$1,447.36
$1,583.74
$2,068.26 		$1,683.42
$1,812.18
$1,948.56
$2,433.08 		$2,048.24
$2,177.00
$2,313.38
$2,797.90 		$364.82
Toc - Plan #42 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406 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
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.35
$473.69
$533.37
$745.39
$1,132.69 		$736.62
$792.96
$852.64
$1,064.66 		$1,055.89
$1,112.23
$1,171.91
$1,383.93 		$1,375.16
$1,431.50
$1,491.18
$1,703.20 		$319.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.70
$947.38
$1,066.74
$1,490.78
$2,265.38 		$1,153.97
$1,266.65
$1,386.01
$1,810.05 		$1,473.24
$1,585.92
$1,705.28
$2,129.32 		$1,792.51
$1,905.19
$2,024.55
$2,448.59 		$319.27
Toc - Plan #43 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409 with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$3,600 $7,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.63
$483.09
$543.96
$760.18
$1,155.16 		$751.24
$808.70
$869.57
$1,085.79 		$1,076.85
$1,134.31
$1,195.18
$1,411.40 		$1,402.46
$1,459.92
$1,520.79
$1,737.01 		$325.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.26
$966.18
$1,087.92
$1,520.36
$2,310.32 		$1,176.87
$1,291.79
$1,413.53
$1,845.97 		$1,502.48
$1,617.40
$1,739.14
$2,171.58 		$1,828.09
$1,943.01
$2,064.75
$2,497.19 		$325.61
Toc - Plan #44 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305 with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$448.39
$508.92
$573.04
$800.81
$1,216.92 		$791.40
$851.93
$916.05
$1,143.82 		$1,134.41
$1,194.94
$1,259.06
$1,486.83 		$1,477.42
$1,537.95
$1,602.07
$1,829.84 		$343.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.78
$1,017.84
$1,146.08
$1,601.62
$2,433.84 		$1,239.79
$1,360.85
$1,489.09
$1,944.63 		$1,582.80
$1,703.86
$1,832.10
$2,287.64 		$1,925.81
$2,046.87
$2,175.11
$2,630.65 		$343.01
Toc - Plan #45 Quartz
Gold

(HMO) Tiered Choice Plus Gold I408 HSA 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
$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 		$441.87
$501.52
$564.71
$789.18
$1,199.23 		$779.90
$839.55
$902.74
$1,127.21 		$1,117.93
$1,177.58
$1,240.77
$1,465.24 		$1,455.96
$1,515.61
$1,578.80
$1,803.27 		$338.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.74
$1,003.04
$1,129.42
$1,578.36
$2,398.46 		$1,221.77
$1,341.07
$1,467.45
$1,916.39 		$1,559.80
$1,679.10
$1,805.48
$2,254.42 		$1,897.83
$2,017.13
$2,143.51
$2,592.45 		$338.03
Toc - Plan #46 Quartz
Silver

(HMO) Tiered Choice Plus Silver I310 HSA 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
$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 		$493.09
$559.66
$630.17
$880.66
$1,338.24 		$870.30
$936.87
$1,007.38
$1,257.87 		$1,247.51
$1,314.08
$1,384.59
$1,635.08 		$1,624.72
$1,691.29
$1,761.80
$2,012.29 		$377.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$986.18
$1,119.32
$1,260.34
$1,761.32
$2,676.48 		$1,363.39
$1,496.53
$1,637.55
$2,138.53 		$1,740.60
$1,873.74
$2,014.76
$2,515.74 		$2,117.81
$2,250.95
$2,391.97
$2,892.95 		$377.21
Toc - Plan #47 Quartz
Silver

