Maricopa County, Arizona 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 Maricopa County, AZ.

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, 110 Plans and 2024 Rates for Maricopa County, Arizona

Below, you’ll find a summary of the 110 plans for Maricopa County, Arizona 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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Oscar Health Plan, Inc.

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

Toc - Plan #1 Oscar Health Plan, Inc.
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
$265.23
$301.03
$338.96
$473.69
$719.82
$468.13
$503.93
$541.86
$676.59
$671.03
$706.83
$744.76
$879.49
$873.93
$909.73
$947.66
$1,082.39
$202.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$530.46
$602.06
$677.92
$947.38
$1,439.64
$733.36
$804.96
$880.82
$1,150.28
$936.26
$1,007.86
$1,083.72
$1,353.18
$1,139.16
$1,210.76
$1,286.62
$1,556.08
$202.90
Toc - Plan #2 Oscar Health Plan, Inc.
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
$9,450 $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
$263.39
$298.93
$336.60
$470.39
$714.81
$464.87
$500.41
$538.08
$671.87
$666.35
$701.89
$739.56
$873.35
$867.83
$903.37
$941.04
$1,074.83
$201.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$526.78
$597.86
$673.20
$940.78
$1,429.62
$728.26
$799.34
$874.68
$1,142.26
$929.74
$1,000.82
$1,076.16
$1,343.74
$1,131.22
$1,202.30
$1,277.64
$1,545.22
$201.48
Toc - Plan #3 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite + PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $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
$295.53
$335.42
$377.67
$527.80
$802.04
$521.60
$561.49
$603.74
$753.87
$747.67
$787.56
$829.81
$979.94
$973.74
$1,013.63
$1,055.88
$1,206.01
$226.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.06
$670.84
$755.34
$1,055.60
$1,604.08
$817.13
$896.91
$981.41
$1,281.67
$1,043.20
$1,122.98
$1,207.48
$1,507.74
$1,269.27
$1,349.05
$1,433.55
$1,733.81
$226.07
Toc - Plan #4 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,250 $10,500 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
$315.02
$357.53
$402.58
$562.60
$854.93
$556.00
$598.51
$643.56
$803.58
$796.98
$839.49
$884.54
$1,044.56
$1,037.96
$1,080.47
$1,125.52
$1,285.54
$240.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.04
$715.06
$805.16
$1,125.20
$1,709.86
$871.02
$956.04
$1,046.14
$1,366.18
$1,112.00
$1,197.02
$1,287.12
$1,607.16
$1,352.98
$1,438.00
$1,528.10
$1,848.14
$240.98
Toc - Plan #5 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple Specialist Saver with COPD

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309.82
$351.63
$395.93
$553.31
$840.82
$546.82
$588.63
$632.93
$790.31
$783.82
$825.63
$869.93
$1,027.31
$1,020.82
$1,062.63
$1,106.93
$1,264.31
$237.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619.64
$703.26
$791.86
$1,106.62
$1,681.64
$856.64
$940.26
$1,028.86
$1,343.62
$1,093.64
$1,177.26
$1,265.86
$1,580.62
$1,330.64
$1,414.26
$1,502.86
$1,817.62
$237.00
Toc - Plan #6 Oscar Health Plan, Inc.
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
$204.37
$231.94
$261.17
$364.98
$554.62
$360.70
$388.27
$417.50
$521.31
$517.03
$544.60
$573.83
$677.64
$673.36
$700.93
$730.16
$833.97
$156.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$408.74
$463.88
$522.34
$729.96
$1,109.24
$565.07
$620.21
$678.67
$886.29
$721.40
$776.54
$835.00
$1,042.62
$877.73
$932.87
$991.33
$1,198.95
$156.33
Toc - Plan #7 Oscar Health Plan, Inc.
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
$385.39
$437.40
$492.51
$688.28
$1,045.92
$680.20
$732.21
$787.32
$983.09
$975.01
$1,027.02
$1,082.13
$1,277.90
$1,269.82
$1,321.83
$1,376.94
$1,572.71
$294.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.78
$874.80
$985.02
$1,376.56
$2,091.84
$1,065.59
$1,169.61
$1,279.83
$1,671.37
$1,360.40
$1,464.42
$1,574.64
$1,966.18
$1,655.21
$1,759.23
$1,869.45
$2,260.99
$294.81
Toc - Plan #8 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic 4700

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$270.66
$307.19
$345.90
$483.39
$734.56
$477.71
$514.24
$552.95
$690.44
$684.76
$721.29
$760.00
$897.49
$891.81
$928.34
$967.05
$1,104.54
$207.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$541.32
$614.38
$691.80
$966.78
$1,469.12
$748.37
$821.43
$898.85
$1,173.83
$955.42
$1,028.48
$1,105.90
$1,380.88
$1,162.47
$1,235.53
$1,312.95
$1,587.93
$207.05
Toc - Plan #9 Oscar Health Plan, Inc.
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
$305.45
$346.67
$390.35
$545.51
$828.96
$539.11
$580.33
$624.01
$779.17
$772.77
$813.99
$857.67
$1,012.83
$1,006.43
$1,047.65
$1,091.33
$1,246.49
$233.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.90
$693.34
$780.70
$1,091.02
$1,657.92
$844.56
$927.00
$1,014.36
$1,324.68
$1,078.22
$1,160.66
$1,248.02
$1,558.34
$1,311.88
$1,394.32
$1,481.68
$1,792.00
$233.66
Toc - Plan #10 Oscar Health Plan, Inc.
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
$323.51
$367.17
$413.43
$577.77
$877.98
$570.99
$614.65
$660.91
$825.25
$818.47
$862.13
$908.39
$1,072.73
$1,065.95
$1,109.61
$1,155.87
$1,320.21
$247.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.02
$734.34
$826.86
$1,155.54
$1,755.96
$894.50
$981.82
$1,074.34
$1,403.02
$1,141.98
$1,229.30
$1,321.82
$1,650.50
$1,389.46
$1,476.78
$1,569.30
$1,897.98
$247.48
Toc - Plan #11 Oscar Health Plan, Inc.
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
$264.74
$300.47
$338.32
$472.80
$718.47
$467.26
$502.99
$540.84
$675.32
$669.78
$705.51
$743.36
$877.84
$872.30
$908.03
$945.88
$1,080.36
$202.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$529.48
$600.94
$676.64
$945.60
$1,436.94
$732.00
$803.46
$879.16
$1,148.12
$934.52
$1,005.98
$1,081.68
$1,350.64
$1,137.04
$1,208.50
$1,284.20
$1,553.16
$202.52
Toc - Plan #12 Oscar Health Plan, Inc.
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
$302.25
$343.04
$386.26
$539.80
$820.28
$533.46
$574.25
$617.47
$771.01
$764.67
$805.46
$848.68
$1,002.22
$995.88
$1,036.67
$1,079.89
$1,233.43
$231.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.50
$686.08
$772.52
$1,079.60
$1,640.56
$835.71
$917.29
$1,003.73
$1,310.81
$1,066.92
$1,148.50
$1,234.94
$1,542.02
$1,298.13
$1,379.71
$1,466.15
$1,773.23
$231.21
Toc - Plan #13 Oscar Health Plan, Inc.
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
$372.18
$422.41
$475.63
$664.69
$1,010.06
$656.89
$707.12
$760.34
$949.40
$941.60
$991.83
$1,045.05
$1,234.11
$1,226.31
$1,276.54
$1,329.76
$1,518.82
$284.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$744.36
$844.82
$951.26
$1,329.38
$2,020.12
$1,029.07
$1,129.53
$1,235.97
$1,614.09
$1,313.78
$1,414.24
$1,520.68
$1,898.80
$1,598.49
$1,698.95
$1,805.39
$2,183.51
$284.71

ADVERTISEMENT

BannerAetna

Local: 1-866-365-7374 | Toll Free: 1-844-365-7374

Toc - Plan #14 BannerAetna
Expanded Bronze

(HMO) BannerAetna Bronze 2 HSA: No PCP required + MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$240.96
$273.49
$307.94
$430.34
$653.95
$425.29
$457.82
$492.27
$614.67
$609.62
$642.15
$676.60
$799.00
$793.95
$826.48
$860.93
$983.33
$184.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$481.92
$546.98
$615.88
$860.68
$1,307.90
$666.25
$731.31
$800.21
$1,045.01
$850.58
$915.64
$984.54
$1,229.34
$1,034.91
$1,099.97
$1,168.87
$1,413.67
$184.33
Toc - Plan #15 BannerAetna
Silver

