Medina County, Ohio Obamacare 2024 Rates

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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 Medina County, OH.

The health insurance rates listed below are for calendar year 2024.

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, 124 Plans and 2024 Rates for Medina County, Ohio

Below, you’ll find a summary of the 124 plans for Medina County, Ohio and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |



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Anthem Blue Cross and Blue Shield

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

Toc - Plan #1 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway HMO 9450 ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$324.66
$368.49
$414.92
$579.84
$881.13
$573.02
$616.85
$663.28
$828.20
$821.38
$865.21
$911.64
$1,076.56
$1,069.74
$1,113.57
$1,160.00
$1,324.92
$248.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.32
$736.98
$829.84
$1,159.68
$1,762.26
$897.68
$985.34
$1,078.20
$1,408.04
$1,146.04
$1,233.70
$1,326.56
$1,656.40
$1,394.40
$1,482.06
$1,574.92
$1,904.76
$248.36
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.62
$483.08
$543.94
$760.16
$1,155.13
$751.22
$808.68
$869.54
$1,085.76
$1,076.82
$1,134.28
$1,195.14
$1,411.36
$1,402.42
$1,459.88
$1,520.74
$1,736.96
$325.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$851.24
$966.16
$1,087.88
$1,520.32
$2,310.26
$1,176.84
$1,291.76
$1,413.48
$1,845.92
$1,502.44
$1,617.36
$1,739.08
$2,171.52
$1,828.04
$1,942.96
$2,064.68
$2,497.12
$325.60
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.76
$402.65
$453.38
$633.60
$962.82
$626.15
$674.04
$724.77
$904.99
$897.54
$945.43
$996.16
$1,176.38
$1,168.93
$1,216.82
$1,267.55
$1,447.77
$271.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.52
$805.30
$906.76
$1,267.20
$1,925.64
$980.91
$1,076.69
$1,178.15
$1,538.59
$1,252.30
$1,348.08
$1,449.54
$1,809.98
$1,523.69
$1,619.47
$1,720.93
$2,081.37
$271.39
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.82
$510.55
$574.87
$803.38
$1,220.81
$793.93
$854.66
$918.98
$1,147.49
$1,138.04
$1,198.77
$1,263.09
$1,491.60
$1,482.15
$1,542.88
$1,607.20
$1,835.71
$344.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.64
$1,021.10
$1,149.74
$1,606.76
$2,441.62
$1,243.75
$1,365.21
$1,493.85
$1,950.87
$1,587.86
$1,709.32
$1,837.96
$2,294.98
$1,931.97
$2,053.43
$2,182.07
$2,639.09
$344.11
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$420.72
$477.52
$537.68
$751.41
$1,141.83
$742.57
$799.37
$859.53
$1,073.26
$1,064.42
$1,121.22
$1,181.38
$1,395.11
$1,386.27
$1,443.07
$1,503.23
$1,716.96
$321.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$841.44
$955.04
$1,075.36
$1,502.82
$2,283.66
$1,163.29
$1,276.89
$1,397.21
$1,824.67
$1,485.14
$1,598.74
$1,719.06
$2,146.52
$1,806.99
$1,920.59
$2,040.91
$2,468.37
$321.85
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway HMO 9450 ( + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$251.70
$285.68
$321.67
$449.54
$683.11
$444.25
$478.23
$514.22
$642.09
$636.80
$670.78
$706.77
$834.64
$829.35
$863.33
$899.32
$1,027.19
$192.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$503.40
$571.36
$643.34
$899.08
$1,366.22
$695.95
$763.91
$835.89
$1,091.63
$888.50
$956.46
$1,028.44
$1,284.18
$1,081.05
$1,149.01
$1,220.99
$1,476.73
$192.55
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.56
$479.61
$540.03
$754.69
$1,146.83
$745.82
$802.87
$863.29
$1,077.95
$1,069.08
$1,126.13
$1,186.55
$1,401.21
$1,392.34
$1,449.39
$1,509.81
$1,724.47
$323.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.12
$959.22
$1,080.06
$1,509.38
$2,293.66
$1,168.38
$1,282.48
$1,403.32
$1,832.64
$1,491.64
$1,605.74
$1,726.58
$2,155.90
$1,814.90
$1,929.00
$2,049.84
$2,479.16
$323.26
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 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
$343.40
$389.76
$438.87
$613.31
$931.99
$606.10
$652.46
$701.57
$876.01
$868.80
$915.16
$964.27
$1,138.71
$1,131.50
$1,177.86
$1,226.97
$1,401.41
$262.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.80
$779.52
$877.74
$1,226.62
$1,863.98
$949.50
$1,042.22
$1,140.44
$1,489.32
$1,212.20
$1,304.92
$1,403.14
$1,752.02
$1,474.90
$1,567.62
$1,665.84
$2,014.72
$262.70
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,450 $18,900 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
$336.56
$382.00
$430.12
$601.10
$913.42
$594.03
$639.47
$687.59
$858.57
$851.50
$896.94
$945.06
$1,116.04
$1,108.97
$1,154.41
$1,202.53
$1,373.51
$257.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$673.12
$764.00
$860.24
$1,202.20
$1,826.84
$930.59
$1,021.47
$1,117.71
$1,459.67
$1,188.06
$1,278.94
$1,375.18
$1,717.14
$1,445.53
$1,536.41
$1,632.65
$1,974.61
$257.47
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$343.02
$389.33
$438.38
$612.63
$930.96
$605.43
$651.74
$700.79
$875.04
$867.84
$914.15
$963.20
$1,137.45
$1,130.25
$1,176.56
$1,225.61
$1,399.86
$262.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.04
$778.66
$876.76
$1,225.26
$1,861.92
$948.45
$1,041.07
$1,139.17
$1,487.67
$1,210.86
$1,303.48
$1,401.58
$1,750.08
$1,473.27
$1,565.89
$1,663.99
$2,012.49
$262.41
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.65
$469.49
$528.64
$738.78
$1,122.65
$730.09
$785.93
$845.08
$1,055.22
$1,046.53
$1,102.37
$1,161.52
$1,371.66
$1,362.97
$1,418.81
$1,477.96
$1,688.10
$316.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$827.30
$938.98
$1,057.28
$1,477.56
$2,245.30
$1,143.74
$1,255.42
$1,373.72
$1,794.00
$1,460.18
$1,571.86
$1,690.16
$2,110.44
$1,776.62
$1,888.30
$2,006.60
$2,426.88
$316.44
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$614.49
$697.45
$785.32
$1,097.48
$1,667.73
$1,084.57
$1,167.53
$1,255.40
$1,567.56
$1,554.65
$1,637.61
$1,725.48
$2,037.64
$2,024.73
$2,107.69
$2,195.56
$2,507.72
$470.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,228.98
$1,394.90
$1,570.64
$2,194.96
$3,335.46
$1,699.06
$1,864.98
$2,040.72
$2,665.04
$2,169.14
$2,335.06
$2,510.80
$3,135.12
$2,639.22
$2,805.14
$2,980.88
$3,605.20
$470.08
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway HMO 9450 Adult Dental & Vision ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$328.68
$373.05
$420.05
$587.02
$892.04
$580.12
$624.49
$671.49
$838.46
$831.56
$875.93
$922.93
$1,089.90
$1,083.00
$1,127.37
$1,174.37
$1,341.34
$251.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$657.36
$746.10
$840.10
$1,174.04
$1,784.08
$908.80
$997.54
$1,091.54
$1,425.48
$1,160.24
$1,248.98
$1,342.98
$1,676.92
$1,411.68
$1,500.42
$1,594.42
$1,928.36
$251.44
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway HMO 5000 Adult Dental & Vision ($0 Virtual PCP + $0 Select Drugs + Incentives)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.74
$482.08
$542.82
$758.59
$1,152.74
$749.67
$807.01
$867.75
$1,083.52
$1,074.60
$1,131.94
$1,192.68
$1,408.45
$1,399.53
$1,456.87
$1,517.61
$1,733.38
$324.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.48
$964.16
$1,085.64
$1,517.18
$2,305.48
$1,174.41
$1,289.09
$1,410.57
$1,842.11
$1,499.34
$1,614.02
$1,735.50
$2,167.04
$1,824.27
$1,938.95
$2,060.43
$2,491.97
$324.93

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-331-4680 | Toll Free: 1-800-331-4680 | TTY: 1-800-331-4680

Toc - Plan #15 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.65
$474.03
$533.76
$745.93
$1,133.51
$737.15
$793.53
$853.26
$1,065.43
$1,056.65
$1,113.03
$1,172.76
$1,384.93
$1,376.15
$1,432.53
$1,492.26
$1,704.43
$319.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.30
$948.06
$1,067.52
$1,491.86
$2,267.02
$1,154.80
$1,267.56
$1,387.02
$1,811.36
$1,474.30
$1,587.06
$1,706.52
$2,130.86
$1,793.80
$1,906.56
$2,026.02
$2,450.36
$319.50
Toc - Plan #16 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$439.32
$498.63
$561.46
$784.63
$1,192.33
$775.40
$834.71
$897.54
$1,120.71
$1,111.48
$1,170.79
$1,233.62
$1,456.79
$1,447.56
$1,506.87
$1,569.70
$1,792.87
$336.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$878.64
$997.26
$1,122.92
$1,569.26
$2,384.66
$1,214.72
$1,333.34
$1,459.00
$1,905.34
$1,550.80
$1,669.42
$1,795.08
$2,241.42
$1,886.88
$2,005.50
$2,131.16
$2,577.50
$336.08
Toc - Plan #17 UnitedHealthcare
Silver