(HMO) Tiered Choice Plus Silver I311 HSA with Vision

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

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 Annual Deductible
$4,400 $8,800 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 		$483.38
$548.63
$617.75
$863.30
$1,311.87 		$853.16
$918.41
$987.53
$1,233.08 		$1,222.94
$1,288.19
$1,357.31
$1,602.86 		$1,592.72
$1,657.97
$1,727.09
$1,972.64 		$369.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966.76
$1,097.26
$1,235.50
$1,726.60
$2,623.74 		$1,336.54
$1,467.04
$1,605.28
$2,096.38 		$1,706.32
$1,836.82
$1,975.06
$2,466.16 		$2,076.10
$2,206.60
$2,344.84
$2,835.94 		$369.78
Toc - Plan #48 Quartz
Gold

(HMO) Quartz One 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 		$470.60
$534.13
$601.42
$840.49
$1,277.20 		$830.61
$894.14
$961.43
$1,200.50 		$1,190.62
$1,254.15
$1,321.44
$1,560.51 		$1,550.63
$1,614.16
$1,681.45
$1,920.52 		$360.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.20
$1,068.26
$1,202.84
$1,680.98
$2,554.40 		$1,301.21
$1,428.27
$1,562.85
$2,040.99 		$1,661.22
$1,788.28
$1,922.86
$2,401.00 		$2,021.23
$2,148.29
$2,282.87
$2,761.01 		$360.01

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-947-3529
Toc - Plan #49 Medica
Gold

(EPO) Engage by Medica Gold Copay ($0 Virtual Care with Designated Providers + $0 Preferred Generic Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$533.97
$606.05
$682.41
$953.66
$1,449.18 		$942.45
$1,014.53
$1,090.89
$1,362.14 		$1,350.93
$1,423.01
$1,499.37
$1,770.62 		$1,759.41
$1,831.49
$1,907.85
$2,179.10 		$408.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,067.94
$1,212.10
$1,364.82
$1,907.32
$2,898.36 		$1,476.42
$1,620.58
$1,773.30
$2,315.80 		$1,884.90
$2,029.06
$2,181.78
$2,724.28 		$2,293.38
$2,437.54
$2,590.26
$3,132.76 		$408.48
Toc - Plan #50 Medica
Expanded Bronze

(EPO) Engage by Medica Bronze Copay ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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 		$408.09
$463.17
$521.53
$728.83
$1,107.53 		$720.27
$775.35
$833.71
$1,041.01 		$1,032.45
$1,087.53
$1,145.89
$1,353.19 		$1,344.63
$1,399.71
$1,458.07
$1,665.37 		$312.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.18
$926.34
$1,043.06
$1,457.66
$2,215.06 		$1,128.36
$1,238.52
$1,355.24
$1,769.84 		$1,440.54
$1,550.70
$1,667.42
$2,082.02 		$1,752.72
$1,862.88
$1,979.60
$2,394.20 		$312.18
Toc - Plan #51 Medica
Expanded Bronze

(EPO) Engage by Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$464.83
$527.57
$594.04
$830.17
$1,261.53 		$820.42
$883.16
$949.63
$1,185.76 		$1,176.01
$1,238.75
$1,305.22
$1,541.35 		$1,531.60
$1,594.34
$1,660.81
$1,896.94 		$355.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.66
$1,055.14
$1,188.08
$1,660.34
$2,523.06 		$1,285.25
$1,410.73
$1,543.67
$2,015.93 		$1,640.84
$1,766.32
$1,899.26
$2,371.52 		$1,996.43
$2,121.91
$2,254.85
$2,727.11 		$355.59
Toc - Plan #52 Medica
Catastrophic

(EPO) Engage by Medica Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$260.69
$295.87
$333.15
$465.57
$707.48 		$460.11
$495.29
$532.57
$664.99 		$659.53
$694.71
$731.99
$864.41 		$858.95
$894.13
$931.41
$1,063.83 		$199.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.38
$591.74
$666.30
$931.14
$1,414.96 		$720.80
$791.16
$865.72
$1,130.56 		$920.22
$990.58
$1,065.14
$1,329.98 		$1,119.64
$1,190.00
$1,264.56
$1,529.40 		$199.42
Toc - Plan #53 Medica
Silver