(HMO) BannerAetna Silver 2: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$294.51
$334.27
$376.38
$525.99
$799.30
$519.81
$559.57
$601.68
$751.29
$745.11
$784.87
$826.98
$976.59
$970.41
$1,010.17
$1,052.28
$1,201.89
$225.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.02
$668.54
$752.76
$1,051.98
$1,598.60
$814.32
$893.84
$978.06
$1,277.28
$1,039.62
$1,119.14
$1,203.36
$1,502.58
$1,264.92
$1,344.44
$1,428.66
$1,727.88
$225.30
Toc - Plan #16 BannerAetna
Expanded Bronze

(HMO) BannerAetna Bronze S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$245.17
$278.27
$313.32
$437.87
$665.38
$432.72
$465.82
$500.87
$625.42
$620.27
$653.37
$688.42
$812.97
$807.82
$840.92
$875.97
$1,000.52
$187.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$490.34
$556.54
$626.64
$875.74
$1,330.76
$677.89
$744.09
$814.19
$1,063.29
$865.44
$931.64
$1,001.74
$1,250.84
$1,052.99
$1,119.19
$1,189.29
$1,438.39
$187.55
Toc - Plan #17 BannerAetna
Gold

(HMO) BannerAetna Gold S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$338.19
$383.84
$432.20
$604.00
$917.83
$596.90
$642.55
$690.91
$862.71
$855.61
$901.26
$949.62
$1,121.42
$1,114.32
$1,159.97
$1,208.33
$1,380.13
$258.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$676.38
$767.68
$864.40
$1,208.00
$1,835.66
$935.09
$1,026.39
$1,123.11
$1,466.71
$1,193.80
$1,285.10
$1,381.82
$1,725.42
$1,452.51
$1,543.81
$1,640.53
$1,984.13
$258.71
Toc - Plan #18 BannerAetna
Silver

(HMO) BannerAetna Silver 4: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,445 $18,890 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
$304.29
$345.37
$388.88
$543.46
$825.83
$537.07
$578.15
$621.66
$776.24
$769.85
$810.93
$854.44
$1,009.02
$1,002.63
$1,043.71
$1,087.22
$1,241.80
$232.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$608.58
$690.74
$777.76
$1,086.92
$1,651.66
$841.36
$923.52
$1,010.54
$1,319.70
$1,074.14
$1,156.30
$1,243.32
$1,552.48
$1,306.92
$1,389.08
$1,476.10
$1,785.26
$232.78
Toc - Plan #19 BannerAetna
Silver

(HMO) BannerAetna Silver S: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$284.74
$323.18
$363.89
$508.54
$772.77
$502.57
$541.01
$581.72
$726.37
$720.40
$758.84
$799.55
$944.20
$938.23
$976.67
$1,017.38
$1,162.03
$217.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.48
$646.36
$727.78
$1,017.08
$1,545.54
$787.31
$864.19
$945.61
$1,234.91
$1,005.14
$1,082.02
$1,163.44
$1,452.74
$1,222.97
$1,299.85
$1,381.27
$1,670.57
$217.83
Toc - Plan #20 BannerAetna
Expanded Bronze

(HMO) BannerAetna Bronze 4: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$270.19
$306.67
$345.30
$482.56
$733.29
$476.89
$513.37
$552.00
$689.26
$683.59
$720.07
$758.70
$895.96
$890.29
$926.77
$965.40
$1,102.66
$206.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$540.38
$613.34
$690.60
$965.12
$1,466.58
$747.08
$820.04
$897.30
$1,171.82
$953.78
$1,026.74
$1,104.00
$1,378.52
$1,160.48
$1,233.44
$1,310.70
$1,585.22
$206.70
Toc - Plan #21 BannerAetna
Gold

(HMO) BannerAetna Gold 3: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$336.79
$382.25
$430.41
$601.50
$914.03
$594.43
$639.89
$688.05
$859.14
$852.07
$897.53
$945.69
$1,116.78
$1,109.71
$1,155.17
$1,203.33
$1,374.42
$257.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$673.58
$764.50
$860.82
$1,203.00
$1,828.06
$931.22
$1,022.14
$1,118.46
$1,460.64
$1,188.86
$1,279.78
$1,376.10
$1,718.28
$1,446.50
$1,537.42
$1,633.74
$1,975.92
$257.64
Toc - Plan #22 BannerAetna
Gold

(HMO) BannerAetna Gold 4: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.35
$387.43
$436.25
$609.65
$926.42
$602.49
$648.57
$697.39
$870.79
$863.63
$909.71
$958.53
$1,131.93
$1,124.77
$1,170.85
$1,219.67
$1,393.07
$261.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.70
$774.86
$872.50
$1,219.30
$1,852.84
$943.84
$1,036.00
$1,133.64
$1,480.44
$1,204.98
$1,297.14
$1,394.78
$1,741.58
$1,466.12
$1,558.28
$1,655.92
$2,002.72
$261.14
Toc - Plan #23 BannerAetna
Silver

(HMO) BannerAetna Silver 5: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$284.54
$322.95
$363.64
$508.19
$772.24
$502.22
$540.63
$581.32
$725.87
$719.90
$758.31
$799.00
$943.55
$937.58
$975.99
$1,016.68
$1,161.23
$217.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.08
$645.90
$727.28
$1,016.38
$1,544.48
$786.76
$863.58
$944.96
$1,234.06
$1,004.44
$1,081.26
$1,162.64
$1,451.74
$1,222.12
$1,298.94
$1,380.32
$1,669.42
$217.68
Toc - Plan #24 BannerAetna
Silver

(HMO) BannerAetna Silver 6: No PCP required + Unlimited $0 MinuteClinic + free 98point6 virtual care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7374

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
$290.42
$329.62
$371.15
$518.68
$788.19
$512.59
$551.79
$593.32
$740.85
$734.76
$773.96
$815.49
$963.02
$956.93
$996.13
$1,037.66
$1,185.19
$222.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.84
$659.24
$742.30
$1,037.36
$1,576.38
$803.01
$881.41
$964.47
$1,259.53
$1,025.18
$1,103.58
$1,186.64
$1,481.70
$1,247.35
$1,325.75
$1,408.81
$1,703.87
$222.17

ADVERTISEMENT

Medica

Local: 1-877-347-0267 | Toll Free: 1-877-347-0267 | TTY: 1-800-676-3777

Toc - Plan #25 Medica
Gold

(HMO) Medica Pinnacle Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$454.78
$516.17
$581.21
$812.23
$1,234.27
$802.69
$864.08
$929.12
$1,160.14
$1,150.60
$1,211.99
$1,277.03
$1,508.05
$1,498.51
$1,559.90
$1,624.94
$1,855.96
$347.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.56
$1,032.34
$1,162.42
$1,624.46
$2,468.54
$1,257.47
$1,380.25
$1,510.33
$1,972.37
$1,605.38
$1,728.16
$1,858.24
$2,320.28
$1,953.29
$2,076.07
$2,206.15
$2,668.19
$347.91
Toc - Plan #26 Medica
Gold

(HMO) Medica Pinnacle Gold Share

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$800 $1,600 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
$475.39
$539.57
$607.55
$849.06
$1,290.22
$839.07
$903.25
$971.23
$1,212.74
$1,202.75
$1,266.93
$1,334.91
$1,576.42
$1,566.43
$1,630.61
$1,698.59
$1,940.10
$363.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$950.78
$1,079.14
$1,215.10
$1,698.12
$2,580.44
$1,314.46
$1,442.82
$1,578.78
$2,061.80
$1,678.14
$1,806.50
$1,942.46
$2,425.48
$2,041.82
$2,170.18
$2,306.14
$2,789.16
$363.68
Toc - Plan #27 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Share Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$294.18
$333.90
$375.96
$525.41
$798.41
$519.23
$558.95
$601.01
$750.46
$744.28
$784.00
$826.06
$975.51
$969.33
$1,009.05
$1,051.11
$1,200.56
$225.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$588.36
$667.80
$751.92
$1,050.82
$1,596.82
$813.41
$892.85
$976.97
$1,275.87
$1,038.46
$1,117.90
$1,202.02
$1,500.92
$1,263.51
$1,342.95
$1,427.07
$1,725.97
$225.05
Toc - Plan #28 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Copay $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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
$294.66
$334.44
$376.58
$526.27
$799.72
$520.08
$559.86
$602.00
$751.69
$745.50
$785.28
$827.42
$977.11
$970.92
$1,010.70
$1,052.84
$1,202.53
$225.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.32
$668.88
$753.16
$1,052.54
$1,599.44
$814.74
$894.30
$978.58
$1,277.96
$1,040.16
$1,119.72
$1,204.00
$1,503.38
$1,265.58
$1,345.14
$1,429.42
$1,728.80
$225.42
Toc - Plan #29 Medica
Silver