(HMO) UHC Silver Value ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.78
$438.99
$494.30
$690.79
$1,049.72
$682.67
$734.88
$790.19
$986.68
$978.56
$1,030.77
$1,086.08
$1,282.57
$1,274.45
$1,326.66
$1,381.97
$1,578.46
$295.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.56
$877.98
$988.60
$1,381.58
$2,099.44
$1,069.45
$1,173.87
$1,284.49
$1,677.47
$1,365.34
$1,469.76
$1,580.38
$1,973.36
$1,661.23
$1,765.65
$1,876.27
$2,269.25
$295.89
Toc - Plan #18 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.76
$443.51
$499.39
$697.89
$1,060.52
$689.69
$742.44
$798.32
$996.82
$988.62
$1,041.37
$1,097.25
$1,295.75
$1,287.55
$1,340.30
$1,396.18
$1,594.68
$298.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.52
$887.02
$998.78
$1,395.78
$2,121.04
$1,080.45
$1,185.95
$1,297.71
$1,694.71
$1,379.38
$1,484.88
$1,596.64
$1,993.64
$1,678.31
$1,783.81
$1,895.57
$2,292.57
$298.93
Toc - Plan #19 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.11
$440.51
$496.01
$693.17
$1,053.33
$685.01
$737.41
$792.91
$990.07
$981.91
$1,034.31
$1,089.81
$1,286.97
$1,278.81
$1,331.21
$1,386.71
$1,583.87
$296.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.22
$881.02
$992.02
$1,386.34
$2,106.66
$1,073.12
$1,177.92
$1,288.92
$1,683.24
$1,370.02
$1,474.82
$1,585.82
$1,980.14
$1,666.92
$1,771.72
$1,882.72
$2,277.04
$296.90
Toc - Plan #20 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$8,050 $16,100 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
$336.42
$381.84
$429.94
$600.85
$913.04
$593.78
$639.20
$687.30
$858.21
$851.14
$896.56
$944.66
$1,115.57
$1,108.50
$1,153.92
$1,202.02
$1,372.93
$257.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.84
$763.68
$859.88
$1,201.70
$1,826.08
$930.20
$1,021.04
$1,117.24
$1,459.06
$1,187.56
$1,278.40
$1,374.60
$1,716.42
$1,444.92
$1,535.76
$1,631.96
$1,973.78
$257.36
Toc - Plan #21 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,450 $18,900 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
$341.27
$387.34
$436.14
$609.50
$926.20
$602.34
$648.41
$697.21
$870.57
$863.41
$909.48
$958.28
$1,131.64
$1,124.48
$1,170.55
$1,219.35
$1,392.71
$261.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.54
$774.68
$872.28
$1,219.00
$1,852.40
$943.61
$1,035.75
$1,133.35
$1,480.07
$1,204.68
$1,296.82
$1,394.42
$1,741.14
$1,465.75
$1,557.89
$1,655.49
$2,002.21
$261.07
Toc - Plan #22 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$345.91
$392.61
$442.07
$617.79
$938.79
$610.53
$657.23
$706.69
$882.41
$875.15
$921.85
$971.31
$1,147.03
$1,139.77
$1,186.47
$1,235.93
$1,411.65
$264.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691.82
$785.22
$884.14
$1,235.58
$1,877.58
$956.44
$1,049.84
$1,148.76
$1,500.20
$1,221.06
$1,314.46
$1,413.38
$1,764.82
$1,485.68
$1,579.08
$1,678.00
$2,029.44
$264.62
Toc - Plan #23 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 PCP Visits, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$9,450 $18,900 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
$340.85
$386.87
$435.61
$608.76
$925.08
$601.60
$647.62
$696.36
$869.51
$862.35
$908.37
$957.11
$1,130.26
$1,123.10
$1,169.12
$1,217.86
$1,391.01
$260.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.70
$773.74
$871.22
$1,217.52
$1,850.16
$942.45
$1,034.49
$1,131.97
$1,478.27
$1,203.20
$1,295.24
$1,392.72
$1,739.02
$1,463.95
$1,555.99
$1,653.47
$1,999.77
$260.75
Toc - Plan #24 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$355.42
$403.41
$454.23
$634.79
$964.62
$627.32
$675.31
$726.13
$906.69
$899.22
$947.21
$998.03
$1,178.59
$1,171.12
$1,219.11
$1,269.93
$1,450.49
$271.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.84
$806.82
$908.46
$1,269.58
$1,929.24
$982.74
$1,078.72
$1,180.36
$1,541.48
$1,254.64
$1,350.62
$1,452.26
$1,813.38
$1,526.54
$1,622.52
$1,724.16
$2,085.28
$271.90
Toc - Plan #25 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $5 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$391.69
$444.57
$500.58
$699.56
$1,063.05
$691.33
$744.21
$800.22
$999.20
$990.97
$1,043.85
$1,099.86
$1,298.84
$1,290.61
$1,343.49
$1,399.50
$1,598.48
$299.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.38
$889.14
$1,001.16
$1,399.12
$2,126.10
$1,083.02
$1,188.78
$1,300.80
$1,698.76
$1,382.66
$1,488.42
$1,600.44
$1,998.40
$1,682.30
$1,788.06
$1,900.08
$2,298.04
$299.64
Toc - Plan #26 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 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
$385.14
$437.14
$492.21
$687.87
$1,045.28
$679.78
$731.78
$786.85
$982.51
$974.42
$1,026.42
$1,081.49
$1,277.15
$1,269.06
$1,321.06
$1,376.13
$1,571.79
$294.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.28
$874.28
$984.42
$1,375.74
$2,090.56
$1,064.92
$1,168.92
$1,279.06
$1,670.38
$1,359.56
$1,463.56
$1,573.70
$1,965.02
$1,654.20
$1,758.20
$1,868.34
$2,259.66
$294.64
Toc - Plan #27 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$442.95
$502.74
$566.08
$791.10
$1,202.15
$781.80
$841.59
$904.93
$1,129.95
$1,120.65
$1,180.44
$1,243.78
$1,468.80
$1,459.50
$1,519.29
$1,582.63
$1,807.65
$338.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$885.90
$1,005.48
$1,132.16
$1,582.20
$2,404.30
$1,224.75
$1,344.33
$1,471.01
$1,921.05
$1,563.60
$1,683.18
$1,809.86
$2,259.90
$1,902.45
$2,022.03
$2,148.71
$2,598.75
$338.85
Toc - Plan #28 UnitedHealthcare
Gold

(HMO) UHC Gold Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$430.48
$488.60
$550.16
$768.84
$1,168.33
$759.80
$817.92
$879.48
$1,098.16
$1,089.12
$1,147.24
$1,208.80
$1,427.48
$1,418.44
$1,476.56
$1,538.12
$1,756.80
$329.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$860.96
$977.20
$1,100.32
$1,537.68
$2,336.66
$1,190.28
$1,306.52
$1,429.64
$1,867.00
$1,519.60
$1,635.84
$1,758.96
$2,196.32
$1,848.92
$1,965.16
$2,088.28
$2,525.64
$329.32
Toc - Plan #29 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, Dental + Vision, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 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
$400.93
$455.05
$512.38
$716.05
$1,088.11
$707.64
$761.76
$819.09
$1,022.76
$1,014.35
$1,068.47
$1,125.80
$1,329.47
$1,321.06
$1,375.18
$1,432.51
$1,636.18
$306.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.86
$910.10
$1,024.76
$1,432.10
$2,176.22
$1,108.57
$1,216.81
$1,331.47
$1,738.81
$1,415.28
$1,523.52
$1,638.18
$2,045.52
$1,721.99
$1,830.23
$1,944.89
$2,352.23
$306.71
Toc - Plan #30 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-331-4680

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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
$448.81
$509.40
$573.58
$801.57
$1,218.07
$792.15
$852.74
$916.92
$1,144.91
$1,135.49
$1,196.08
$1,260.26
$1,488.25
$1,478.83
$1,539.42
$1,603.60
$1,831.59
$343.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$897.62
$1,018.80
$1,147.16
$1,603.14
$2,436.14
$1,240.96
$1,362.14
$1,490.50
$1,946.48
$1,584.30
$1,705.48
$1,833.84
$2,289.82
$1,927.64
$2,048.82
$2,177.18
$2,633.16
$343.34