(EPO) Engage by Medica Silver Share ($0 Virtual Care with Designated Providers + $5 Preferred Generic Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$533.76
$605.80
$682.13
$953.27
$1,448.59 		$942.08
$1,014.12
$1,090.45
$1,361.59 		$1,350.40
$1,422.44
$1,498.77
$1,769.91 		$1,758.72
$1,830.76
$1,907.09
$2,178.23 		$408.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,067.52
$1,211.60
$1,364.26
$1,906.54
$2,897.18 		$1,475.84
$1,619.92
$1,772.58
$2,314.86 		$1,884.16
$2,028.24
$2,180.90
$2,723.18 		$2,292.48
$2,436.56
$2,589.22
$3,131.50 		$408.32
Toc - Plan #54 Medica
Expanded Bronze

(EPO) Engage by Medica Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.54
$475.03
$534.88
$747.50
$1,135.89 		$738.72
$795.21
$855.06
$1,067.68 		$1,058.90
$1,115.39
$1,175.24
$1,387.86 		$1,379.08
$1,435.57
$1,495.42
$1,708.04 		$320.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.08
$950.06
$1,069.76
$1,495.00
$2,271.78 		$1,157.26
$1,270.24
$1,389.94
$1,815.18 		$1,477.44
$1,590.42
$1,710.12
$2,135.36 		$1,797.62
$1,910.60
$2,030.30
$2,455.54 		$320.18
Toc - Plan #55 Medica
Gold

(EPO) Engage by Medica Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$533.16
$605.13
$681.37
$952.21
$1,446.98 		$941.02
$1,012.99
$1,089.23
$1,360.07 		$1,348.88
$1,420.85
$1,497.09
$1,767.93 		$1,756.74
$1,828.71
$1,904.95
$2,175.79 		$407.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,066.32
$1,210.26
$1,362.74
$1,904.42
$2,893.96 		$1,474.18
$1,618.12
$1,770.60
$2,312.28 		$1,882.04
$2,025.98
$2,178.46
$2,720.14 		$2,289.90
$2,433.84
$2,586.32
$3,128.00 		$407.86
Toc - Plan #56 Medica
Silver

(EPO) Engage by Medica Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$514.48
$583.93
$657.50
$918.85
$1,396.28 		$908.05
$977.50
$1,051.07
$1,312.42 		$1,301.62
$1,371.07
$1,444.64
$1,705.99 		$1,695.19
$1,764.64
$1,838.21
$2,099.56 		$393.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,028.96
$1,167.86
$1,315.00
$1,837.70
$2,792.56 		$1,422.53
$1,561.43
$1,708.57
$2,231.27 		$1,816.10
$1,955.00
$2,102.14
$2,624.84 		$2,209.67
$2,348.57
$2,495.71
$3,018.41 		$393.57
Toc - Plan #57 Medica
Bronze

(EPO) Engage by Medica Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$398.24
$451.99
$508.93
$711.23
$1,080.79 		$702.88
$756.63
$813.57
$1,015.87 		$1,007.52
$1,061.27
$1,118.21
$1,320.51 		$1,312.16
$1,365.91
$1,422.85
$1,625.15 		$304.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.48
$903.98
$1,017.86
$1,422.46
$2,161.58 		$1,101.12
$1,208.62
$1,322.50
$1,727.10 		$1,405.76
$1,513.26
$1,627.14
$2,031.74 		$1,710.40
$1,817.90
$1,931.78
$2,336.38 		$304.64

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1813 | Toll Free: 1-855-748-1813