(HMO) Medica Pinnacle Silver Copay $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.65
$475.17
$535.04
$747.71
$1,136.22
$738.92
$795.44
$855.31
$1,067.98
$1,059.19
$1,115.71
$1,175.58
$1,388.25
$1,379.46
$1,435.98
$1,495.85
$1,708.52
$320.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$837.30
$950.34
$1,070.08
$1,495.42
$2,272.44
$1,157.57
$1,270.61
$1,390.35
$1,815.69
$1,477.84
$1,590.88
$1,710.62
$2,135.96
$1,798.11
$1,911.15
$2,030.89
$2,456.23
$320.27
Toc - Plan #30 Medica
Gold

(HMO) Medica Pinnacle Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

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
$468.14
$531.34
$598.28
$836.10
$1,270.53
$826.27
$889.47
$956.41
$1,194.23
$1,184.40
$1,247.60
$1,314.54
$1,552.36
$1,542.53
$1,605.73
$1,672.67
$1,910.49
$358.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$936.28
$1,062.68
$1,196.56
$1,672.20
$2,541.06
$1,294.41
$1,420.81
$1,554.69
$2,030.33
$1,652.54
$1,778.94
$1,912.82
$2,388.46
$2,010.67
$2,137.07
$2,270.95
$2,746.59
$358.13
Toc - Plan #31 Medica
Silver

(HMO) Medica Pinnacle Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

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
$417.58
$473.96
$533.67
$745.80
$1,133.32
$737.03
$793.41
$853.12
$1,065.25
$1,056.48
$1,112.86
$1,172.57
$1,384.70
$1,375.93
$1,432.31
$1,492.02
$1,704.15
$319.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.16
$947.92
$1,067.34
$1,491.60
$2,266.64
$1,154.61
$1,267.37
$1,386.79
$1,811.05
$1,474.06
$1,586.82
$1,706.24
$2,130.50
$1,793.51
$1,906.27
$2,025.69
$2,449.95
$319.45
Toc - Plan #32 Medica
Bronze

(HMO) Medica Pinnacle Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 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
$264.71
$300.45
$338.31
$472.78
$718.44
$467.22
$502.96
$540.82
$675.29
$669.73
$705.47
$743.33
$877.80
$872.24
$907.98
$945.84
$1,080.31
$202.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$529.42
$600.90
$676.62
$945.56
$1,436.88
$731.93
$803.41
$879.13
$1,148.07
$934.44
$1,005.92
$1,081.64
$1,350.58
$1,136.95
$1,208.43
$1,284.15
$1,553.09
$202.51
Toc - Plan #33 Medica
Expanded Bronze

(HMO) Medica Pinnacle Expanded Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

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
$275.92
$313.17
$352.63
$492.79
$748.85
$487.00
$524.25
$563.71
$703.87
$698.08
$735.33
$774.79
$914.95
$909.16
$946.41
$985.87
$1,126.03
$211.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.84
$626.34
$705.26
$985.58
$1,497.70
$762.92
$837.42
$916.34
$1,196.66
$974.00
$1,048.50
$1,127.42
$1,407.74
$1,185.08
$1,259.58
$1,338.50
$1,618.82
$211.08

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-482-9045 | Toll Free: 1-877-482-9045 | TTY: 1-877-482-9045

Toc - Plan #34 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$305.40
$346.62
$390.30
$545.44
$828.84
$539.03
$580.25
$623.93
$779.07
$772.66
$813.88
$857.56
$1,012.70
$1,006.29
$1,047.51
$1,091.19
$1,246.33
$233.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.80
$693.24
$780.60
$1,090.88
$1,657.68
$844.43
$926.87
$1,014.23
$1,324.51
$1,078.06
$1,160.50
$1,247.86
$1,558.14
$1,311.69
$1,394.13
$1,481.49
$1,791.77
$233.63
Toc - Plan #35 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$243.03
$275.83
$310.59
$434.05
$659.57
$428.95
$461.75
$496.51
$619.97
$614.87
$647.67
$682.43
$805.89
$800.79
$833.59
$868.35
$991.81
$185.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$486.06
$551.66
$621.18
$868.10
$1,319.14
$671.98
$737.58
$807.10
$1,054.02
$857.90
$923.50
$993.02
$1,239.94
$1,043.82
$1,109.42
$1,178.94
$1,425.86
$185.92
Toc - Plan #36 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$235.12
$266.86
$300.48
$419.92
$638.11
$414.99
$446.73
$480.35
$599.79
$594.86
$626.60
$660.22
$779.66
$774.73
$806.47
$840.09
$959.53
$179.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$470.24
$533.72
$600.96
$839.84
$1,276.22
$650.11
$713.59
$780.83
$1,019.71
$829.98
$893.46
$960.70
$1,199.58
$1,009.85
$1,073.33
$1,140.57
$1,379.45
$179.87
Toc - Plan #37 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$235.70
$267.52
$301.23
$420.96
$639.69
$416.01
$447.83
$481.54
$601.27
$596.32
$628.14
$661.85
$781.58
$776.63
$808.45
$842.16
$961.89
$180.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$471.40
$535.04
$602.46
$841.92
$1,279.38
$651.71
$715.35
$782.77
$1,022.23
$832.02
$895.66
$963.08
$1,202.54
$1,012.33
$1,075.97
$1,143.39
$1,382.85
$180.31
Toc - Plan #38 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$373.82
$424.29
$477.74
$667.64
$1,014.55
$659.79
$710.26
$763.71
$953.61
$945.76
$996.23
$1,049.68
$1,239.58
$1,231.73
$1,282.20
$1,335.65
$1,525.55
$285.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.64
$848.58
$955.48
$1,335.28
$2,029.10
$1,033.61
$1,134.55
$1,241.45
$1,621.25
$1,319.58
$1,420.52
$1,527.42
$1,907.22
$1,605.55
$1,706.49
$1,813.39
$2,193.19
$285.97
Toc - Plan #39 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$382.22
$433.82
$488.48
$682.65
$1,037.36
$674.62
$726.22
$780.88
$975.05
$967.02
$1,018.62
$1,073.28
$1,267.45
$1,259.42
$1,311.02
$1,365.68
$1,559.85
$292.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.44
$867.64
$976.96
$1,365.30
$2,074.72
$1,056.84
$1,160.04
$1,269.36
$1,657.70
$1,349.24
$1,452.44
$1,561.76
$1,950.10
$1,641.64
$1,744.84
$1,854.16
$2,242.50
$292.40
Toc - Plan #40 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: 1-877-482-9045

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
$303.57
$344.55
$387.96
$542.18
$823.89
$535.80
$576.78
$620.19
$774.41
$768.03
$809.01
$852.42
$1,006.64
$1,000.26
$1,041.24
$1,084.65
$1,238.87
$232.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607.14
$689.10
$775.92
$1,084.36
$1,647.78
$839.37
$921.33
$1,008.15
$1,316.59
$1,071.60
$1,153.56
$1,240.38
$1,548.82
$1,303.83
$1,385.79
$1,472.61
$1,781.05
$232.23
Toc - Plan #41 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$306.22
$347.57
$391.36
$546.92
$831.09
$540.48
$581.83
$625.62
$781.18
$774.74
$816.09
$859.88
$1,015.44
$1,009.00
$1,050.35
$1,094.14
$1,249.70
$234.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.44
$695.14
$782.72
$1,093.84
$1,662.18
$846.70
$929.40
$1,016.98
$1,328.10
$1,080.96
$1,163.66
$1,251.24
$1,562.36
$1,315.22
$1,397.92
$1,485.50
$1,796.62
$234.26
Toc - Plan #42 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$241.57
$274.18
$308.73
$431.45
$655.63
$426.37
$458.98
$493.53
$616.25
$611.17
$643.78
$678.33
$801.05
$795.97
$828.58
$863.13
$985.85
$184.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$483.14
$548.36
$617.46
$862.90
$1,311.26
$667.94
$733.16
$802.26
$1,047.70
$852.74
$917.96
$987.06
$1,232.50
$1,037.54
$1,102.76
$1,171.86
$1,417.30
$184.80
Toc - Plan #43 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: 1-877-482-9045

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
$384.37
$436.26
$491.22
$686.48
$1,043.17
$678.41
$730.30
$785.26
$980.52
$972.45
$1,024.34
$1,079.30
$1,274.56
$1,266.49
$1,318.38
$1,373.34
$1,568.60
$294.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.74
$872.52
$982.44
$1,372.96
$2,086.34
$1,062.78
$1,166.56
$1,276.48
$1,667.00
$1,356.82
$1,460.60
$1,570.52
$1,961.04
$1,650.86
$1,754.64
$1,864.56
$2,255.08
$294.04
Toc - Plan #44 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: 1-877-482-9045

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
$310.83
$352.79
$397.24
$555.15
$843.60
$548.62
$590.58
$635.03
$792.94
$786.41
$828.37
$872.82
$1,030.73
$1,024.20
$1,066.16
$1,110.61
$1,268.52
$237.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.66
$705.58
$794.48
$1,110.30
$1,687.20
$859.45
$943.37
$1,032.27
$1,348.09
$1,097.24
$1,181.16
$1,270.06
$1,585.88
$1,335.03
$1,418.95
$1,507.85
$1,823.67
$237.79
Toc - Plan #45 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$253.91
$288.19
$324.49
$453.48
$689.11
$448.15
$482.43
$518.73
$647.72
$642.39
$676.67
$712.97
$841.96
$836.63
$870.91
$907.21
$1,036.20
$194.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$507.82
$576.38
$648.98
$906.96
$1,378.22
$702.06
$770.62
$843.22
$1,101.20
$896.30
$964.86
$1,037.46
$1,295.44
$1,090.54
$1,159.10
$1,231.70
$1,489.68
$194.24
Toc - Plan #46 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.71
$416.22
$468.66
$654.95
$995.25
$647.24
$696.75
$749.19
$935.48
$927.77
$977.28
$1,029.72
$1,216.01
$1,208.30
$1,257.81
$1,310.25
$1,496.54
$280.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.42
$832.44
$937.32
$1,309.90
$1,990.50
$1,013.95
$1,112.97
$1,217.85
$1,590.43
$1,294.48
$1,393.50
$1,498.38
$1,870.96
$1,575.01
$1,674.03
$1,778.91
$2,151.49
$280.53
Toc - Plan #47 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: 1-877-482-9045

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
$391.77
$444.66
$500.68
$699.70
$1,063.27
$691.47
$744.36
$800.38
$999.40
$991.17
$1,044.06
$1,100.08
$1,299.10
$1,290.87
$1,343.76
$1,399.78
$1,598.80
$299.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.54
$889.32
$1,001.36
$1,399.40
$2,126.54
$1,083.24
$1,189.02
$1,301.06
$1,699.10
$1,382.94
$1,488.72
$1,600.76
$1,998.80
$1,682.64
$1,788.42
$1,900.46
$2,298.50
$299.70
Toc - Plan #48 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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
$320.13
$363.35
$409.13
$571.75
$868.84
$565.03
$608.25
$654.03
$816.65
$809.93
$853.15
$898.93
$1,061.55
$1,054.83
$1,098.05
$1,143.83
$1,306.45
$244.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.26
$726.70
$818.26
$1,143.50
$1,737.68
$885.16
$971.60
$1,063.16
$1,388.40
$1,130.06
$1,216.50
$1,308.06
$1,633.30
$1,374.96
$1,461.40
$1,552.96
$1,878.20
$244.90

ADVERTISEMENT

Blue Cross Blue Shield of Arizona

Local: 1-844-341-5837 | Toll Free: 1-844-341-5837 | TTY: 1-602-864-4823

Toc - Plan #49 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue EverydayHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 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
$409.02
$464.23
$522.72
$730.50
$1,110.06
$721.92
$777.13
$835.62
$1,043.40
$1,034.82
$1,090.03
$1,148.52
$1,356.30
$1,347.72
$1,402.93
$1,461.42
$1,669.20
$312.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.04
$928.46
$1,045.44
$1,461.00
$2,220.12
$1,130.94
$1,241.36
$1,358.34
$1,773.90
$1,443.84
$1,554.26
$1,671.24
$2,086.80
$1,756.74
$1,867.16
$1,984.14
$2,399.70
$312.90
Toc - Plan #50 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue EverydayHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309.01
$350.73
$394.92
$551.90
$838.66
$545.41
$587.13
$631.32
$788.30
$781.81
$823.53
$867.72
$1,024.70
$1,018.21
$1,059.93
$1,104.12
$1,261.10
$236.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.02
$701.46
$789.84
$1,103.80
$1,677.32
$854.42
$937.86
$1,026.24
$1,340.20
$1,090.82
$1,174.26
$1,262.64
$1,576.60
$1,327.22
$1,410.66
$1,499.04
$1,813.00
$236.40
Toc - Plan #51 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue EverydayHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,300 $18,600 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
$273.18
$310.06
$349.12
$487.90
$741.40
$482.16
$519.04
$558.10
$696.88
$691.14
$728.02
$767.08
$905.86
$900.12
$937.00
$976.06
$1,114.84
$208.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$546.36
$620.12
$698.24
$975.80
$1,482.80
$755.34
$829.10
$907.22
$1,184.78
$964.32
$1,038.08
$1,116.20
$1,393.76
$1,173.30
$1,247.06
$1,325.18
$1,602.74
$208.98
Toc - Plan #52 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue AdvanceHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299.21
$339.60
$382.39
$534.39
$812.05
$528.11
$568.50
$611.29
$763.29
$757.01
$797.40
$840.19
$992.19
$985.91
$1,026.30
$1,069.09
$1,221.09
$228.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.42
$679.20
$764.78
$1,068.78
$1,624.10
$827.32
$908.10
$993.68
$1,297.68
$1,056.22
$1,137.00
$1,222.58
$1,526.58
$1,285.12
$1,365.90
$1,451.48
$1,755.48
$228.90
Toc - Plan #53 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue Portfolio HSA Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$294.39
$334.13
$376.23
$525.78
$798.97
$519.60
$559.34
$601.44
$750.99
$744.81
$784.55
$826.65
$976.20
$970.02
$1,009.76
$1,051.86
$1,201.41
$225.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$588.78
$668.26
$752.46
$1,051.56
$1,597.94
$813.99
$893.47
$977.67
$1,276.77
$1,039.20
$1,118.68
$1,202.88
$1,501.98
$1,264.41
$1,343.89
$1,428.09
$1,727.19
$225.21
Toc - Plan #54 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue AdvanceHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$9,000 $18,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$255.74
$290.27
$326.84
$456.75
$694.08
$451.38
$485.91
$522.48
$652.39
$647.02
$681.55
$718.12
$848.03
$842.66
$877.19
$913.76
$1,043.67
$195.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$511.48
$580.54
$653.68
$913.50
$1,388.16
$707.12
$776.18
$849.32
$1,109.14
$902.76
$971.82
$1,044.96
$1,304.78
$1,098.40
$1,167.46
$1,240.60
$1,500.42
$195.64
Toc - Plan #55 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue AdvanceHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$4,375 $8,750 Annual Deductible
$4,375 $8,750 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.06
$452.93
$509.99
$712.71
$1,083.03
$704.34
$758.21
$815.27
$1,017.99
$1,009.62
$1,063.49
$1,120.55
$1,323.27
$1,314.90
$1,368.77
$1,425.83
$1,628.55
$305.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.12
$905.86
$1,019.98
$1,425.42
$2,166.06
$1,103.40
$1,211.14
$1,325.26
$1,730.70
$1,408.68
$1,516.42
$1,630.54
$2,035.98
$1,713.96
$1,821.70
$1,935.82
$2,341.26
$305.28
Toc - Plan #56 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue StandardHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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
$408.97
$464.18
$522.66
$730.41
$1,109.93
$721.83
$777.04
$835.52
$1,043.27
$1,034.69
$1,089.90
$1,148.38
$1,356.13
$1,347.55
$1,402.76
$1,461.24
$1,668.99
$312.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817.94
$928.36
$1,045.32
$1,460.82
$2,219.86
$1,130.80
$1,241.22
$1,358.18
$1,773.68
$1,443.66
$1,554.08
$1,671.04
$2,086.54
$1,756.52
$1,866.94
$1,983.90
$2,399.40
$312.86
Toc - Plan #57 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue StandardHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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
$305.05
$346.23
$389.85
$544.81
$827.89
$538.41
$579.59
$623.21
$778.17
$771.77
$812.95
$856.57
$1,011.53
$1,005.13
$1,046.31
$1,089.93
$1,244.89
$233.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.10
$692.46
$779.70
$1,089.62
$1,655.78
$843.46
$925.82
$1,013.06
$1,322.98
$1,076.82
$1,159.18
$1,246.42
$1,556.34
$1,310.18
$1,392.54
$1,479.78
$1,789.70
$233.36
Toc - Plan #58 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue StandardHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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
$274.94
$312.06
$351.37
$491.04
$746.18
$485.27
$522.39
$561.70
$701.37
$695.60
$732.72
$772.03
$911.70
$905.93
$943.05
$982.36
$1,122.03
$210.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$549.88
$624.12
$702.74
$982.08
$1,492.36
$760.21
$834.45
$913.07
$1,192.41
$970.54
$1,044.78
$1,123.40
$1,402.74
$1,180.87
$1,255.11
$1,333.73
$1,613.07
$210.33
Toc - Plan #59 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue ACA StandardHealth Silver with Health Choice

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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
$259.87
$294.95
$332.12
$464.13
$705.29
$458.67
$493.75
$530.92
$662.93
$657.47
$692.55
$729.72
$861.73
$856.27
$891.35
$928.52
$1,060.53
$198.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$519.74
$589.90
$664.24
$928.26
$1,410.58
$718.54
$788.70
$863.04
$1,127.06
$917.34
$987.50
$1,061.84
$1,325.86
$1,116.14
$1,186.30
$1,260.64
$1,524.66
$198.80
Toc - Plan #60 Blue Cross Blue Shield of Arizona
Gold

(PPO) Blue PPO PremierHealth Gold - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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
$629.87
$714.90
$804.98
$1,124.95
$1,709.46
$1,111.72
$1,196.75
$1,286.83
$1,606.80
$1,593.57
$1,678.60
$1,768.68
$2,088.65
$2,075.42
$2,160.45
$2,250.53
$2,570.50
$481.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,259.74
$1,429.80
$1,609.96
$2,249.90
$3,418.92
$1,741.59
$1,911.65
$2,091.81
$2,731.75
$2,223.44
$2,393.50
$2,573.66
$3,213.60
$2,705.29
$2,875.35
$3,055.51
$3,695.45
$481.85
Toc - Plan #61 Blue Cross Blue Shield of Arizona
Silver

(PPO) Blue PPO PremierHealth Silver - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$512.48
$581.66
$654.94
$915.28
$1,390.85
$904.53
$973.71
$1,046.99
$1,307.33
$1,296.58
$1,365.76
$1,439.04
$1,699.38
$1,688.63
$1,757.81
$1,831.09
$2,091.43
$392.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,024.96
$1,163.32
$1,309.88
$1,830.56
$2,781.70
$1,417.01
$1,555.37
$1,701.93
$2,222.61
$1,809.06
$1,947.42
$2,093.98
$2,614.66
$2,201.11
$2,339.47
$2,486.03
$3,006.71
$392.05
Toc - Plan #62 Blue Cross Blue Shield of Arizona
Gold

(PPO) Blue PPO StandardHealth Gold - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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
$608.76
$690.94
$777.99
$1,087.24
$1,652.16
$1,074.46
$1,156.64
$1,243.69
$1,552.94
$1,540.16
$1,622.34
$1,709.39
$2,018.64
$2,005.86
$2,088.04
$2,175.09
$2,484.34
$465.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,217.52
$1,381.88
$1,555.98
$2,174.48
$3,304.32
$1,683.22
$1,847.58
$2,021.68
$2,640.18
$2,148.92
$2,313.28
$2,487.38
$3,105.88
$2,614.62
$2,778.98
$2,953.08
$3,571.58
$465.70
Toc - Plan #63 Blue Cross Blue Shield of Arizona
Silver

(PPO) Blue PPO StandardHealth Silver - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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
$495.12
$561.96
$632.76
$884.28
$1,343.75
$873.89
$940.73
$1,011.53
$1,263.05
$1,252.66
$1,319.50
$1,390.30
$1,641.82
$1,631.43
$1,698.27
$1,769.07
$2,020.59
$378.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$990.24
$1,123.92
$1,265.52
$1,768.56
$2,687.50
$1,369.01
$1,502.69
$1,644.29
$2,147.33
$1,747.78
$1,881.46
$2,023.06
$2,526.10
$2,126.55
$2,260.23
$2,401.83
$2,904.87
$378.77
Toc - Plan #64 Blue Cross Blue Shield of Arizona
Gold

(PPO) Blue Portfolio HSA Gold - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$650.35
$738.15
$831.15
$1,161.52
$1,765.05
$1,147.87
$1,235.67
$1,328.67
$1,659.04
$1,645.39
$1,733.19
$1,826.19
$2,156.56
$2,142.91
$2,230.71
$2,323.71
$2,654.08
$497.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,300.70
$1,476.30
$1,662.30
$2,323.04
$3,530.10
$1,798.22
$1,973.82
$2,159.82
$2,820.56
$2,295.74
$2,471.34
$2,657.34
$3,318.08
$2,793.26
$2,968.86
$3,154.86
$3,815.60
$497.52

ADVERTISEMENT

Imperial Insurance Companies, Inc.

Local: 1-626-838-5100x8 | Toll Free: 1-800-595-0619 | TTY: 1-800-595-0619

Toc - Plan #65 Imperial Insurance Companies, Inc.
Expanded Bronze

(HMO) Imperial Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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
$284.84
$323.29
$364.02
$508.72
$773.05
$502.74
$541.19
$581.92
$726.62
$720.64
$759.09
$799.82
$944.52
$938.54
$976.99
$1,017.72
$1,162.42
$217.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.68
$646.58
$728.04
$1,017.44
$1,546.10
$787.58
$864.48
$945.94
$1,235.34
$1,005.48
$1,082.38
$1,163.84
$1,453.24
$1,223.38
$1,300.28
$1,381.74
$1,671.14
$217.90
Toc - Plan #66 Imperial Insurance Companies, Inc.
Silver

(HMO) Imperial Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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
$332.89
$377.83
$425.43
$594.54
$903.46
$587.55
$632.49
$680.09
$849.20
$842.21
$887.15
$934.75
$1,103.86
$1,096.87
$1,141.81
$1,189.41
$1,358.52
$254.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.78
$755.66
$850.86
$1,189.08
$1,806.92
$920.44
$1,010.32
$1,105.52
$1,443.74
$1,175.10
$1,264.98
$1,360.18
$1,698.40
$1,429.76
$1,519.64
$1,614.84
$1,953.06
$254.66
Toc - Plan #67 Imperial Insurance Companies, Inc.
Gold

(HMO) Imperial Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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
$413.17
$468.95
$528.03
$737.92
$1,121.35
$729.25
$785.03
$844.11
$1,054.00
$1,045.33
$1,101.11
$1,160.19
$1,370.08
$1,361.41
$1,417.19
$1,476.27
$1,686.16
$316.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.34
$937.90
$1,056.06
$1,475.84
$2,242.70
$1,142.42
$1,253.98
$1,372.14
$1,791.92
$1,458.50
$1,570.06
$1,688.22
$2,108.00
$1,774.58
$1,886.14
$2,004.30
$2,424.08
$316.08
Toc - Plan #68 Imperial Insurance Companies, Inc.
Silver

(HMO) Imperial Preferred Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

Annual Out of Pocket Expenses:

Individual Family
$3,750 $7,500 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$334.35
$379.49
$427.30
$597.16
$907.44
$590.13
$635.27
$683.08
$852.94
$845.91
$891.05
$938.86
$1,108.72
$1,101.69
$1,146.83
$1,194.64
$1,364.50
$255.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$668.70
$758.98
$854.60
$1,194.32
$1,814.88
$924.48
$1,014.76
$1,110.38
$1,450.10
$1,180.26
$1,270.54
$1,366.16
$1,705.88
$1,436.04
$1,526.32
$1,621.94
$1,961.66
$255.78
Toc - Plan #69 Imperial Insurance Companies, Inc.
Gold

(HMO) Imperial Preferred Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.90
$484.53
$545.58
$762.44
$1,158.61
$753.48
$811.11
$872.16
$1,089.02
$1,080.06
$1,137.69
$1,198.74
$1,415.60
$1,406.64
$1,464.27
$1,525.32
$1,742.18
$326.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.80
$969.06
$1,091.16
$1,524.88
$2,317.22
$1,180.38
$1,295.64
$1,417.74
$1,851.46
$1,506.96
$1,622.22
$1,744.32
$2,178.04
$1,833.54
$1,948.80
$2,070.90
$2,504.62
$326.58

ADVERTISEMENT

Ambetter from Arizona Complete Health

Local: 1-888-926-5057 | Toll Free: 1-888-926-5057 | TTY: 1-888-926-5180

Toc - Plan #70 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$276.90
$314.28
$353.87
$494.53
$751.49
$488.72
$526.10
$565.69
$706.35
$700.54
$737.92
$777.51
$918.17
$912.36
$949.74
$989.33
$1,129.99
$211.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$553.80
$628.56
$707.74
$989.06
$1,502.98
$765.62
$840.38
$919.56
$1,200.88
$977.44
$1,052.20
$1,131.38
$1,412.70
$1,189.26
$1,264.02
$1,343.20
$1,624.52
$211.82
Toc - Plan #71 Ambetter from Arizona Complete Health
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$324.62
$368.44
$414.86
$579.77
$881.01
$572.95
$616.77
$663.19
$828.10
$821.28
$865.10
$911.52
$1,076.43
$1,069.61
$1,113.43
$1,159.85
$1,324.76
$248.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.24
$736.88
$829.72
$1,159.54
$1,762.02
$897.57
$985.21
$1,078.05
$1,407.87
$1,145.90
$1,233.54
$1,326.38
$1,656.20
$1,394.23
$1,481.87
$1,574.71
$1,904.53
$248.33
Toc - Plan #72 Ambetter from Arizona Complete Health
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$321.58
$365.00
$410.99
$574.35
$872.78
$567.59
$611.01
$657.00
$820.36
$813.60
$857.02
$903.01
$1,066.37
$1,059.61
$1,103.03
$1,149.02
$1,312.38
$246.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.16
$730.00
$821.98
$1,148.70
$1,745.56
$889.17
$976.01
$1,067.99
$1,394.71
$1,135.18
$1,222.02
$1,314.00
$1,640.72
$1,381.19
$1,468.03
$1,560.01
$1,886.73
$246.01
Toc - Plan #73 Ambetter from Arizona Complete Health
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$362.97
$411.97
$463.87
$648.26
$985.10
$640.64
$689.64
$741.54
$925.93
$918.31
$967.31
$1,019.21
$1,203.60
$1,195.98
$1,244.98
$1,296.88
$1,481.27
$277.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725.94
$823.94
$927.74
$1,296.52
$1,970.20
$1,003.61
$1,101.61
$1,205.41
$1,574.19
$1,281.28
$1,379.28
$1,483.08
$1,851.86
$1,558.95
$1,656.95
$1,760.75
$2,129.53
$277.67
Toc - Plan #74 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$310.88
$352.85
$397.31
$555.24
$843.74
$548.71
$590.68
$635.14
$793.07
$786.54
$828.51
$872.97
$1,030.90
$1,024.37
$1,066.34
$1,110.80
$1,268.73
$237.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.76
$705.70
$794.62
$1,110.48
$1,687.48
$859.59
$943.53
$1,032.45
$1,348.31
$1,097.42
$1,181.36
$1,270.28
$1,586.14
$1,335.25
$1,419.19
$1,508.11
$1,823.97
$237.83
Toc - Plan #75 Ambetter from Arizona Complete Health
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$312.60
$354.81
$399.51
$558.31
$848.41
$551.74
$593.95
$638.65
$797.45
$790.88
$833.09
$877.79
$1,036.59
$1,030.02
$1,072.23
$1,116.93
$1,275.73
$239.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$625.20
$709.62
$799.02
$1,116.62
$1,696.82
$864.34
$948.76
$1,038.16
$1,355.76
$1,103.48
$1,187.90
$1,277.30
$1,594.90
$1,342.62
$1,427.04
$1,516.44
$1,834.04
$239.14
Toc - Plan #76 Ambetter from Arizona Complete Health
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$319.35
$362.46
$408.13
$570.36
$866.71
$563.65
$606.76
$652.43
$814.66
$807.95
$851.06
$896.73
$1,058.96
$1,052.25
$1,095.36
$1,141.03
$1,303.26
$244.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$638.70
$724.92
$816.26
$1,140.72
$1,733.42
$883.00
$969.22
$1,060.56
$1,385.02
$1,127.30
$1,213.52
$1,304.86
$1,629.32
$1,371.60
$1,457.82
$1,549.16
$1,873.62
$244.30
Toc - Plan #77 Ambetter from Arizona Complete Health
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$342.82
$389.10
$438.12
$612.28
$930.41
$605.08
$651.36
$700.38
$874.54
$867.34
$913.62
$962.64
$1,136.80
$1,129.60
$1,175.88
$1,224.90
$1,399.06
$262.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.64
$778.20
$876.24
$1,224.56
$1,860.82
$947.90
$1,040.46
$1,138.50
$1,486.82
$1,210.16
$1,302.72
$1,400.76
$1,749.08
$1,472.42
$1,564.98
$1,663.02
$2,011.34
$262.26
Toc - Plan #78 Ambetter from Arizona Complete Health
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$395.86
$449.30
$505.91
$707.01
$1,074.37
$698.69
$752.13
$808.74
$1,009.84
$1,001.52
$1,054.96
$1,111.57
$1,312.67
$1,304.35
$1,357.79
$1,414.40
$1,615.50
$302.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.72
$898.60
$1,011.82
$1,414.02
$2,148.74
$1,094.55
$1,201.43
$1,314.65
$1,716.85
$1,397.38
$1,504.26
$1,617.48
$2,019.68
$1,700.21
$1,807.09
$1,920.31
$2,322.51
$302.83
Toc - Plan #79 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$272.06
$308.79
$347.69
$485.90
$738.37
$480.19
$516.92
$555.82
$694.03
$688.32
$725.05
$763.95
$902.16
$896.45
$933.18
$972.08
$1,110.29
$208.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$544.12
$617.58
$695.38
$971.80
$1,476.74
$752.25
$825.71
$903.51
$1,179.93
$960.38
$1,033.84
$1,111.64
$1,388.06
$1,168.51
$1,241.97
$1,319.77
$1,596.19
$208.13
Toc - Plan #80 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$267.50
$303.61
$341.86
$477.75
$725.99
$472.14
$508.25
$546.50
$682.39
$676.78
$712.89
$751.14
$887.03
$881.42
$917.53
$955.78
$1,091.67
$204.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$535.00
$607.22
$683.72
$955.50
$1,451.98
$739.64
$811.86
$888.36
$1,160.14
$944.28
$1,016.50
$1,093.00
$1,364.78
$1,148.92
$1,221.14
$1,297.64
$1,569.42
$204.64
Toc - Plan #81 Ambetter from Arizona Complete Health
Silver

(HMO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$313.64
$355.98
$400.83
$560.15
$851.21
$553.57
$595.91
$640.76
$800.08
$793.50
$835.84
$880.69
$1,040.01
$1,033.43
$1,075.77
$1,120.62
$1,279.94
$239.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.28
$711.96
$801.66
$1,120.30
$1,702.42
$867.21
$951.89
$1,041.59
$1,360.23
$1,107.14
$1,191.82
$1,281.52
$1,600.16
$1,347.07
$1,431.75
$1,521.45
$1,840.09
$239.93
Toc - Plan #82 Ambetter from Arizona Complete Health
Gold

(HMO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$349.06
$396.19
$446.10
$623.43
$947.36
$616.09
$663.22
$713.13
$890.46
$883.12
$930.25
$980.16
$1,157.49
$1,150.15
$1,197.28
$1,247.19
$1,424.52
$267.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.12
$792.38
$892.20
$1,246.86
$1,894.72
$965.15
$1,059.41
$1,159.23
$1,513.89
$1,232.18
$1,326.44
$1,426.26
$1,780.92
$1,499.21
$1,593.47
$1,693.29
$2,047.95
$267.03
Toc - Plan #83 Ambetter from Arizona Complete Health
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$333.93
$379.01
$426.76
$596.40
$906.29
$589.39
$634.47
$682.22
$851.86
$844.85
$889.93
$937.68
$1,107.32
$1,100.31
$1,145.39
$1,193.14
$1,362.78
$255.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667.86
$758.02
$853.52
$1,192.80
$1,812.58
$923.32
$1,013.48
$1,108.98
$1,448.26
$1,178.78
$1,268.94
$1,364.44
$1,703.72
$1,434.24
$1,524.40
$1,619.90
$1,959.18
$255.46
Toc - Plan #84 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$287.53
$326.34
$367.46
$513.52
$780.34
$507.49
$546.30
$587.42
$733.48
$727.45
$766.26
$807.38
$953.44
$947.41
$986.22
$1,027.34
$1,173.40
$219.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$575.06
$652.68
$734.92
$1,027.04
$1,560.68
$795.02
$872.64
$954.88
$1,247.00
$1,014.98
$1,092.60
$1,174.84
$1,466.96
$1,234.94
$1,312.56
$1,394.80
$1,686.92
$219.96
Toc - Plan #85 Ambetter from Arizona Complete Health
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$337.08
$382.59
$430.79
$602.03
$914.84
$594.95
$640.46
$688.66
$859.90
$852.82
$898.33
$946.53
$1,117.77
$1,110.69
$1,156.20
$1,204.40
$1,375.64
$257.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$674.16
$765.18
$861.58
$1,204.06
$1,829.68
$932.03
$1,023.05
$1,119.45
$1,461.93
$1,189.90
$1,280.92
$1,377.32
$1,719.80
$1,447.77
$1,538.79
$1,635.19
$1,977.67
$257.87
Toc - Plan #86 Ambetter from Arizona Complete Health
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$376.90
$427.79
$481.68
$673.15
$1,022.92
$665.23
$716.12
$770.01
$961.48
$953.56
$1,004.45
$1,058.34
$1,249.81
$1,241.89
$1,292.78
$1,346.67
$1,538.14
$288.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.80
$855.58
$963.36
$1,346.30
$2,045.84
$1,042.13
$1,143.91
$1,251.69
$1,634.63
$1,330.46
$1,432.24
$1,540.02
$1,922.96
$1,618.79
$1,720.57
$1,828.35
$2,211.29
$288.33
Toc - Plan #87 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$322.82
$366.40
$412.56
$576.56
$876.13
$569.78
$613.36
$659.52
$823.52
$816.74
$860.32
$906.48
$1,070.48
$1,063.70
$1,107.28
$1,153.44
$1,317.44
$246.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645.64
$732.80
$825.12
$1,153.12
$1,752.26
$892.60
$979.76
$1,072.08
$1,400.08
$1,139.56
$1,226.72
$1,319.04
$1,647.04
$1,386.52
$1,473.68
$1,566.00
$1,894.00
$246.96
Toc - Plan #88 Ambetter from Arizona Complete Health
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$324.61
$368.43
$414.85
$579.75
$880.98
$572.93
$616.75
$663.17
$828.07
$821.25
$865.07
$911.49
$1,076.39
$1,069.57
$1,113.39
$1,159.81
$1,324.71
$248.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.22
$736.86
$829.70
$1,159.50
$1,761.96
$897.54
$985.18
$1,078.02
$1,407.82
$1,145.86
$1,233.50
$1,326.34
$1,656.14
$1,394.18
$1,481.82
$1,574.66
$1,904.46
$248.32
Toc - Plan #89 Ambetter from Arizona Complete Health
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$331.61
$376.38
$423.80
$592.25
$899.99
$585.29
$630.06
$677.48
$845.93
$838.97
$883.74
$931.16
$1,099.61
$1,092.65
$1,137.42
$1,184.84
$1,353.29
$253.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$663.22
$752.76
$847.60
$1,184.50
$1,799.98
$916.90
$1,006.44
$1,101.28
$1,438.18
$1,170.58
$1,260.12
$1,354.96
$1,691.86
$1,424.26
$1,513.80
$1,608.64
$1,945.54
$253.68
Toc - Plan #90 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Standard Expanded Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$277.77
$315.27
$354.99
$496.09
$753.86
$490.26
$527.76
$567.48
$708.58
$702.75
$740.25
$779.97
$921.07
$915.24
$952.74
$992.46
$1,133.56
$212.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$555.54
$630.54
$709.98
$992.18
$1,507.72
$768.03
$843.03
$922.47
$1,204.67
$980.52
$1,055.52
$1,134.96
$1,417.16
$1,193.01
$1,268.01
$1,347.45
$1,629.65
$212.49
Toc - Plan #91 Ambetter from Arizona Complete Health
Silver

(HMO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$325.68
$369.64
$416.22
$581.66
$883.89
$574.82
$618.78
$665.36
$830.80
$823.96
$867.92
$914.50
$1,079.94
$1,073.10
$1,117.06
$1,163.64
$1,329.08
$249.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$651.36
$739.28
$832.44
$1,163.32
$1,767.78
$900.50
$988.42
$1,081.58
$1,412.46
$1,149.64
$1,237.56
$1,330.72
$1,661.60
$1,398.78
$1,486.70
$1,579.86
$1,910.74
$249.14
Toc - Plan #92 Ambetter from Arizona Complete Health
Gold

(HMO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$362.47
$411.40
$463.23
$647.36
$983.73
$639.76
$688.69
$740.52
$924.65
$917.05
$965.98
$1,017.81
$1,201.94
$1,194.34
$1,243.27
$1,295.10
$1,479.23
$277.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.94
$822.80
$926.46
$1,294.72
$1,967.46
$1,002.23
$1,100.09
$1,203.75
$1,572.01
$1,279.52
$1,377.38
$1,481.04
$1,849.30
$1,556.81
$1,654.67
$1,758.33
$2,126.59
$277.29
Toc - Plan #93 Ambetter from Arizona Complete Health
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$355.98
$404.04
$454.94
$635.78
$966.13
$628.31
$676.37
$727.27
$908.11
$900.64
$948.70
$999.60
$1,180.44
$1,172.97
$1,221.03
$1,271.93
$1,452.77
$272.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.96
$808.08
$909.88
$1,271.56
$1,932.26
$984.29
$1,080.41
$1,182.21
$1,543.89
$1,256.62
$1,352.74
$1,454.54
$1,816.22
$1,528.95
$1,625.07
$1,726.87
$2,088.55
$272.33
Toc - Plan #94 Ambetter from Arizona Complete Health
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$411.06
$466.55
$525.33
$734.15
$1,115.62
$725.52
$781.01
$839.79
$1,048.61
$1,039.98
$1,095.47
$1,154.25
$1,363.07
$1,354.44
$1,409.93
$1,468.71
$1,677.53
$314.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.12
$933.10
$1,050.66
$1,468.30
$2,231.24
$1,136.58
$1,247.56
$1,365.12
$1,782.76
$1,451.04
$1,562.02
$1,679.58
$2,097.22
$1,765.50
$1,876.48
$1,994.04
$2,411.68
$314.46
Toc - Plan #95 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$282.50
$320.64
$361.04
$504.55
$766.72
$498.62
$536.76
$577.16
$720.67
$714.74
$752.88
$793.28
$936.79
$930.86
$969.00
$1,009.40
$1,152.91
$216.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$565.00
$641.28
$722.08
$1,009.10
$1,533.44
$781.12
$857.40
$938.20
$1,225.22
$997.24
$1,073.52
$1,154.32
$1,441.34
$1,213.36
$1,289.64
$1,370.44
$1,657.46
$216.12
Toc - Plan #96 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Standard Expanded Bronze SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$256.80
$291.46
$328.19
$458.64
$696.95
$453.25
$487.91
$524.64
$655.09
$649.70
$684.36
$721.09
$851.54
$846.15
$880.81
$917.54
$1,047.99
$196.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$513.60
$582.92
$656.38
$917.28
$1,393.90
$710.05
$779.37
$852.83
$1,113.73
$906.50
$975.82
$1,049.28
$1,310.18
$1,102.95
$1,172.27
$1,245.73
$1,506.63
$196.45
Toc - Plan #97 Ambetter from Arizona Complete Health
Silver

(HMO) Standard Silver SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$301.09
$341.74
$384.79
$537.75
$817.16
$531.42
$572.07
$615.12
$768.08
$761.75
$802.40
$845.45
$998.41
$992.08
$1,032.73
$1,075.78
$1,228.74
$230.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$602.18
$683.48
$769.58
$1,075.50
$1,634.32
$832.51
$913.81
$999.91
$1,305.83
$1,062.84
$1,144.14
$1,230.24
$1,536.16
$1,293.17
$1,374.47
$1,460.57
$1,766.49
$230.33
Toc - Plan #98 Ambetter from Arizona Complete Health
Gold

(HMO) Standard Gold SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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
$335.10
$380.34
$428.26
$598.49
$909.47
$591.45
$636.69
$684.61
$854.84
$847.80
$893.04
$940.96
$1,111.19
$1,104.15
$1,149.39
$1,197.31
$1,367.54
$256.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.20
$760.68
$856.52
$1,196.98
$1,818.94
$926.55
$1,017.03
$1,112.87
$1,453.33
$1,182.90
$1,273.38
$1,369.22
$1,709.68
$1,439.25
$1,529.73
$1,625.57
$1,966.03
$256.35

ADVERTISEMENT

Cigna HealthCare of Arizona, Inc

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #99 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Connect Silver 5000 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$358.13
$406.47
$457.69
$639.62
$971.96
$632.10
$680.44
$731.66
$913.59
$906.07
$954.41
$1,005.63
$1,187.56
$1,180.04
$1,228.38
$1,279.60
$1,461.53
$273.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.26
$812.94
$915.38
$1,279.24
$1,943.92
$990.23
$1,086.91
$1,189.35
$1,553.21
$1,264.20
$1,360.88
$1,463.32
$1,827.18
$1,538.17
$1,634.85
$1,737.29
$2,101.15
$273.97
Toc - Plan #100 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Connect Bronze 6500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$342.57
$388.82
$437.81
$611.84
$929.75
$604.64
$650.89
$699.88
$873.91
$866.71
$912.96
$961.95
$1,135.98
$1,128.78
$1,175.03
$1,224.02
$1,398.05
$262.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.14
$777.64
$875.62
$1,223.68
$1,859.50
$947.21
$1,039.71
$1,137.69
$1,485.75
$1,209.28
$1,301.78
$1,399.76
$1,747.82
$1,471.35
$1,563.85
$1,661.83
$2,009.89
$262.07
Toc - Plan #101 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Connect Bronze 8900 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$8,900 $17,800 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
$352.35
$399.91
$450.30
$629.29
$956.27
$621.90
$669.46
$719.85
$898.84
$891.45
$939.01
$989.40
$1,168.39
$1,161.00
$1,208.56
$1,258.95
$1,437.94
$269.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$704.70
$799.82
$900.60
$1,258.58
$1,912.54
$974.25
$1,069.37
$1,170.15
$1,528.13
$1,243.80
$1,338.92
$1,439.70
$1,797.68
$1,513.35
$1,608.47
$1,709.25
$2,067.23
$269.55
Toc - Plan #102 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Connect Silver 4000 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$357.21
$405.43
$456.51
$637.98
$969.47
$630.48
$678.70
$729.78
$911.25
$903.75
$951.97
$1,003.05
$1,184.52
$1,177.02
$1,225.24
$1,276.32
$1,457.79
$273.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.42
$810.86
$913.02
$1,275.96
$1,938.94
$987.69
$1,084.13
$1,186.29
$1,549.23
$1,260.96
$1,357.40
$1,459.56
$1,822.50
$1,534.23
$1,630.67
$1,732.83
$2,095.77
$273.27
Toc - Plan #103 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Connect Gold 2500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$464.70
$527.44
$593.89
$829.96
$1,261.20
$820.20
$882.94
$949.39
$1,185.46
$1,175.70
$1,238.44
$1,304.89
$1,540.96
$1,531.20
$1,593.94
$1,660.39
$1,896.46
$355.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$929.40
$1,054.88
$1,187.78
$1,659.92
$2,522.40
$1,284.90
$1,410.38
$1,543.28
$2,015.42
$1,640.40
$1,765.88
$1,898.78
$2,370.92
$1,995.90
$2,121.38
$2,254.28
$2,726.42
$355.50
Toc - Plan #104 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Connect Silver 7000 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$356.89
$405.07
$456.10
$637.40
$968.60
$629.91
$678.09
$729.12
$910.42
$902.93
$951.11
$1,002.14
$1,183.44
$1,175.95
$1,224.13
$1,275.16
$1,456.46
$273.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.78
$810.14
$912.20
$1,274.80
$1,937.20
$986.80
$1,083.16
$1,185.22
$1,547.82
$1,259.82
$1,356.18
$1,458.24
$1,820.84
$1,532.84
$1,629.20
$1,731.26
$2,093.86
$273.02
Toc - Plan #105 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,450 $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
$353.40
$401.11
$451.65
$631.18
$959.13
$623.75
$671.46
$722.00
$901.53
$894.10
$941.81
$992.35
$1,171.88
$1,164.45
$1,212.16
$1,262.70
$1,442.23
$270.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.80
$802.22
$903.30
$1,262.36
$1,918.26
$977.15
$1,072.57
$1,173.65
$1,532.71
$1,247.50
$1,342.92
$1,444.00
$1,803.06
$1,517.85
$1,613.27
$1,714.35
$2,073.41
$270.35
Toc - Plan #106 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Connect Bronze 0 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $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
$373.91
$424.39
$477.86
$667.80
$1,014.79
$659.95
$710.43
$763.90
$953.84
$945.99
$996.47
$1,049.94
$1,239.88
$1,232.03
$1,282.51
$1,335.98
$1,525.92
$286.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.82
$848.78
$955.72
$1,335.60
$2,029.58
$1,033.86
$1,134.82
$1,241.76
$1,621.64
$1,319.90
$1,420.86
$1,527.80
$1,907.68
$1,605.94
$1,706.90
$1,813.84
$2,193.72
$286.04
Toc - Plan #107 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Connect Silver 0 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $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
$360.74
$409.44
$461.03
$644.29
$979.05
$636.71
$685.41
$737.00
$920.26
$912.68
$961.38
$1,012.97
$1,196.23
$1,188.65
$1,237.35
$1,288.94
$1,472.20
$275.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.48
$818.88
$922.06
$1,288.58
$1,958.10
$997.45
$1,094.85
$1,198.03
$1,564.55
$1,273.42
$1,370.82
$1,474.00
$1,840.52
$1,549.39
$1,646.79
$1,749.97
$2,116.49
$275.97
Toc - Plan #108 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Connect Bronze CMS Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $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
$350.83
$398.20
$448.36
$626.59
$952.16
$619.22
$666.59
$716.75
$894.98
$887.61
$934.98
$985.14
$1,163.37
$1,156.00
$1,203.37
$1,253.53
$1,431.76
$268.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$701.66
$796.40
$896.72
$1,253.18
$1,904.32
$970.05
$1,064.79
$1,165.11
$1,521.57
$1,238.44
$1,333.18
$1,433.50
$1,789.96
$1,506.83
$1,601.57
$1,701.89
$2,058.35
$268.39
Toc - Plan #109 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Connect Silver CMS Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.65
$403.66
$454.52
$635.19
$965.23
$627.72
$675.73
$726.59
$907.26
$899.79
$947.80
$998.66
$1,179.33
$1,171.86
$1,219.87
$1,270.73
$1,451.40
$272.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.30
$807.32
$909.04
$1,270.38
$1,930.46
$983.37
$1,079.39
$1,181.11
$1,542.45
$1,255.44
$1,351.46
$1,453.18
$1,814.52
$1,527.51
$1,623.53
$1,725.25
$2,086.59
$272.07
Toc - Plan #110 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Connect Gold CMS Standard

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

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
$469.29
$532.65
$599.75
$838.15
$1,273.66
$828.30
$891.66
$958.76
$1,197.16
$1,187.31
$1,250.67
$1,317.77
$1,556.17
$1,546.32
$1,609.68
$1,676.78
$1,915.18
$359.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$938.58
$1,065.30
$1,199.50
$1,676.30
$2,547.32
$1,297.59
$1,424.31
$1,558.51
$2,035.31
$1,656.60
$1,783.32
$1,917.52
$2,394.32
$2,015.61
$2,142.33
$2,276.53
$2,753.33
$359.01

‡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 Maricopa County here.

Maricopa County is in “Rating Area 4” of Arizona.

Currently, there are 110 plans offered in Rating Area 4.

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2024 Obamacare Plans for Maricopa County, AZ

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