ADVERTISEMENT

Ambetter from Buckeye Health Plan

Local: 1-877-687-1189 | Toll Free: 1-877-687-1189 | TTY: 1-877-941-9236

Toc - Plan #31 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.84
$406.14
$457.31
$639.09
$971.15
$631.58
$679.88
$731.05
$912.83
$905.32
$953.62
$1,004.79
$1,186.57
$1,179.06
$1,227.36
$1,278.53
$1,460.31
$273.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.68
$812.28
$914.62
$1,278.18
$1,942.30
$989.42
$1,086.02
$1,188.36
$1,551.92
$1,263.16
$1,359.76
$1,462.10
$1,825.66
$1,536.90
$1,633.50
$1,735.84
$2,099.40
$273.74
Toc - Plan #32 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$369.07
$418.88
$471.66
$659.14
$1,001.63
$651.40
$701.21
$753.99
$941.47
$933.73
$983.54
$1,036.32
$1,223.80
$1,216.06
$1,265.87
$1,318.65
$1,506.13
$282.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.14
$837.76
$943.32
$1,318.28
$2,003.26
$1,020.47
$1,120.09
$1,225.65
$1,600.61
$1,302.80
$1,402.42
$1,507.98
$1,882.94
$1,585.13
$1,684.75
$1,790.31
$2,165.27
$282.33
Toc - Plan #33 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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
$304.15
$345.20
$388.69
$543.19
$825.43
$536.81
$577.86
$621.35
$775.85
$769.47
$810.52
$854.01
$1,008.51
$1,002.13
$1,043.18
$1,086.67
$1,241.17
$232.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$608.30
$690.40
$777.38
$1,086.38
$1,650.86
$840.96
$923.06
$1,010.04
$1,319.04
$1,073.62
$1,155.72
$1,242.70
$1,551.70
$1,306.28
$1,388.38
$1,475.36
$1,784.36
$232.66
Toc - Plan #34 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 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
$295.97
$335.91
$378.23
$528.58
$803.23
$522.38
$562.32
$604.64
$754.99
$748.79
$788.73
$831.05
$981.40
$975.20
$1,015.14
$1,057.46
$1,207.81
$226.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.94
$671.82
$756.46
$1,057.16
$1,606.46
$818.35
$898.23
$982.87
$1,283.57
$1,044.76
$1,124.64
$1,209.28
$1,509.98
$1,271.17
$1,351.05
$1,435.69
$1,736.39
$226.41
Toc - Plan #35 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 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
$335.21
$380.45
$428.38
$598.66
$909.72
$591.63
$636.87
$684.80
$855.08
$848.05
$893.29
$941.22
$1,111.50
$1,104.47
$1,149.71
$1,197.64
$1,367.92
$256.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.42
$760.90
$856.76
$1,197.32
$1,819.44
$926.84
$1,017.32
$1,113.18
$1,453.74
$1,183.26
$1,273.74
$1,369.60
$1,710.16
$1,439.68
$1,530.16
$1,626.02
$1,966.58
$256.42
Toc - Plan #36 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$349.11
$396.22
$446.14
$623.48
$947.45
$616.17
$663.28
$713.20
$890.54
$883.23
$930.34
$980.26
$1,157.60
$1,150.29
$1,197.40
$1,247.32
$1,424.66
$267.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.22
$792.44
$892.28
$1,246.96
$1,894.90
$965.28
$1,059.50
$1,159.34
$1,514.02
$1,232.34
$1,326.56
$1,426.40
$1,781.08
$1,499.40
$1,593.62
$1,693.46
$2,048.14
$267.06
Toc - Plan #37 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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
$353.02
$400.67
$451.15
$630.48
$958.08
$623.07
$670.72
$721.20
$900.53
$893.12
$940.77
$991.25
$1,170.58
$1,163.17
$1,210.82
$1,261.30
$1,440.63
$270.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.04
$801.34
$902.30
$1,260.96
$1,916.16
$976.09
$1,071.39
$1,172.35
$1,531.01
$1,246.14
$1,341.44
$1,442.40
$1,801.06
$1,516.19
$1,611.49
$1,712.45
$2,071.11
$270.05
Toc - Plan #38 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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
$354.44
$402.28
$452.97
$633.02
$961.93
$625.58
$673.42
$724.11
$904.16
$896.72
$944.56
$995.25
$1,175.30
$1,167.86
$1,215.70
$1,266.39
$1,446.44
$271.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.88
$804.56
$905.94
$1,266.04
$1,923.86
$980.02
$1,075.70
$1,177.08
$1,537.18
$1,251.16
$1,346.84
$1,448.22
$1,808.32
$1,522.30
$1,617.98
$1,719.36
$2,079.46
$271.14
Toc - Plan #39 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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
$349.38
$396.54
$446.50
$623.98
$948.20
$616.65
$663.81
$713.77
$891.25
$883.92
$931.08
$981.04
$1,158.52
$1,151.19
$1,198.35
$1,248.31
$1,425.79
$267.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.76
$793.08
$893.00
$1,247.96
$1,896.40
$966.03
$1,060.35
$1,160.27
$1,515.23
$1,233.30
$1,327.62
$1,427.54
$1,782.50
$1,500.57
$1,594.89
$1,694.81
$2,049.77
$267.27
Toc - Plan #40 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$291.60
$330.95
$372.65
$520.78
$791.37
$514.67
$554.02
$595.72
$743.85
$737.74
$777.09
$818.79
$966.92
$960.81
$1,000.16
$1,041.86
$1,189.99
$223.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583.20
$661.90
$745.30
$1,041.56
$1,582.74
$806.27
$884.97
$968.37
$1,264.63
$1,029.34
$1,108.04
$1,191.44
$1,487.70
$1,252.41
$1,331.11
$1,414.51
$1,710.77
$223.07
Toc - Plan #41 Ambetter from Buckeye Health Plan
Silver

(HMO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346.64
$393.43
$443.00
$619.09
$940.77
$611.82
$658.61
$708.18
$884.27
$877.00
$923.79
$973.36
$1,149.45
$1,142.18
$1,188.97
$1,238.54
$1,414.63
$265.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.28
$786.86
$886.00
$1,238.18
$1,881.54
$958.46
$1,052.04
$1,151.18
$1,503.36
$1,223.64
$1,317.22
$1,416.36
$1,768.54
$1,488.82
$1,582.40
$1,681.54
$2,033.72
$265.18
Toc - Plan #42 Ambetter from Buckeye Health Plan
Gold

(HMO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$356.42
$404.52
$455.49
$636.55
$967.30
$629.07
$677.17
$728.14
$909.20
$901.72
$949.82
$1,000.79
$1,181.85
$1,174.37
$1,222.47
$1,273.44
$1,454.50
$272.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.84
$809.04
$910.98
$1,273.10
$1,934.60
$985.49
$1,081.69
$1,183.63
$1,545.75
$1,258.14
$1,354.34
$1,456.28
$1,818.40
$1,530.79
$1,626.99
$1,728.93
$2,091.05
$272.65
Toc - Plan #43 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$368.45
$418.18
$470.87
$658.04
$999.95
$650.31
$700.04
$752.73
$939.90
$932.17
$981.90
$1,034.59
$1,221.76
$1,214.03
$1,263.76
$1,316.45
$1,503.62
$281.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$736.90
$836.36
$941.74
$1,316.08
$1,999.90
$1,018.76
$1,118.22
$1,223.60
$1,597.94
$1,300.62
$1,400.08
$1,505.46
$1,879.80
$1,582.48
$1,681.94
$1,787.32
$2,161.66
$281.86
Toc - Plan #44 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.02
$431.31
$485.65
$678.69
$1,031.34
$670.73
$722.02
$776.36
$969.40
$961.44
$1,012.73
$1,067.07
$1,260.11
$1,252.15
$1,303.44
$1,357.78
$1,550.82
$290.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.04
$862.62
$971.30
$1,357.38
$2,062.68
$1,050.75
$1,153.33
$1,262.01
$1,648.09
$1,341.46
$1,444.04
$1,552.72
$1,938.80
$1,632.17
$1,734.75
$1,843.43
$2,229.51
$290.71
Toc - Plan #45 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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
$313.17
$355.43
$400.21
$559.30
$849.91
$552.74
$595.00
$639.78
$798.87
$792.31
$834.57
$879.35
$1,038.44
$1,031.88
$1,074.14
$1,118.92
$1,278.01
$239.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.34
$710.86
$800.42
$1,118.60
$1,699.82
$865.91
$950.43
$1,039.99
$1,358.17
$1,105.48
$1,190.00
$1,279.56
$1,597.74
$1,345.05
$1,429.57
$1,519.13
$1,837.31
$239.57
Toc - Plan #46 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$8,450 $16,900 Annual Deductible
$9,250 $18,500 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
$304.74
$345.87
$389.45
$544.25
$827.05
$537.86
$578.99
$622.57
$777.37
$770.98
$812.11
$855.69
$1,010.49
$1,004.10
$1,045.23
$1,088.81
$1,243.61
$233.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609.48
$691.74
$778.90
$1,088.50
$1,654.10
$842.60
$924.86
$1,012.02
$1,321.62
$1,075.72
$1,157.98
$1,245.14
$1,554.74
$1,308.84
$1,391.10
$1,478.26
$1,787.86
$233.12
Toc - Plan #47 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 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
$345.15
$391.73
$441.08
$616.41
$936.70
$609.18
$655.76
$705.11
$880.44
$873.21
$919.79
$969.14
$1,144.47
$1,137.24
$1,183.82
$1,233.17
$1,408.50
$264.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$690.30
$783.46
$882.16
$1,232.82
$1,873.40
$954.33
$1,047.49
$1,146.19
$1,496.85
$1,218.36
$1,311.52
$1,410.22
$1,760.88
$1,482.39
$1,575.55
$1,674.25
$2,024.91
$264.03
Toc - Plan #48 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$359.46
$407.97
$459.38
$641.98
$975.54
$634.44
$682.95
$734.36
$916.96
$909.42
$957.93
$1,009.34
$1,191.94
$1,184.40
$1,232.91
$1,284.32
$1,466.92
$274.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.92
$815.94
$918.76
$1,283.96
$1,951.08
$993.90
$1,090.92
$1,193.74
$1,558.94
$1,268.88
$1,365.90
$1,468.72
$1,833.92
$1,543.86
$1,640.88
$1,743.70
$2,108.90
$274.98
Toc - Plan #49 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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
$363.49
$412.55
$464.53
$649.18
$986.49
$641.55
$690.61
$742.59
$927.24
$919.61
$968.67
$1,020.65
$1,205.30
$1,197.67
$1,246.73
$1,298.71
$1,483.36
$278.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$726.98
$825.10
$929.06
$1,298.36
$1,972.98
$1,005.04
$1,103.16
$1,207.12
$1,576.42
$1,283.10
$1,381.22
$1,485.18
$1,854.48
$1,561.16
$1,659.28
$1,763.24
$2,132.54
$278.06
Toc - Plan #50 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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
$364.96
$414.21
$466.40
$651.79
$990.46
$644.14
$693.39
$745.58
$930.97
$923.32
$972.57
$1,024.76
$1,210.15
$1,202.50
$1,251.75
$1,303.94
$1,489.33
$279.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.92
$828.42
$932.80
$1,303.58
$1,980.92
$1,009.10
$1,107.60
$1,211.98
$1,582.76
$1,288.28
$1,386.78
$1,491.16
$1,861.94
$1,567.46
$1,665.96
$1,770.34
$2,141.12
$279.18
Toc - Plan #51 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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
$359.74
$408.30
$459.74
$642.49
$976.32
$634.94
$683.50
$734.94
$917.69
$910.14
$958.70
$1,010.14
$1,192.89
$1,185.34
$1,233.90
$1,285.34
$1,468.09
$275.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$719.48
$816.60
$919.48
$1,284.98
$1,952.64
$994.68
$1,091.80
$1,194.68
$1,560.18
$1,269.88
$1,367.00
$1,469.88
$1,835.38
$1,545.08
$1,642.20
$1,745.08
$2,110.58
$275.20
Toc - Plan #52 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Standard Expanded Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$300.25
$340.77
$383.70
$536.22
$814.84
$529.93
$570.45
$613.38
$765.90
$759.61
$800.13
$843.06
$995.58
$989.29
$1,029.81
$1,072.74
$1,225.26
$229.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600.50
$681.54
$767.40
$1,072.44
$1,629.68
$830.18
$911.22
$997.08
$1,302.12
$1,059.86
$1,140.90
$1,226.76
$1,531.80
$1,289.54
$1,370.58
$1,456.44
$1,761.48
$229.68
Toc - Plan #53 Ambetter from Buckeye Health Plan
Silver

(HMO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.92
$405.10
$456.14
$637.45
$968.67
$629.96
$678.14
$729.18
$910.49
$903.00
$951.18
$1,002.22
$1,183.53
$1,176.04
$1,224.22
$1,275.26
$1,456.57
$273.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.84
$810.20
$912.28
$1,274.90
$1,937.34
$986.88
$1,083.24
$1,185.32
$1,547.94
$1,259.92
$1,356.28
$1,458.36
$1,820.98
$1,532.96
$1,629.32
$1,731.40
$2,094.02
$273.04
Toc - Plan #54 Ambetter from Buckeye Health Plan
Gold

(HMO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$366.99
$416.52
$469.00
$655.43
$995.98
$647.73
$697.26
$749.74
$936.17
$928.47
$978.00
$1,030.48
$1,216.91
$1,209.21
$1,258.74
$1,311.22
$1,497.65
$280.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.98
$833.04
$938.00
$1,310.86
$1,991.96
$1,014.72
$1,113.78
$1,218.74
$1,591.60
$1,295.46
$1,394.52
$1,499.48
$1,872.34
$1,576.20
$1,675.26
$1,780.22
$2,153.08
$280.74

ADVERTISEMENT

Oscar Insurance Corporation of Ohio

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

Toc - Plan #55 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.14
$462.09
$520.31
$727.13
$1,104.95
$718.59
$773.54
$831.76
$1,038.58
$1,030.04
$1,084.99
$1,143.21
$1,350.03
$1,341.49
$1,396.44
$1,454.66
$1,661.48
$311.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.28
$924.18
$1,040.62
$1,454.26
$2,209.90
$1,125.73
$1,235.63
$1,352.07
$1,765.71
$1,437.18
$1,547.08
$1,663.52
$2,077.16
$1,748.63
$1,858.53
$1,974.97
$2,388.61
$311.45
Toc - Plan #56 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.75
$468.45
$527.48
$737.15
$1,120.16
$728.49
$784.19
$843.22
$1,052.89
$1,044.23
$1,099.93
$1,158.96
$1,368.63
$1,359.97
$1,415.67
$1,474.70
$1,684.37
$315.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825.50
$936.90
$1,054.96
$1,474.30
$2,240.32
$1,141.24
$1,252.64
$1,370.70
$1,790.04
$1,456.98
$1,568.38
$1,686.44
$2,105.78
$1,772.72
$1,884.12
$2,002.18
$2,421.52
$315.74
Toc - Plan #57 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$422.62
$479.67
$540.10
$754.79
$1,146.97
$745.92
$802.97
$863.40
$1,078.09
$1,069.22
$1,126.27
$1,186.70
$1,401.39
$1,392.52
$1,449.57
$1,510.00
$1,724.69
$323.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.24
$959.34
$1,080.20
$1,509.58
$2,293.94
$1,168.54
$1,282.64
$1,403.50
$1,832.88
$1,491.84
$1,605.94
$1,726.80
$2,156.18
$1,815.14
$1,929.24
$2,050.10
$2,479.48
$323.30
Toc - Plan #58 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $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
$482.68
$547.83
$616.86
$862.05
$1,309.97
$851.92
$917.07
$986.10
$1,231.29
$1,221.16
$1,286.31
$1,355.34
$1,600.53
$1,590.40
$1,655.55
$1,724.58
$1,969.77
$369.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$965.36
$1,095.66
$1,233.72
$1,724.10
$2,619.94
$1,334.60
$1,464.90
$1,602.96
$2,093.34
$1,703.84
$1,834.14
$1,972.20
$2,462.58
$2,073.08
$2,203.38
$2,341.44
$2,831.82
$369.24
Toc - Plan #59 Oscar Insurance Corporation of Ohio
Catastrophic

(HMO) Secure

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$327.35
$371.54
$418.35
$584.64
$888.41
$577.77
$621.96
$668.77
$835.06
$828.19
$872.38
$919.19
$1,085.48
$1,078.61
$1,122.80
$1,169.61
$1,335.90
$250.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$654.70
$743.08
$836.70
$1,169.28
$1,776.82
$905.12
$993.50
$1,087.12
$1,419.70
$1,155.54
$1,243.92
$1,337.54
$1,670.12
$1,405.96
$1,494.34
$1,587.96
$1,920.54
$250.42
Toc - Plan #60 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$544.07
$617.51
$695.31
$971.70
$1,476.59
$960.28
$1,033.72
$1,111.52
$1,387.91
$1,376.49
$1,449.93
$1,527.73
$1,804.12
$1,792.70
$1,866.14
$1,943.94
$2,220.33
$416.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,088.14
$1,235.02
$1,390.62
$1,943.40
$2,953.18
$1,504.35
$1,651.23
$1,806.83
$2,359.61
$1,920.56
$2,067.44
$2,223.04
$2,775.82
$2,336.77
$2,483.65
$2,639.25
$3,192.03
$416.21
Toc - Plan #61 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.58
$475.08
$534.93
$747.57
$1,136.00
$738.79
$795.29
$855.14
$1,067.78
$1,059.00
$1,115.50
$1,175.35
$1,387.99
$1,379.21
$1,435.71
$1,495.56
$1,708.20
$320.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$837.16
$950.16
$1,069.86
$1,495.14
$2,272.00
$1,157.37
$1,270.37
$1,390.07
$1,815.35
$1,477.58
$1,590.58
$1,710.28
$2,135.56
$1,797.79
$1,910.79
$2,030.49
$2,455.77
$320.21
Toc - Plan #62 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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
$461.12
$523.36
$589.29
$823.54
$1,251.44
$813.87
$876.11
$942.04
$1,176.29
$1,166.62
$1,228.86
$1,294.79
$1,529.04
$1,519.37
$1,581.61
$1,647.54
$1,881.79
$352.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$922.24
$1,046.72
$1,178.58
$1,647.08
$2,502.88
$1,274.99
$1,399.47
$1,531.33
$1,999.83
$1,627.74
$1,752.22
$1,884.08
$2,352.58
$1,980.49
$2,104.97
$2,236.83
$2,705.33
$352.75
Toc - Plan #63 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$496.25
$563.23
$634.19
$886.28
$1,346.78
$875.87
$942.85
$1,013.81
$1,265.90
$1,255.49
$1,322.47
$1,393.43
$1,645.52
$1,635.11
$1,702.09
$1,773.05
$2,025.14
$379.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992.50
$1,126.46
$1,268.38
$1,772.56
$2,693.56
$1,372.12
$1,506.08
$1,648.00
$2,152.18
$1,751.74
$1,885.70
$2,027.62
$2,531.80
$2,131.36
$2,265.32
$2,407.24
$2,911.42
$379.62
Toc - Plan #64 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$590.26
$669.93
$754.33
$1,054.18
$1,601.93
$1,041.80
$1,121.47
$1,205.87
$1,505.72
$1,493.34
$1,573.01
$1,657.41
$1,957.26
$1,944.88
$2,024.55
$2,108.95
$2,408.80
$451.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,180.52
$1,339.86
$1,508.66
$2,108.36
$3,203.86
$1,632.06
$1,791.40
$1,960.20
$2,559.90
$2,083.60
$2,242.94
$2,411.74
$3,011.44
$2,535.14
$2,694.48
$2,863.28
$3,462.98
$451.54
Toc - Plan #65 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$573.72
$651.16
$733.21
$1,024.65
$1,557.06
$1,012.61
$1,090.05
$1,172.10
$1,463.54
$1,451.50
$1,528.94
$1,610.99
$1,902.43
$1,890.39
$1,967.83
$2,049.88
$2,341.32
$438.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,147.44
$1,302.32
$1,466.42
$2,049.30
$3,114.12
$1,586.33
$1,741.21
$1,905.31
$2,488.19
$2,025.22
$2,180.10
$2,344.20
$2,927.08
$2,464.11
$2,618.99
$2,783.09
$3,365.97
$438.89
Toc - Plan #66 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple Diabetes

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$477.37
$541.81
$610.07
$852.57
$1,295.57
$842.55
$906.99
$975.25
$1,217.75
$1,207.73
$1,272.17
$1,340.43
$1,582.93
$1,572.91
$1,637.35
$1,705.61
$1,948.11
$365.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.74
$1,083.62
$1,220.14
$1,705.14
$2,591.14
$1,319.92
$1,448.80
$1,585.32
$2,070.32
$1,685.10
$1,813.98
$1,950.50
$2,435.50
$2,050.28
$2,179.16
$2,315.68
$2,800.68
$365.18
Toc - Plan #67 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$413.92
$469.79
$528.98
$739.25
$1,123.36
$730.56
$786.43
$845.62
$1,055.89
$1,047.20
$1,103.07
$1,162.26
$1,372.53
$1,363.84
$1,419.71
$1,478.90
$1,689.17
$316.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$827.84
$939.58
$1,057.96
$1,478.50
$2,246.72
$1,144.48
$1,256.22
$1,374.60
$1,795.14
$1,461.12
$1,572.86
$1,691.24
$2,111.78
$1,777.76
$1,889.50
$2,007.88
$2,428.42
$316.64
Toc - Plan #68 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic Standard

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$456.93
$518.60
$583.94
$816.05
$1,240.07
$806.47
$868.14
$933.48
$1,165.59
$1,156.01
$1,217.68
$1,283.02
$1,515.13
$1,505.55
$1,567.22
$1,632.56
$1,864.67
$349.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$913.86
$1,037.20
$1,167.88
$1,632.10
$2,480.14
$1,263.40
$1,386.74
$1,517.42
$1,981.64
$1,612.94
$1,736.28
$1,866.96
$2,331.18
$1,962.48
$2,085.82
$2,216.50
$2,680.72
$349.54
Toc - Plan #69 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic Standard

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$532.07
$603.89
$679.97
$950.26
$1,444.01
$939.10
$1,010.92
$1,087.00
$1,357.29
$1,346.13
$1,417.95
$1,494.03
$1,764.32
$1,753.16
$1,824.98
$1,901.06
$2,171.35
$407.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,064.14
$1,207.78
$1,359.94
$1,900.52
$2,888.02
$1,471.17
$1,614.81
$1,766.97
$2,307.55
$1,878.20
$2,021.84
$2,174.00
$2,714.58
$2,285.23
$2,428.87
$2,581.03
$3,121.61
$407.03

ADVERTISEMENT

SummaCare

Local: 1-330-996-8675 | Toll Free: 1-888-996-8675 | TTY: 1-800-750-0750

Toc - Plan #70 SummaCare
Catastrophic

(HMO) SummaCare Value with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$206.02
$233.83
$263.29
$367.95
$559.13
$363.62
$391.43
$420.89
$525.55
$521.22
$549.03
$578.49
$683.15
$678.82
$706.63
$736.09
$840.75
$157.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$412.04
$467.66
$526.58
$735.90
$1,118.26
$569.64
$625.26
$684.18
$893.50
$727.24
$782.86
$841.78
$1,051.10
$884.84
$940.46
$999.38
$1,208.70
$157.60
Toc - Plan #71 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$260.20
$295.32
$332.53
$464.71
$706.17
$459.25
$494.37
$531.58
$663.76
$658.30
$693.42
$730.63
$862.81
$857.35
$892.47
$929.68
$1,061.86
$199.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$520.40
$590.64
$665.06
$929.42
$1,412.34
$719.45
$789.69
$864.11
$1,128.47
$918.50
$988.74
$1,063.16
$1,327.52
$1,117.55
$1,187.79
$1,262.21
$1,526.57
$199.05
Toc - Plan #72 SummaCare
Gold

(HMO) SummaCare Gold 2000 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$398.79
$452.63
$509.66
$712.24
$1,082.32
$703.87
$757.71
$814.74
$1,017.32
$1,008.95
$1,062.79
$1,119.82
$1,322.40
$1,314.03
$1,367.87
$1,424.90
$1,627.48
$305.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797.58
$905.26
$1,019.32
$1,424.48
$2,164.64
$1,102.66
$1,210.34
$1,324.40
$1,729.56
$1,407.74
$1,515.42
$1,629.48
$2,034.64
$1,712.82
$1,820.50
$1,934.56
$2,339.72
$305.08
Toc - Plan #73 SummaCare
Silver

(HMO) SummaCare Silver 6000 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$328.06
$372.35
$419.26
$585.92
$890.36
$579.03
$623.32
$670.23
$836.89
$830.00
$874.29
$921.20
$1,087.86
$1,080.97
$1,125.26
$1,172.17
$1,338.83
$250.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.12
$744.70
$838.52
$1,171.84
$1,780.72
$907.09
$995.67
$1,089.49
$1,422.81
$1,158.06
$1,246.64
$1,340.46
$1,673.78
$1,409.03
$1,497.61
$1,591.43
$1,924.75
$250.97
Toc - Plan #74 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 9450 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$260.02
$295.12
$332.31
$464.40
$705.70
$458.94
$494.04
$531.23
$663.32
$657.86
$692.96
$730.15
$862.24
$856.78
$891.88
$929.07
$1,061.16
$198.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$520.04
$590.24
$664.62
$928.80
$1,411.40
$718.96
$789.16
$863.54
$1,127.72
$917.88
$988.08
$1,062.46
$1,326.64
$1,116.80
$1,187.00
$1,261.38
$1,525.56
$198.92
Toc - Plan #75 SummaCare
Bronze

(HMO) SummaCare Bronze 8000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,450 $18,900 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
$249.65
$283.36
$319.06
$445.88
$677.56
$440.64
$474.35
$510.05
$636.87
$631.63
$665.34
$701.04
$827.86
$822.62
$856.33
$892.03
$1,018.85
$190.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$499.30
$566.72
$638.12
$891.76
$1,355.12
$690.29
$757.71
$829.11
$1,082.75
$881.28
$948.70
$1,020.10
$1,273.74
$1,072.27
$1,139.69
$1,211.09
$1,464.73
$190.99
Toc - Plan #76 SummaCare
Silver

(HMO) SummaCare Silver 5000 1000 Rx with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$326.30
$370.36
$417.02
$582.78
$885.59
$575.92
$619.98
$666.64
$832.40
$825.54
$869.60
$916.26
$1,082.02
$1,075.16
$1,119.22
$1,165.88
$1,331.64
$249.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652.60
$740.72
$834.04
$1,165.56
$1,771.18
$902.22
$990.34
$1,083.66
$1,415.18
$1,151.84
$1,239.96
$1,333.28
$1,664.80
$1,401.46
$1,489.58
$1,582.90
$1,914.42
$249.62
Toc - Plan #77 SummaCare
Gold

(HMO) SummaCare Gold 2000 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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
$398.15
$451.90
$508.83
$711.09
$1,080.57
$702.73
$756.48
$813.41
$1,015.67
$1,007.31
$1,061.06
$1,117.99
$1,320.25
$1,311.89
$1,365.64
$1,422.57
$1,624.83
$304.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.30
$903.80
$1,017.66
$1,422.18
$2,161.14
$1,100.88
$1,208.38
$1,322.24
$1,726.76
$1,405.46
$1,512.96
$1,626.82
$2,031.34
$1,710.04
$1,817.54
$1,931.40
$2,335.92
$304.58
Toc - Plan #78 SummaCare
Silver

(HMO) SummaCare Silver 3500 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 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
$336.12
$381.50
$429.56
$600.31
$912.23
$593.25
$638.63
$686.69
$857.44
$850.38
$895.76
$943.82
$1,114.57
$1,107.51
$1,152.89
$1,200.95
$1,371.70
$257.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.24
$763.00
$859.12
$1,200.62
$1,824.46
$929.37
$1,020.13
$1,116.25
$1,457.75
$1,186.50
$1,277.26
$1,373.38
$1,714.88
$1,443.63
$1,534.39
$1,630.51
$1,972.01
$257.13
Toc - Plan #79 SummaCare
Silver

(HMO) SummaCare Silver 7000 with 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,190 $16,380 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.66
$367.36
$413.64
$578.06
$878.42
$571.26
$614.96
$661.24
$825.66
$818.86
$862.56
$908.84
$1,073.26
$1,066.46
$1,110.16
$1,156.44
$1,320.86
$247.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.32
$734.72
$827.28
$1,156.12
$1,756.84
$894.92
$982.32
$1,074.88
$1,403.72
$1,142.52
$1,229.92
$1,322.48
$1,651.32
$1,390.12
$1,477.52
$1,570.08
$1,898.92
$247.60
Toc - Plan #80 SummaCare
Expanded Bronze

(HMO) SummaCare Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$268.93
$305.23
$343.69
$480.31
$729.87
$474.66
$510.96
$549.42
$686.04
$680.39
$716.69
$755.15
$891.77
$886.12
$922.42
$960.88
$1,097.50
$205.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.86
$610.46
$687.38
$960.62
$1,459.74
$743.59
$816.19
$893.11
$1,166.35
$949.32
$1,021.92
$1,098.84
$1,372.08
$1,155.05
$1,227.65
$1,304.57
$1,577.81
$205.73
Toc - Plan #81 SummaCare
Bronze

(HMO) SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,450 $18,900 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
$249.83
$283.56
$319.28
$446.20
$678.04
$440.95
$474.68
$510.40
$637.32
$632.07
$665.80
$701.52
$828.44
$823.19
$856.92
$892.64
$1,019.56
$191.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$499.66
$567.12
$638.56
$892.40
$1,356.08
$690.78
$758.24
$829.68
$1,083.52
$881.90
$949.36
$1,020.80
$1,274.64
$1,073.02
$1,140.48
$1,211.92
$1,465.76
$191.12
Toc - Plan #82 SummaCare
Silver

(HMO) SummaCare Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$331.23
$375.95
$423.32
$591.58
$898.97
$584.62
$629.34
$676.71
$844.97
$838.01
$882.73
$930.10
$1,098.36
$1,091.40
$1,136.12
$1,183.49
$1,351.75
$253.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$662.46
$751.90
$846.64
$1,183.16
$1,797.94
$915.85
$1,005.29
$1,100.03
$1,436.55
$1,169.24
$1,258.68
$1,353.42
$1,689.94
$1,422.63
$1,512.07
$1,606.81
$1,943.33
$253.39
Toc - Plan #83 SummaCare
Gold

(HMO) SummaCare Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$403.09
$457.50
$515.14
$719.91
$1,093.98
$711.45
$765.86
$823.50
$1,028.27
$1,019.81
$1,074.22
$1,131.86
$1,336.63
$1,328.17
$1,382.58
$1,440.22
$1,644.99
$308.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.18
$915.00
$1,030.28
$1,439.82
$2,187.96
$1,114.54
$1,223.36
$1,338.64
$1,748.18
$1,422.90
$1,531.72
$1,647.00
$2,056.54
$1,731.26
$1,840.08
$1,955.36
$2,364.90
$308.36

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-750-0750

Toc - Plan #84 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.57
$410.37
$462.08
$645.75
$981.28
$638.17
$686.97
$738.68
$922.35
$914.77
$963.57
$1,015.28
$1,198.95
$1,191.37
$1,240.17
$1,291.88
$1,475.55
$276.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.14
$820.74
$924.16
$1,291.50
$1,962.56
$999.74
$1,097.34
$1,200.76
$1,568.10
$1,276.34
$1,373.94
$1,477.36
$1,844.70
$1,552.94
$1,650.54
$1,753.96
$2,121.30
$276.60
Toc - Plan #85 CareSource
Gold

(HMO) CareSource Marketplace Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$577.06
$654.96
$737.48
$1,030.62
$1,566.13
$1,018.51
$1,096.41
$1,178.93
$1,472.07
$1,459.96
$1,537.86
$1,620.38
$1,913.52
$1,901.41
$1,979.31
$2,061.83
$2,354.97
$441.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,154.12
$1,309.92
$1,474.96
$2,061.24
$3,132.26
$1,595.57
$1,751.37
$1,916.41
$2,502.69
$2,037.02
$2,192.82
$2,357.86
$2,944.14
$2,478.47
$2,634.27
$2,799.31
$3,385.59
$441.45
Toc - Plan #86 CareSource
Silver

(HMO) CareSource Marketplace Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.66
$403.67
$454.53
$635.21
$965.26
$627.74
$675.75
$726.61
$907.29
$899.82
$947.83
$998.69
$1,179.37
$1,171.90
$1,219.91
$1,270.77
$1,451.45
$272.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.32
$807.34
$909.06
$1,270.42
$1,930.52
$983.40
$1,079.42
$1,181.14
$1,542.50
$1,255.48
$1,351.50
$1,453.22
$1,814.58
$1,527.56
$1,623.58
$1,725.30
$2,086.66
$272.08
Toc - Plan #87 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$286.14
$324.77
$365.69
$511.05
$776.59
$505.04
$543.67
$584.59
$729.95
$723.94
$762.57
$803.49
$948.85
$942.84
$981.47
$1,022.39
$1,167.75
$218.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.28
$649.54
$731.38
$1,022.10
$1,553.18
$791.18
$868.44
$950.28
$1,241.00
$1,010.08
$1,087.34
$1,169.18
$1,459.90
$1,228.98
$1,306.24
$1,388.08
$1,678.80
$218.90
Toc - Plan #88 CareSource
Silver

(HMO) CareSource Marketplace Diabetes Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 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
$375.35
$426.01
$479.69
$670.36
$1,018.68
$662.49
$713.15
$766.83
$957.50
$949.63
$1,000.29
$1,053.97
$1,244.64
$1,236.77
$1,287.43
$1,341.11
$1,531.78
$287.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.70
$852.02
$959.38
$1,340.72
$2,037.36
$1,037.84
$1,139.16
$1,246.52
$1,627.86
$1,324.98
$1,426.30
$1,533.66
$1,915.00
$1,612.12
$1,713.44
$1,820.80
$2,202.14
$287.14
Toc - Plan #89 CareSource
Gold

(HMO) CareSource Marketplace Diabetes Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$591.11
$670.91
$755.44
$1,055.72
$1,604.27
$1,043.31
$1,123.11
$1,207.64
$1,507.92
$1,495.51
$1,575.31
$1,659.84
$1,960.12
$1,947.71
$2,027.51
$2,112.04
$2,412.32
$452.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,182.22
$1,341.82
$1,510.88
$2,111.44
$3,208.54
$1,634.42
$1,794.02
$1,963.08
$2,563.64
$2,086.62
$2,246.22
$2,415.28
$3,015.84
$2,538.82
$2,698.42
$2,867.48
$3,468.04
$452.20
Toc - Plan #90 CareSource
Gold

(HMO) CareSource Marketplace Core Gold

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$539.10
$611.87
$688.96
$962.82
$1,463.11
$951.51
$1,024.28
$1,101.37
$1,375.23
$1,363.92
$1,436.69
$1,513.78
$1,787.64
$1,776.33
$1,849.10
$1,926.19
$2,200.05
$412.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,078.20
$1,223.74
$1,377.92
$1,925.64
$2,926.22
$1,490.61
$1,636.15
$1,790.33
$2,338.05
$1,903.02
$2,048.56
$2,202.74
$2,750.46
$2,315.43
$2,460.97
$2,615.15
$3,162.87
$412.41
Toc - Plan #91 CareSource
Silver

(HMO) CareSource Marketplace Core Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.04
$416.58
$469.07
$655.52
$996.13
$647.82
$697.36
$749.85
$936.30
$928.60
$978.14
$1,030.63
$1,217.08
$1,209.38
$1,258.92
$1,311.41
$1,497.86
$280.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.08
$833.16
$938.14
$1,311.04
$1,992.26
$1,014.86
$1,113.94
$1,218.92
$1,591.82
$1,295.64
$1,394.72
$1,499.70
$1,872.60
$1,576.42
$1,675.50
$1,780.48
$2,153.38
$280.78
Toc - Plan #92 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.40
$415.87
$468.26
$654.39
$994.41
$646.70
$696.17
$748.56
$934.69
$927.00
$976.47
$1,028.86
$1,214.99
$1,207.30
$1,256.77
$1,309.16
$1,495.29
$280.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.80
$831.74
$936.52
$1,308.78
$1,988.82
$1,013.10
$1,112.04
$1,216.82
$1,589.08
$1,293.40
$1,392.34
$1,497.12
$1,869.38
$1,573.70
$1,672.64
$1,777.42
$2,149.68
$280.30
Toc - Plan #93 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$583.68
$662.47
$745.93
$1,042.44
$1,584.09
$1,030.19
$1,108.98
$1,192.44
$1,488.95
$1,476.70
$1,555.49
$1,638.95
$1,935.46
$1,923.21
$2,002.00
$2,085.46
$2,381.97
$446.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,167.36
$1,324.94
$1,491.86
$2,084.88
$3,168.18
$1,613.87
$1,771.45
$1,938.37
$2,531.39
$2,060.38
$2,217.96
$2,384.88
$2,977.90
$2,506.89
$2,664.47
$2,831.39
$3,424.41
$446.51
Toc - Plan #94 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.50
$409.17
$460.72
$643.85
$978.39
$636.28
$684.95
$736.50
$919.63
$912.06
$960.73
$1,012.28
$1,195.41
$1,187.84
$1,236.51
$1,288.06
$1,471.19
$275.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.00
$818.34
$921.44
$1,287.70
$1,956.78
$996.78
$1,094.12
$1,197.22
$1,563.48
$1,272.56
$1,369.90
$1,473.00
$1,839.26
$1,548.34
$1,645.68
$1,748.78
$2,115.04
$275.78
Toc - Plan #95 CareSource
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$290.77
$330.02
$371.60
$519.31
$789.14
$513.21
$552.46
$594.04
$741.75
$735.65
$774.90
$816.48
$964.19
$958.09
$997.34
$1,038.92
$1,186.63
$222.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$581.54
$660.04
$743.20
$1,038.62
$1,578.28
$803.98
$882.48
$965.64
$1,261.06
$1,026.42
$1,104.92
$1,188.08
$1,483.50
$1,248.86
$1,327.36
$1,410.52
$1,705.94
$222.44
Toc - Plan #96 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 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
$380.18
$431.50
$485.87
$679.00
$1,031.81
$671.02
$722.34
$776.71
$969.84
$961.86
$1,013.18
$1,067.55
$1,260.68
$1,252.70
$1,304.02
$1,358.39
$1,551.52
$290.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.36
$863.00
$971.74
$1,358.00
$2,063.62
$1,051.20
$1,153.84
$1,262.58
$1,648.84
$1,342.04
$1,444.68
$1,553.42
$1,939.68
$1,632.88
$1,735.52
$1,844.26
$2,230.52
$290.84
Toc - Plan #97 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$597.73
$678.42
$763.90
$1,067.54
$1,622.23
$1,054.99
$1,135.68
$1,221.16
$1,524.80
$1,512.25
$1,592.94
$1,678.42
$1,982.06
$1,969.51
$2,050.20
$2,135.68
$2,439.32
$457.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,195.46
$1,356.84
$1,527.80
$2,135.08
$3,244.46
$1,652.72
$1,814.10
$1,985.06
$2,592.34
$2,109.98
$2,271.36
$2,442.32
$3,049.60
$2,567.24
$2,728.62
$2,899.58
$3,506.86
$457.26
Toc - Plan #98 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$545.72
$619.39
$697.42
$974.65
$1,481.07
$963.19
$1,036.86
$1,114.89
$1,392.12
$1,380.66
$1,454.33
$1,532.36
$1,809.59
$1,798.13
$1,871.80
$1,949.83
$2,227.06
$417.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,091.44
$1,238.78
$1,394.84
$1,949.30
$2,962.14
$1,508.91
$1,656.25
$1,812.31
$2,366.77
$1,926.38
$2,073.72
$2,229.78
$2,784.24
$2,343.85
$2,491.19
$2,647.25
$3,201.71
$417.47
Toc - Plan #99 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$371.88
$422.08
$475.25
$664.16
$1,009.26
$656.36
$706.56
$759.73
$948.64
$940.84
$991.04
$1,044.21
$1,233.12
$1,225.32
$1,275.52
$1,328.69
$1,517.60
$284.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$743.76
$844.16
$950.50
$1,328.32
$2,018.52
$1,028.24
$1,128.64
$1,234.98
$1,612.80
$1,312.72
$1,413.12
$1,519.46
$1,897.28
$1,597.20
$1,697.60
$1,803.94
$2,181.76
$284.48

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Aetna CVS Health

Local: 1-888-438-8581 | Toll Free: 1-877-336-3915

Toc - Plan #100 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 2 HSA: Aetna network of doctors & hospitals + MinuteClinic + Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.69
$358.31
$403.45
$563.82
$856.78
$557.20
$599.82
$644.96
$805.33
$798.71
$841.33
$886.47
$1,046.84
$1,040.22
$1,082.84
$1,127.98
$1,288.35
$241.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.38
$716.62
$806.90
$1,127.64
$1,713.56
$872.89
$958.13
$1,048.41
$1,369.15
$1,114.40
$1,199.64
$1,289.92
$1,610.66
$1,355.91
$1,441.15
$1,531.43
$1,852.17
$241.51
Toc - Plan #101 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 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
$336.13
$381.50
$429.57
$600.32
$912.24
$593.27
$638.64
$686.71
$857.46
$850.41
$895.78
$943.85
$1,114.60
$1,107.55
$1,152.92
$1,200.99
$1,371.74
$257.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$672.26
$763.00
$859.14
$1,200.64
$1,824.48
$929.40
$1,020.14
$1,116.28
$1,457.78
$1,186.54
$1,277.28
$1,373.42
$1,714.92
$1,443.68
$1,534.42
$1,630.56
$1,972.06
$257.14
Toc - Plan #102 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$321.45
$364.85
$410.81
$574.11
$872.41
$567.36
$610.76
$656.72
$820.02
$813.27
$856.67
$902.63
$1,065.93
$1,059.18
$1,102.58
$1,148.54
$1,311.84
$245.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.90
$729.70
$821.62
$1,148.22
$1,744.82
$888.81
$975.61
$1,067.53
$1,394.13
$1,134.72
$1,221.52
$1,313.44
$1,640.04
$1,380.63
$1,467.43
$1,559.35
$1,885.95
$245.91
Toc - Plan #103 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$466.94
$529.97
$596.74
$833.95
$1,267.26
$824.15
$887.18
$953.95
$1,191.16
$1,181.36
$1,244.39
$1,311.16
$1,548.37
$1,538.57
$1,601.60
$1,668.37
$1,905.58
$357.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$933.88
$1,059.94
$1,193.48
$1,667.90
$2,534.52
$1,291.09
$1,417.15
$1,550.69
$2,025.11
$1,648.30
$1,774.36
$1,907.90
$2,382.32
$2,005.51
$2,131.57
$2,265.11
$2,739.53
$357.21
Toc - Plan #104 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$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
$469.21
$532.55
$599.64
$838.00
$1,273.42
$828.15
$891.49
$958.58
$1,196.94
$1,187.09
$1,250.43
$1,317.52
$1,555.88
$1,546.03
$1,609.37
$1,676.46
$1,914.82
$358.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$938.42
$1,065.10
$1,199.28
$1,676.00
$2,546.84
$1,297.36
$1,424.04
$1,558.22
$2,034.94
$1,656.30
$1,782.98
$1,917.16
$2,393.88
$2,015.24
$2,141.92
$2,276.10
$2,752.82
$358.94
Toc - Plan #105 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$8,395 $16,790 Annual Deductible
$8,885 $17,770 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.34
$435.09
$489.91
$684.65
$1,040.38
$676.60
$728.35
$783.17
$977.91
$969.86
$1,021.61
$1,076.43
$1,271.17
$1,263.12
$1,314.87
$1,369.69
$1,564.43
$293.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$766.68
$870.18
$979.82
$1,369.30
$2,080.76
$1,059.94
$1,163.44
$1,273.08
$1,662.56
$1,353.20
$1,456.70
$1,566.34
$1,955.82
$1,646.46
$1,749.96
$1,859.60
$2,249.08
$293.26
Toc - Plan #106 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.39
$444.23
$500.19
$699.02
$1,062.22
$690.80
$743.64
$799.60
$998.43
$990.21
$1,043.05
$1,099.01
$1,297.84
$1,289.62
$1,342.46
$1,398.42
$1,597.25
$299.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.78
$888.46
$1,000.38
$1,398.04
$2,124.44
$1,082.19
$1,187.87
$1,299.79
$1,697.45
$1,381.60
$1,487.28
$1,599.20
$1,996.86
$1,681.01
$1,786.69
$1,898.61
$2,296.27
$299.41
Toc - Plan #107 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.55
$444.40
$500.40
$699.30
$1,062.65
$691.08
$743.93
$799.93
$998.83
$990.61
$1,043.46
$1,099.46
$1,298.36
$1,290.14
$1,342.99
$1,398.99
$1,597.89
$299.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.10
$888.80
$1,000.80
$1,398.60
$2,125.30
$1,082.63
$1,188.33
$1,300.33
$1,698.13
$1,382.16
$1,487.86
$1,599.86
$1,997.66
$1,681.69
$1,787.39
$1,899.39
$2,297.19
$299.53
Toc - Plan #108 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.50
$435.27
$490.11
$684.93
$1,040.81
$676.88
$728.65
$783.49
$978.31
$970.26
$1,022.03
$1,076.87
$1,271.69
$1,263.64
$1,315.41
$1,370.25
$1,565.07
$293.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.00
$870.54
$980.22
$1,369.86
$2,081.62
$1,060.38
$1,163.92
$1,273.60
$1,663.24
$1,353.76
$1,457.30
$1,566.98
$1,956.62
$1,647.14
$1,750.68
$1,860.36
$2,250.00
$293.38

ADVERTISEMENT

MedMutual

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

Toc - Plan #109 MedMutual
Gold

(HMO) Market HMO 2500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$499.62
$567.07
$638.51
$892.32
$1,355.96
$881.83
$949.28
$1,020.72
$1,274.53
$1,264.04
$1,331.49
$1,402.93
$1,656.74
$1,646.25
$1,713.70
$1,785.14
$2,038.95
$382.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$999.24
$1,134.14
$1,277.02
$1,784.64
$2,711.92
$1,381.45
$1,516.35
$1,659.23
$2,166.85
$1,763.66
$1,898.56
$2,041.44
$2,549.06
$2,145.87
$2,280.77
$2,423.65
$2,931.27
$382.21
Toc - Plan #110 MedMutual
Gold

(HMO) Market HMO Standard Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$513.91
$583.29
$656.78
$917.85
$1,394.76
$907.05
$976.43
$1,049.92
$1,310.99
$1,300.19
$1,369.57
$1,443.06
$1,704.13
$1,693.33
$1,762.71
$1,836.20
$2,097.27
$393.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,027.82
$1,166.58
$1,313.56
$1,835.70
$2,789.52
$1,420.96
$1,559.72
$1,706.70
$2,228.84
$1,814.10
$1,952.86
$2,099.84
$2,621.98
$2,207.24
$2,346.00
$2,492.98
$3,015.12
$393.14
Toc - Plan #111 MedMutual
Silver

(HMO) Market HMO 3850

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

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$9,450 $18,900 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
$457.80
$519.61
$585.07
$817.64
$1,242.48
$808.02
$869.83
$935.29
$1,167.86
$1,158.24
$1,220.05
$1,285.51
$1,518.08
$1,508.46
$1,570.27
$1,635.73
$1,868.30
$350.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$915.60
$1,039.22
$1,170.14
$1,635.28
$2,484.96
$1,265.82
$1,389.44
$1,520.36
$1,985.50
$1,616.04
$1,739.66
$1,870.58
$2,335.72
$1,966.26
$2,089.88
$2,220.80
$2,685.94
$350.22
Toc - Plan #112 MedMutual
Silver

(HMO) Market HMO 4000 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$5,850 $11,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$467.10
$530.15
$596.95
$834.23
$1,267.70
$824.43
$887.48
$954.28
$1,191.56
$1,181.76
$1,244.81
$1,311.61
$1,548.89
$1,539.09
$1,602.14
$1,668.94
$1,906.22
$357.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$934.20
$1,060.30
$1,193.90
$1,668.46
$2,535.40
$1,291.53
$1,417.63
$1,551.23
$2,025.79
$1,648.86
$1,774.96
$1,908.56
$2,383.12
$2,006.19
$2,132.29
$2,265.89
$2,740.45
$357.33
Toc - Plan #113 MedMutual
Silver

(HMO) Market HMO Select Silver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$486.04
$551.65
$621.16
$868.06
$1,319.11
$857.86
$923.47
$992.98
$1,239.88
$1,229.68
$1,295.29
$1,364.80
$1,611.70
$1,601.50
$1,667.11
$1,736.62
$1,983.52
$371.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.08
$1,103.30
$1,242.32
$1,736.12
$2,638.22
$1,343.90
$1,475.12
$1,614.14
$2,107.94
$1,715.72
$1,846.94
$1,985.96
$2,479.76
$2,087.54
$2,218.76
$2,357.78
$2,851.58
$371.82
Toc - Plan #114 MedMutual
Silver

(HMO) Market HMO Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$455.66
$517.17
$582.33
$813.81
$1,236.66
$804.24
$865.75
$930.91
$1,162.39
$1,152.82
$1,214.33
$1,279.49
$1,510.97
$1,501.40
$1,562.91
$1,628.07
$1,859.55
$348.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$911.32
$1,034.34
$1,164.66
$1,627.62
$2,473.32
$1,259.90
$1,382.92
$1,513.24
$1,976.20
$1,608.48
$1,731.50
$1,861.82
$2,324.78
$1,957.06
$2,080.08
$2,210.40
$2,673.36
$348.58
Toc - Plan #115 MedMutual
Silver

(HMO) Market HMO 6900

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,450 $18,900 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
$451.37
$512.31
$576.85
$806.15
$1,225.02
$796.67
$857.61
$922.15
$1,151.45
$1,141.97
$1,202.91
$1,267.45
$1,496.75
$1,487.27
$1,548.21
$1,612.75
$1,842.05
$345.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$902.74
$1,024.62
$1,153.70
$1,612.30
$2,450.04
$1,248.04
$1,369.92
$1,499.00
$1,957.60
$1,593.34
$1,715.22
$1,844.30
$2,302.90
$1,938.64
$2,060.52
$2,189.60
$2,648.20
$345.30
Toc - Plan #116 MedMutual
Expanded Bronze

(HMO) Market HMO 7300 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 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
$330.58
$375.21
$422.48
$590.41
$897.19
$583.47
$628.10
$675.37
$843.30
$836.36
$880.99
$928.26
$1,096.19
$1,089.25
$1,133.88
$1,181.15
$1,349.08
$252.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$661.16
$750.42
$844.96
$1,180.82
$1,794.38
$914.05
$1,003.31
$1,097.85
$1,433.71
$1,166.94
$1,256.20
$1,350.74
$1,686.60
$1,419.83
$1,509.09
$1,603.63
$1,939.49
$252.89
Toc - Plan #117 MedMutual
Expanded Bronze

(HMO) Market HMO 8300

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

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$9,450 $18,900 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
$317.35
$360.20
$405.58
$566.79
$861.30
$560.13
$602.98
$648.36
$809.57
$802.91
$845.76
$891.14
$1,052.35
$1,045.69
$1,088.54
$1,133.92
$1,295.13
$242.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.70
$720.40
$811.16
$1,133.58
$1,722.60
$877.48
$963.18
$1,053.94
$1,376.36
$1,120.26
$1,205.96
$1,296.72
$1,619.14
$1,363.04
$1,448.74
$1,539.50
$1,861.92
$242.78
Toc - Plan #118 MedMutual
Expanded Bronze

(HMO) Market HMO Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$341.66
$387.78
$436.64
$610.20
$927.25
$603.03
$649.15
$698.01
$871.57
$864.40
$910.52
$959.38
$1,132.94
$1,125.77
$1,171.89
$1,220.75
$1,394.31
$261.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.32
$775.56
$873.28
$1,220.40
$1,854.50
$944.69
$1,036.93
$1,134.65
$1,481.77
$1,206.06
$1,298.30
$1,396.02
$1,743.14
$1,467.43
$1,559.67
$1,657.39
$2,004.51
$261.37
Toc - Plan #119 MedMutual
Bronze

(HMO) Market HMO 9450

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$314.49
$356.95
$401.92
$561.69
$853.54
$555.08
$597.54
$642.51
$802.28
$795.67
$838.13
$883.10
$1,042.87
$1,036.26
$1,078.72
$1,123.69
$1,283.46
$240.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.98
$713.90
$803.84
$1,123.38
$1,707.08
$869.57
$954.49
$1,044.43
$1,363.97
$1,110.16
$1,195.08
$1,285.02
$1,604.56
$1,350.75
$1,435.67
$1,525.61
$1,845.15
$240.59
Toc - Plan #120 MedMutual
Expanded Bronze

(HMO) Market HMO Select Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$374.53
$425.10
$478.66
$668.92
$1,016.49
$661.05
$711.62
$765.18
$955.44
$947.57
$998.14
$1,051.70
$1,241.96
$1,234.09
$1,284.66
$1,338.22
$1,528.48
$286.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.06
$850.20
$957.32
$1,337.84
$2,032.98
$1,035.58
$1,136.72
$1,243.84
$1,624.36
$1,322.10
$1,423.24
$1,530.36
$1,910.88
$1,608.62
$1,709.76
$1,816.88
$2,197.40
$286.52
Toc - Plan #121 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$205.49
$233.24
$262.62
$367.01
$557.71
$362.69
$390.44
$419.82
$524.21
$519.89
$547.64
$577.02
$681.41
$677.09
$704.84
$734.22
$838.61
$157.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$410.98
$466.48
$525.24
$734.02
$1,115.42
$568.18
$623.68
$682.44
$891.22
$725.38
$780.88
$839.64
$1,048.42
$882.58
$938.08
$996.84
$1,205.62
$157.20
Toc - Plan #122 MedMutual
Gold

(HMO) Market HMO Standard Gold - CLE-Care

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$454.23
$515.55
$580.51
$811.26
$1,232.78
$801.72
$863.04
$928.00
$1,158.75
$1,149.21
$1,210.53
$1,275.49
$1,506.24
$1,496.70
$1,558.02
$1,622.98
$1,853.73
$347.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$908.46
$1,031.10
$1,161.02
$1,622.52
$2,465.56
$1,255.95
$1,378.59
$1,508.51
$1,970.01
$1,603.44
$1,726.08
$1,856.00
$2,317.50
$1,950.93
$2,073.57
$2,203.49
$2,664.99
$347.49
Toc - Plan #123 MedMutual
Silver

(HMO) Market HMO Standard Silver - CLE-Care

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$402.77
$457.14
$514.74
$719.34
$1,093.11
$710.89
$765.26
$822.86
$1,027.46
$1,019.01
$1,073.38
$1,130.98
$1,335.58
$1,327.13
$1,381.50
$1,439.10
$1,643.70
$308.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.54
$914.28
$1,029.48
$1,438.68
$2,186.22
$1,113.66
$1,222.40
$1,337.60
$1,746.80
$1,421.78
$1,530.52
$1,645.72
$2,054.92
$1,729.90
$1,838.64
$1,953.84
$2,363.04
$308.12
Toc - Plan #124 MedMutual
Expanded Bronze

(HMO) Market HMO Standard Expanded Bronze - CLE-Care

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$301.99
$342.75
$385.94
$539.35
$819.59
$533.01
$573.77
$616.96
$770.37
$764.03
$804.79
$847.98
$1,001.39
$995.05
$1,035.81
$1,079.00
$1,232.41
$231.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$603.98
$685.50
$771.88
$1,078.70
$1,639.18
$835.00
$916.52
$1,002.90
$1,309.72
$1,066.02
$1,147.54
$1,233.92
$1,540.74
$1,297.04
$1,378.56
$1,464.94
$1,771.76
$231.02

‡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 Medina County here.

Medina County is in “Rating Area 12” of Ohio.

Currently, there are 124 plans offered in Rating Area 12.

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