Toc - Plan #58 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$441.87
$501.52
$564.71
$789.18
$1,199.24 		$779.90
$839.55
$902.74
$1,127.21 		$1,117.93
$1,177.58
$1,240.77
$1,465.24 		$1,455.96
$1,515.61
$1,578.80
$1,803.27 		$338.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.74
$1,003.04
$1,129.42
$1,578.36
$2,398.48 		$1,221.77
$1,341.07
$1,467.45
$1,916.39 		$1,559.80
$1,679.10
$1,805.48
$2,254.42 		$1,897.83
$2,017.13
$2,143.51
$2,592.45 		$338.03
Toc - Plan #59 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$428.43
$486.27
$547.53
$765.18
$1,162.76 		$756.18
$814.02
$875.28
$1,092.93 		$1,083.93
$1,141.77
$1,203.03
$1,420.68 		$1,411.68
$1,469.52
$1,530.78
$1,748.43 		$327.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.86
$972.54
$1,095.06
$1,530.36
$2,325.52 		$1,184.61
$1,300.29
$1,422.81
$1,858.11 		$1,512.36
$1,628.04
$1,750.56
$2,185.86 		$1,840.11
$1,955.79
$2,078.31
$2,513.61 		$327.75
Toc - Plan #60 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$6,550 $13,100 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.76
$477.56
$537.73
$751.48
$1,141.94 		$742.64
$799.44
$859.61
$1,073.36 		$1,064.52
$1,121.32
$1,181.49
$1,395.24 		$1,386.40
$1,443.20
$1,503.37
$1,717.12 		$321.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.52
$955.12
$1,075.46
$1,502.96
$2,283.88 		$1,163.40
$1,277.00
$1,397.34
$1,824.84 		$1,485.28
$1,598.88
$1,719.22
$2,146.72 		$1,807.16
$1,920.76
$2,041.10
$2,468.60 		$321.88
Toc - Plan #61 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$398.82
$452.66
$509.69
$712.29
$1,082.40 		$703.92
$757.76
$814.79
$1,017.39 		$1,009.02
$1,062.86
$1,119.89
$1,322.49 		$1,314.12
$1,367.96
$1,424.99
$1,627.59 		$305.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.64
$905.32
$1,019.38
$1,424.58
$2,164.80 		$1,102.74
$1,210.42
$1,324.48
$1,729.68 		$1,407.84
$1,515.52
$1,629.58
$2,034.78 		$1,712.94
$1,820.62
$1,934.68
$2,339.88 		$305.10
Toc - Plan #62 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.89
$476.58
$536.62
$749.92
$1,139.58 		$741.11
$797.80
$857.84
$1,071.14 		$1,062.33
$1,119.02
$1,179.06
$1,392.36 		$1,383.55
$1,440.24
$1,500.28
$1,713.58 		$321.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.78
$953.16
$1,073.24
$1,499.84
$2,279.16 		$1,161.00
$1,274.38
$1,394.46
$1,821.06 		$1,482.22
$1,595.60
$1,715.68
$2,142.28 		$1,803.44
$1,916.82
$2,036.90
$2,463.50 		$321.22
Toc - Plan #63 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$544.67
$618.20
$696.09
$972.78
$1,478.23 		$961.34
$1,034.87
$1,112.76
$1,389.45 		$1,378.01
$1,451.54
$1,529.43
$1,806.12 		$1,794.68
$1,868.21
$1,946.10
$2,222.79 		$416.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,089.34
$1,236.40
$1,392.18
$1,945.56
$2,956.46 		$1,506.01
$1,653.07
$1,808.85
$2,362.23 		$1,922.68
$2,069.74
$2,225.52
$2,778.90 		$2,339.35
$2,486.41
$2,642.19
$3,195.57 		$416.67
Toc - Plan #64 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$525.87
$596.86
$672.06
$939.20
$1,427.21 		$928.16
$999.15
$1,074.35
$1,341.49 		$1,330.45
$1,401.44
$1,476.64
$1,743.78 		$1,732.74
$1,803.73
$1,878.93
$2,146.07 		$402.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.74
$1,193.72
$1,344.12
$1,878.40
$2,854.42 		$1,454.03
$1,596.01
$1,746.41
$2,280.69 		$1,856.32
$1,998.30
$2,148.70
$2,682.98 		$2,258.61
$2,400.59
$2,550.99
$3,085.27 		$402.29
Toc - Plan #65 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$532.19
$604.04
$680.14
$950.49
$1,444.36 		$939.32
$1,011.17
$1,087.27
$1,357.62 		$1,346.45
$1,418.30
$1,494.40
$1,764.75 		$1,753.58
$1,825.43
$1,901.53
$2,171.88 		$407.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,064.38
$1,208.08
$1,360.28
$1,900.98
$2,888.72 		$1,471.51
$1,615.21
$1,767.41
$2,308.11 		$1,878.64
$2,022.34
$2,174.54
$2,715.24 		$2,285.77
$2,429.47
$2,581.67
$3,122.37 		$407.13
Toc - Plan #66 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$522.77
$593.34
$668.10
$933.67
$1,418.80 		$922.69
$993.26
$1,068.02
$1,333.59 		$1,322.61
$1,393.18
$1,467.94
$1,733.51 		$1,722.53
$1,793.10
$1,867.86
$2,133.43 		$399.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,045.54
$1,186.68
$1,336.20
$1,867.34
$2,837.60 		$1,445.46
$1,586.60
$1,736.12
$2,267.26 		$1,845.38
$1,986.52
$2,136.04
$2,667.18 		$2,245.30
$2,386.44
$2,535.96
$3,067.10 		$399.92
Toc - Plan #67 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$399.39
$453.31
$510.42
$713.31
$1,083.94 		$704.92
$758.84
$815.95
$1,018.84 		$1,010.45
$1,064.37
$1,121.48
$1,324.37 		$1,315.98
$1,369.90
$1,427.01
$1,629.90 		$305.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.78
$906.62
$1,020.84
$1,426.62
$2,167.88 		$1,104.31
$1,212.15
$1,326.37
$1,732.15 		$1,409.84
$1,517.68
$1,631.90
$2,037.68 		$1,715.37
$1,823.21
$1,937.43
$2,343.21 		$305.53
Toc - Plan #68 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$434.10
$492.70
$554.78
$775.30
$1,178.15 		$766.19
$824.79
$886.87
$1,107.39 		$1,098.28
$1,156.88
$1,218.96
$1,439.48 		$1,430.37
$1,488.97
$1,551.05
$1,771.57 		$332.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.20
$985.40
$1,109.56
$1,550.60
$2,356.30 		$1,200.29
$1,317.49
$1,441.65
$1,882.69 		$1,532.38
$1,649.58
$1,773.74
$2,214.78 		$1,864.47
$1,981.67
$2,105.83
$2,546.87 		$332.09
Toc - Plan #69 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$518.33
$588.30
$662.43
$925.74
$1,406.75 		$914.85
$984.82
$1,058.95
$1,322.26 		$1,311.37
$1,381.34
$1,455.47
$1,718.78 		$1,707.89
$1,777.86
$1,851.99
$2,115.30 		$396.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,036.66
$1,176.60
$1,324.86
$1,851.48
$2,813.50 		$1,433.18
$1,573.12
$1,721.38
$2,248.00 		$1,829.70
$1,969.64
$2,117.90
$2,644.52 		$2,226.22
$2,366.16
$2,514.42
$3,041.04 		$396.52
Toc - Plan #70 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Preferred/Broad 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$545.06
$618.64
$696.59
$973.48
$1,479.29 		$962.03
$1,035.61
$1,113.56
$1,390.45 		$1,379.00
$1,452.58
$1,530.53
$1,807.42 		$1,795.97
$1,869.55
$1,947.50
$2,224.39 		$416.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,090.12
$1,237.28
$1,393.18
$1,946.96
$2,958.58 		$1,507.09
$1,654.25
$1,810.15
$2,363.93 		$1,924.06
$2,071.22
$2,227.12
$2,780.90 		$2,341.03
$2,488.19
$2,644.09
$3,197.87 		$416.97

‡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 Monroe County here.

Monroe County is in “Rating Area 6” of Wisconsin.

Currently, there are 70 plans offered in Rating Area 6.

Top

2023 Obamacare Plans for Monroe County, WI

Plan Browser: 70 Plans
scroll down for more
Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork