Providers for Zip Code 37075

Obamacare 2015 Marketplace Rates For Sumner County, Tennessee

Sunday, December 21st, 2014

Click for Hendersonville, Tennessee Forecast

The health insurance rates listed below are for calendar year 2015.

2015 Rates and Providers

(click here for 2014)

This page gives you an overview of the rates for individual and family health insurance plans available from HealthCare.gov, the marketplace for Sumner County, Tennessee.

Obamacare Providers, Plans and 2015 Rates for Sumner County

Sumner County is in “Rating Area 4” of Tennessee.

Currently, there are 4 providers offering 74 plans to Rating Area 4.

Below, you’ll find a summary of plans and rates for each of these providers. This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must complete an application at HealthCare.gov or contact the provider directly.

The table below shows premiums for the following scenarios for:

  • Individual
  • Couple
  • Couple with 1 2 or 3 children
  • Individual with 1 2 or 3 children
  • A child alone

Each scenario is covered for age

  • Age 21, 30, 40, 50
  • Age 60 (Individual and Couple only)

For each plan, there are links that go to the insurance provider's website in a new window. You can find links to:

  • a summary of plan benefits and costs,
  • a plan brochure, and
  • a "Provider Directory" -- where you can find out which doctors and hospitals in the Hendersonville, TN area accept this insurance coverage as within the plan's "network".

BlueCross BlueShield of Tennessee

Local: 1-888-743-0455 | Toll Free: 1-888-743-0455

Plan: (PPO) BlueCross B04P, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $5,300 : Family: $10,600
Out of Pocket Maximum per year: Individual: $5,300 : Family: $10,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$186.36
$211.52
$238.17
$332.84
$505.78
$372.72
$423.04
$476.34
$665.68
$1011.56
$491.06
$541.38
$594.68
$784.02
$609.40
$659.72
$713.02
$902.36
$727.74
$778.06
$831.36
$1020.70
$304.70
$329.86
$356.51
$451.18
$423.04
$448.20
$474.85
$569.52
$541.38
$566.54
$593.19
$687.86
$118.34

Plan: (PPO) BlueCross S09P, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$236.08
$267.96
$301.71
$421.65
$640.73
$472.16
$535.92
$603.42
$843.30
$1281.46
$622.07
$685.83
$753.33
$993.21
$771.98
$835.74
$903.24
$1143.12
$921.89
$985.65
$1053.15
$1293.03
$385.99
$417.87
$451.62
$571.56
$535.90
$567.78
$601.53
$721.47
$685.81
$717.69
$751.44
$871.38
$149.91

Plan: (PPO) BlueCross S11P, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$275.68
$312.90
$352.32
$492.36
$748.20
$551.36
$625.80
$704.64
$984.72
$1496.40
$726.42
$800.86
$879.70
$1159.78
$901.48
$975.92
$1054.76
$1334.84
$1076.54
$1150.98
$1229.82
$1509.90
$450.74
$487.96
$527.38
$667.42
$625.80
$663.02
$702.44
$842.48
$800.86
$838.08
$877.50
$1017.54
$175.06

Plan: (PPO) BlueCross S12P, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$271.10
$307.69
$346.47
$484.19
$735.77
$542.20
$615.38
$692.94
$968.38
$1471.54
$714.35
$787.53
$865.09
$1140.53
$886.50
$959.68
$1037.24
$1312.68
$1058.65
$1131.83
$1209.39
$1484.83
$443.25
$479.84
$518.62
$656.34
$615.40
$651.99
$690.77
$828.49
$787.55
$824.14
$862.92
$1000.64
$172.15

Plan: (PPO) BlueCross G08P, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,100 : Family: $4,200
Out of Pocket Maximum per year: Individual: $2,100 : Family: $4,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$301.02
$341.65
$384.70
$537.62
$816.96
$602.04
$683.30
$769.40
$1075.24
$1633.92
$793.18
$874.44
$960.54
$1266.38
$984.32
$1065.58
$1151.68
$1457.52
$1175.46
$1256.72
$1342.82
$1648.66
$492.16
$532.79
$575.84
$728.76
$683.30
$723.93
$766.98
$919.90
$874.44
$915.07
$958.12
$1111.04
$191.14

Plan: (PPO) BlueCross G11P, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$344.24
$390.71
$439.94
$614.81
$934.27
$688.48
$781.42
$879.88
$1229.62
$1868.54
$907.07
$1000.01
$1098.47
$1448.21
$1125.66
$1218.60
$1317.06
$1666.80
$1344.25
$1437.19
$1535.65
$1885.39
$562.83
$609.30
$658.53
$833.40
$781.42
$827.89
$877.12
$1051.99
$1000.01
$1046.48
$1095.71
$1270.58
$218.59

Plan: (PPO) BlueCross Bronze B01S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$179.36
$203.58
$229.22
$320.34
$486.79
$358.72
$407.16
$458.44
$640.68
$973.58
$472.61
$521.05
$572.33
$754.57
$586.50
$634.94
$686.22
$868.46
$700.39
$748.83
$800.11
$982.35
$293.25
$317.47
$343.11
$434.23
$407.14
$431.36
$457.00
$548.12
$521.03
$545.25
$570.89
$662.01
$113.89

Plan: (PPO) BlueCross Bronze B02S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$155.46
$176.45
$198.69
$277.65
$421.92
$310.92
$352.90
$397.38
$555.30
$843.84
$409.64
$451.62
$496.10
$654.02
$508.36
$550.34
$594.82
$752.74
$607.08
$649.06
$693.54
$851.46
$254.18
$275.17
$297.41
$376.37
$352.90
$373.89
$396.13
$475.09
$451.62
$472.61
$494.85
$573.81
$98.72

Plan: (PPO) BlueCross Bronze B03S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$172.19
$195.44
$220.06
$307.53
$467.31
$344.38
$390.88
$440.12
$615.06
$934.62
$453.72
$500.22
$549.46
$724.40
$563.06
$609.56
$658.80
$833.74
$672.40
$718.90
$768.14
$943.08
$281.53
$304.78
$329.40
$416.87
$390.87
$414.12
$438.74
$526.21
$500.21
$523.46
$548.08
$635.55
$109.34

Plan: (PPO) BlueCross Bronze B04S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $5,300 : Family: $10,600
Out of Pocket Maximum per year: Individual: $5,300 : Family: $10,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$166.50
$188.98
$212.78
$297.37
$451.87
$333.00
$377.96
$425.56
$594.74
$903.74
$438.73
$483.69
$531.29
$700.47
$544.46
$589.42
$637.02
$806.20
$650.19
$695.15
$742.75
$911.93
$272.23
$294.71
$318.51
$403.10
$377.96
$400.44
$424.24
$508.83
$483.69
$506.17
$529.97
$614.56
$105.73

Plan: (PPO) BlueCross Bronze B01E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$152.46
$173.04
$194.84
$272.29
$413.77
$304.92
$346.08
$389.68
$544.58
$827.54
$401.73
$442.89
$486.49
$641.39
$498.54
$539.70
$583.30
$738.20
$595.35
$636.51
$680.11
$835.01
$249.27
$269.85
$291.65
$369.10
$346.08
$366.66
$388.46
$465.91
$442.89
$463.47
$485.27
$562.72
$96.81

Plan: (PPO) BlueCross Bronze B02E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$132.14
$149.98
$168.88
$236.01
$358.64
$264.28
$299.96
$337.76
$472.02
$717.28
$348.19
$383.87
$421.67
$555.93
$432.10
$467.78
$505.58
$639.84
$516.01
$551.69
$589.49
$723.75
$216.05
$233.89
$252.79
$319.92
$299.96
$317.80
$336.70
$403.83
$383.87
$401.71
$420.61
$487.74
$83.91

Plan: (PPO) BlueCross Bronze B03E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$146.36
$166.12
$187.05
$261.40
$397.22
$292.72
$332.24
$374.10
$522.80
$794.44
$385.66
$425.18
$467.04
$615.74
$478.60
$518.12
$559.98
$708.68
$571.54
$611.06
$652.92
$801.62
$239.30
$259.06
$279.99
$354.34
$332.24
$352.00
$372.93
$447.28
$425.18
$444.94
$465.87
$540.22
$92.94

Plan: (PPO) BlueCross Bronze B04E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $5,300 : Family: $10,600
Out of Pocket Maximum per year: Individual: $5,300 : Family: $10,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$141.52
$160.63
$180.86
$252.76
$384.09
$283.04
$321.26
$361.72
$505.52
$768.18
$372.91
$411.13
$451.59
$595.39
$462.78
$501.00
$541.46
$685.26
$552.65
$590.87
$631.33
$775.13
$231.39
$250.50
$270.73
$342.63
$321.26
$340.37
$360.60
$432.50
$411.13
$430.24
$450.47
$522.37
$89.87

Plan: (PPO) BlueCross Bronze B07E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $5,200 : Family: $10,400
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$119.59
$135.74
$152.83
$213.59
$324.57
$239.18
$271.48
$305.66
$427.18
$649.14
$315.12
$347.42
$381.60
$503.12
$391.06
$423.36
$457.54
$579.06
$467.00
$499.30
$533.48
$655.00
$195.53
$211.68
$228.77
$289.53
$271.47
$287.62
$304.71
$365.47
$347.41
$363.56
$380.65
$441.41
$75.94

Plan: (PPO) BlueCross Bronze B07S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $5,200 : Family: $10,400
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$140.69
$159.69
$179.80
$251.28
$381.85
$281.38
$319.38
$359.60
$502.56
$763.70
$370.72
$408.72
$448.94
$591.90
$460.06
$498.06
$538.28
$681.24
$549.40
$587.40
$627.62
$770.58
$230.03
$249.03
$269.14
$340.62
$319.37
$338.37
$358.48
$429.96
$408.71
$427.71
$447.82
$519.30
$89.34

Plan: (PPO) BlueCross Silver S01S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$237.80
$269.90
$303.90
$424.70
$645.38
$475.60
$539.80
$607.80
$849.40
$1290.76
$626.60
$690.80
$758.80
$1000.40
$777.60
$841.80
$909.80
$1151.40
$928.60
$992.80
$1060.80
$1302.40
$388.80
$420.90
$454.90
$575.70
$539.80
$571.90
$605.90
$726.70
$690.80
$722.90
$756.90
$877.70
$151.00

Plan: (PPO) BlueCross Silver S02S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $6,250 : Family: $12,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$218.96
$248.52
$279.83
$391.06
$594.25
$437.92
$497.04
$559.66
$782.12
$1188.50
$576.96
$636.08
$698.70
$921.16
$716.00
$775.12
$837.74
$1060.20
$855.04
$914.16
$976.78
$1199.24
$358.00
$387.56
$418.87
$530.10
$497.04
$526.60
$557.91
$669.14
$636.08
$665.64
$696.95
$808.18
$139.04

Plan: (PPO) BlueCross Silver S04S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$202.62
$229.97
$258.95
$361.88
$549.91
$405.24
$459.94
$517.90
$723.76
$1099.82
$533.90
$588.60
$646.56
$852.42
$662.56
$717.26
$775.22
$981.08
$791.22
$845.92
$903.88
$1109.74
$331.28
$358.63
$387.61
$490.54
$459.94
$487.29
$516.27
$619.20
$588.60
$615.95
$644.93
$747.86
$128.66

Plan: (PPO) BlueCross Silver S07S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$229.34
$260.30
$293.10
$409.60
$622.43
$458.68
$520.60
$586.20
$819.20
$1244.86
$604.31
$666.23
$731.83
$964.83
$749.94
$811.86
$877.46
$1110.46
$895.57
$957.49
$1023.09
$1256.09
$374.97
$405.93
$438.73
$555.23
$520.60
$551.56
$584.36
$700.86
$666.23
$697.19
$729.99
$846.49
$145.63

Plan: (PPO) BlueCross Silver S08S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$228.93
$259.83
$292.57
$408.87
$621.31
$457.86
$519.66
$585.14
$817.74
$1242.62
$603.23
$665.03
$730.51
$963.11
$748.60
$810.40
$875.88
$1108.48
$893.97
$955.77
$1021.25
$1253.85
$374.30
$405.20
$437.94
$554.24
$519.67
$550.57
$583.31
$699.61
$665.04
$695.94
$728.68
$844.98
$145.37

Plan: (PPO) BlueCross Silver S09S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$210.92
$239.40
$269.55
$376.70
$572.43
$421.84
$478.80
$539.10
$753.40
$1144.86
$555.77
$612.73
$673.03
$887.33
$689.70
$746.66
$806.96
$1021.26
$823.63
$880.59
$940.89
$1155.19
$344.85
$373.33
$403.48
$510.63
$478.78
$507.26
$537.41
$644.56
$612.71
$641.19
$671.34
$778.49
$133.93

Plan: (PPO) BlueCross Silver S11S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$246.30
$279.55
$314.77
$439.88
$668.45
$492.60
$559.10
$629.54
$879.76
$1336.90
$649.00
$715.50
$785.94
$1036.16
$805.40
$871.90
$942.34
$1192.56
$961.80
$1028.30
$1098.74
$1348.96
$402.70
$435.95
$471.17
$596.28
$559.10
$592.35
$627.57
$752.68
$715.50
$748.75
$783.97
$909.08
$156.40

Plan: (PPO) BlueCross Silver S12S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$242.20
$274.90
$309.54
$432.58
$657.34
$484.40
$549.80
$619.08
$865.16
$1314.68
$638.20
$703.60
$772.88
$1018.96
$792.00
$857.40
$926.68
$1172.76
$945.80
$1011.20
$1080.48
$1326.56
$396.00
$428.70
$463.34
$586.38
$549.80
$582.50
$617.14
$740.18
$703.60
$736.30
$770.94
$893.98
$153.80

Plan: (PPO) BlueCross Silver S14S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$259.31
$294.32
$331.40
$463.13
$703.76
$518.62
$588.64
$662.80
$926.26
$1407.52
$683.28
$753.30
$827.46
$1090.92
$847.94
$917.96
$992.12
$1255.58
$1012.60
$1082.62
$1156.78
$1420.24
$423.97
$458.98
$496.06
$627.79
$588.63
$623.64
$660.72
$792.45
$753.29
$788.30
$825.38
$957.11
$164.66

Plan: (PPO) BlueCross Silver S16S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$212.10
$240.73
$271.06
$378.81
$575.63
$424.20
$481.46
$542.12
$757.62
$1151.26
$558.89
$616.15
$676.81
$892.31
$693.58
$750.84
$811.50
$1027.00
$828.27
$885.53
$946.19
$1161.69
$346.79
$375.42
$405.75
$513.50
$481.48
$510.11
$540.44
$648.19
$616.17
$644.80
$675.13
$782.88
$134.69

Plan: (PPO) BlueCross Silver S01E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$202.13
$229.42
$258.31
$361.00
$548.57
$404.26
$458.84
$516.62
$722.00
$1097.14
$532.61
$587.19
$644.97
$850.35
$660.96
$715.54
$773.32
$978.70
$789.31
$843.89
$901.67
$1107.05
$330.48
$357.77
$386.66
$489.35
$458.83
$486.12
$515.01
$617.70
$587.18
$614.47
$643.36
$746.05
$128.35

Plan: (PPO) BlueCross Silver S02E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $6,250 : Family: $12,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$186.11
$211.24
$237.86
$332.40
$505.11
$372.22
$422.48
$475.72
$664.80
$1010.22
$490.41
$540.67
$593.91
$782.99
$608.60
$658.86
$712.10
$901.18
$726.79
$777.05
$830.29
$1019.37
$304.30
$329.43
$356.05
$450.59
$422.49
$447.62
$474.24
$568.78
$540.68
$565.81
$592.43
$686.97
$118.19

Plan: (PPO) BlueCross Silver S04E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$172.23
$195.47
$220.11
$307.60
$467.42
$344.46
$390.94
$440.22
$615.20
$934.84
$453.82
$500.30
$549.58
$724.56
$563.18
$609.66
$658.94
$833.92
$672.54
$719.02
$768.30
$943.28
$281.59
$304.83
$329.47
$416.96
$390.95
$414.19
$438.83
$526.32
$500.31
$523.55
$548.19
$635.68
$109.36

Plan: (PPO) BlueCross Silver S07E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$194.94
$221.25
$249.13
$348.16
$529.07
$389.88
$442.50
$498.26
$696.32
$1058.14
$513.66
$566.28
$622.04
$820.10
$637.44
$690.06
$745.82
$943.88
$761.22
$813.84
$869.60
$1067.66
$318.72
$345.03
$372.91
$471.94
$442.50
$468.81
$496.69
$595.72
$566.28
$592.59
$620.47
$719.50
$123.78

Plan: (PPO) BlueCross Silver S08E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$194.59
$220.86
$248.68
$347.54
$528.12
$389.18
$441.72
$497.36
$695.08
$1056.24
$512.75
$565.29
$620.93
$818.65
$636.32
$688.86
$744.50
$942.22
$759.89
$812.43
$868.07
$1065.79
$318.16
$344.43
$372.25
$471.11
$441.73
$468.00
$495.82
$594.68
$565.30
$591.57
$619.39
$718.25
$123.57

Plan: (PPO) BlueCross Silver S09E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$179.28
$203.49
$229.12
$320.20
$486.57
$358.56
$406.98
$458.24
$640.40
$973.14
$472.40
$520.82
$572.08
$754.24
$586.24
$634.66
$685.92
$868.08
$700.08
$748.50
$799.76
$981.92
$293.12
$317.33
$342.96
$434.04
$406.96
$431.17
$456.80
$547.88
$520.80
$545.01
$570.64
$661.72
$113.84

Plan: (PPO) BlueCross Silver S11E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$209.35
$237.61
$267.55
$373.90
$568.18
$418.70
$475.22
$535.10
$747.80
$1136.36
$551.64
$608.16
$668.04
$880.74
$684.58
$741.10
$800.98
$1013.68
$817.52
$874.04
$933.92
$1146.62
$342.29
$370.55
$400.49
$506.84
$475.23
$503.49
$533.43
$639.78
$608.17
$636.43
$666.37
$772.72
$132.94

Plan: (PPO) BlueCross Silver S12E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$205.87
$233.66
$263.11
$367.69
$558.74
$411.74
$467.32
$526.22
$735.38
$1117.48
$542.47
$598.05
$656.95
$866.11
$673.20
$728.78
$787.68
$996.84
$803.93
$859.51
$918.41
$1127.57
$336.60
$364.39
$393.84
$498.42
$467.33
$495.12
$524.57
$629.15
$598.06
$625.85
$655.30
$759.88
$130.73

Plan: (PPO) BlueCross Silver S14E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$220.41
$250.17
$281.69
$393.66
$598.20
$440.82
$500.34
$563.38
$787.32
$1196.40
$580.78
$640.30
$703.34
$927.28
$720.74
$780.26
$843.30
$1067.24
$860.70
$920.22
$983.26
$1207.20
$360.37
$390.13
$421.65
$533.62
$500.33
$530.09
$561.61
$673.58
$640.29
$670.05
$701.57
$813.54
$139.96

Plan: (PPO) BlueCross Silver S16E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$180.28
$204.62
$230.40
$321.98
$489.29
$360.56
$409.24
$460.80
$643.96
$978.58
$475.04
$523.72
$575.28
$758.44
$589.52
$638.20
$689.76
$872.92
$704.00
$752.68
$804.24
$987.40
$294.76
$319.10
$344.88
$436.46
$409.24
$433.58
$459.36
$550.94
$523.72
$548.06
$573.84
$665.42
$114.48

Plan: (PPO) BlueCross Silver S19E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $4,250 : Family: $8,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$179.78
$204.05
$229.76
$321.09
$487.93
$359.56
$408.10
$459.52
$642.18
$975.86
$473.72
$522.26
$573.68
$756.34
$587.88
$636.42
$687.84
$870.50
$702.04
$750.58
$802.00
$984.66
$293.94
$318.21
$343.92
$435.25
$408.10
$432.37
$458.08
$549.41
$522.26
$546.53
$572.24
$663.57
$114.16

Plan: (PPO) BlueCross Silver S19S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $4,250 : Family: $8,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$211.51
$240.06
$270.31
$377.75
$574.03
$423.02
$480.12
$540.62
$755.50
$1148.06
$557.33
$614.43
$674.93
$889.81
$691.64
$748.74
$809.24
$1024.12
$825.95
$883.05
$943.55
$1158.43
$345.82
$374.37
$404.62
$512.06
$480.13
$508.68
$538.93
$646.37
$614.44
$642.99
$673.24
$780.68
$134.31

Plan: (PPO) BlueCross Gold G01S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $5,250 : Family: $10,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$286.08
$324.70
$365.60
$510.94
$776.42
$572.16
$649.40
$731.20
$1021.88
$1552.84
$753.82
$831.06
$912.86
$1203.54
$935.48
$1012.72
$1094.52
$1385.20
$1117.14
$1194.38
$1276.18
$1566.86
$467.74
$506.36
$547.26
$692.60
$649.40
$688.02
$728.92
$874.26
$831.06
$869.68
$910.58
$1055.92
$181.66

Plan: (PPO) BlueCross Gold G02S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$321.48
$364.88
$410.85
$574.16
$872.49
$642.96
$729.76
$821.70
$1148.32
$1744.98
$847.10
$933.90
$1025.84
$1352.46
$1051.24
$1138.04
$1229.98
$1556.60
$1255.38
$1342.18
$1434.12
$1760.74
$525.62
$569.02
$614.99
$778.30
$729.76
$773.16
$819.13
$982.44
$933.90
$977.30
$1023.27
$1186.58
$204.14

Plan: (PPO) BlueCross Gold G04S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$348.99
$396.11
$446.01
$623.30
$947.17
$697.98
$792.22
$892.02
$1246.60
$1894.34
$919.59
$1013.83
$1113.63
$1468.21
$1141.20
$1235.44
$1335.24
$1689.82
$1362.81
$1457.05
$1556.85
$1911.43
$570.60
$617.72
$667.62
$844.91
$792.21
$839.33
$889.23
$1066.52
$1013.82
$1060.94
$1110.84
$1288.13
$221.61

Plan: (PPO) BlueCross Gold G06S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$331.23
$375.94
$423.31
$591.58
$898.95
$662.46
$751.88
$846.62
$1183.16
$1797.90
$872.79
$962.21
$1056.95
$1393.49
$1083.12
$1172.54
$1267.28
$1603.82
$1293.45
$1382.87
$1477.61
$1814.15
$541.56
$586.27
$633.64
$801.91
$751.89
$796.60
$843.97
$1012.24
$962.22
$1006.93
$1054.30
$1222.57
$210.33

Plan: (PPO) BlueCross Gold G08S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,100 : Family: $4,200
Out of Pocket Maximum per year: Individual: $2,100 : Family: $4,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$268.93
$305.23
$343.69
$480.32
$729.88
$537.86
$610.46
$687.38
$960.64
$1459.76
$708.63
$781.23
$858.15
$1131.41
$879.40
$952.00
$1028.92
$1302.18
$1050.17
$1122.77
$1199.69
$1472.95
$439.70
$476.00
$514.46
$651.09
$610.47
$646.77
$685.23
$821.86
$781.24
$817.54
$856.00
$992.63
$170.77

Plan: (PPO) BlueCross Gold G10S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$270.34
$306.84
$345.50
$482.83
$733.71
$540.68
$613.68
$691.00
$965.66
$1467.42
$712.35
$785.35
$862.67
$1137.33
$884.02
$957.02
$1034.34
$1309.00
$1055.69
$1128.69
$1206.01
$1480.67
$442.01
$478.51
$517.17
$654.50
$613.68
$650.18
$688.84
$826.17
$785.35
$821.85
$860.51
$997.84
$171.67

Plan: (PPO) BlueCross Gold G11S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$307.55
$349.07
$393.05
$549.28
$834.69
$615.10
$698.14
$786.10
$1098.56
$1669.38
$810.39
$893.43
$981.39
$1293.85
$1005.68
$1088.72
$1176.68
$1489.14
$1200.97
$1284.01
$1371.97
$1684.43
$502.84
$544.36
$588.34
$744.57
$698.13
$739.65
$783.63
$939.86
$893.42
$934.94
$978.92
$1135.15
$195.29

Plan: (PPO) BlueCross Gold G01E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $5,250 : Family: $10,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$243.17
$275.99
$310.76
$434.30
$659.96
$486.34
$551.98
$621.52
$868.60
$1319.92
$640.75
$706.39
$775.93
$1023.01
$795.16
$860.80
$930.34
$1177.42
$949.57
$1015.21
$1084.75
$1331.83
$397.58
$430.40
$465.17
$588.71
$551.99
$584.81
$619.58
$743.12
$706.40
$739.22
$773.99
$897.53
$154.41

Plan: (PPO) BlueCross Gold G02E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$273.25
$310.15
$349.22
$488.03
$741.62
$546.50
$620.30
$698.44
$976.06
$1483.24
$720.01
$793.81
$871.95
$1149.57
$893.52
$967.32
$1045.46
$1323.08
$1067.03
$1140.83
$1218.97
$1496.59
$446.76
$483.66
$522.73
$661.54
$620.27
$657.17
$696.24
$835.05
$793.78
$830.68
$869.75
$1008.56
$173.51

Plan: (PPO) BlueCross Gold G04E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$296.65
$336.69
$379.11
$529.81
$805.09
$593.30
$673.38
$758.22
$1059.62
$1610.18
$781.67
$861.75
$946.59
$1247.99
$970.04
$1050.12
$1134.96
$1436.36
$1158.41
$1238.49
$1323.33
$1624.73
$485.02
$525.06
$567.48
$718.18
$673.39
$713.43
$755.85
$906.55
$861.76
$901.80
$944.22
$1094.92
$188.37

Plan: (PPO) BlueCross Gold G06E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $4,500 : Family: $9,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$281.54
$319.55
$359.82
$502.84
$764.10
$563.08
$639.10
$719.64
$1005.68
$1528.20
$741.86
$817.88
$898.42
$1184.46
$920.64
$996.66
$1077.20
$1363.24
$1099.42
$1175.44
$1255.98
$1542.02
$460.32
$498.33
$538.60
$681.62
$639.10
$677.11
$717.38
$860.40
$817.88
$855.89
$896.16
$1039.18
$178.78

Plan: (PPO) BlueCross Gold G08E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $2,100 : Family: $4,200
Out of Pocket Maximum per year: Individual: $2,100 : Family: $4,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$228.59
$259.45
$292.14
$408.27
$620.40
$457.18
$518.90
$584.28
$816.54
$1240.80
$602.33
$664.05
$729.43
$961.69
$747.48
$809.20
$874.58
$1106.84
$892.63
$954.35
$1019.73
$1251.99
$373.74
$404.60
$437.29
$553.42
$518.89
$549.75
$582.44
$698.57
$664.04
$694.90
$727.59
$843.72
$145.15

Plan: (PPO) BlueCross Gold G10E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$229.79
$260.82
$293.68
$410.41
$623.65
$459.58
$521.64
$587.36
$820.82
$1247.30
$605.50
$667.56
$733.28
$966.74
$751.42
$813.48
$879.20
$1112.66
$897.34
$959.40
$1025.12
$1258.58
$375.71
$406.74
$439.60
$556.33
$521.63
$552.66
$585.52
$702.25
$667.55
$698.58
$731.44
$848.17
$145.92

Plan: (PPO) BlueCross Gold G11E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$261.42
$296.71
$334.09
$466.89
$709.48
$522.84
$593.42
$668.18
$933.78
$1418.96
$688.84
$759.42
$834.18
$1099.78
$854.84
$925.42
$1000.18
$1265.78
$1020.84
$1091.42
$1166.18
$1431.78
$427.42
$462.71
$500.09
$632.89
$593.42
$628.71
$666.09
$798.89
$759.42
$794.71
$832.09
$964.89
$166.00

Plan: (PPO) BlueCross Platinum P01S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $1,800 : Family: $3,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$363.16
$412.19
$464.13
$648.61
$985.63
$726.32
$824.38
$928.26
$1297.22
$1971.26
$956.93
$1054.99
$1158.87
$1527.83
$1187.54
$1285.60
$1389.48
$1758.44
$1418.15
$1516.21
$1620.09
$1989.05
$593.77
$642.80
$694.74
$879.22
$824.38
$873.41
$925.35
$1109.83
$1054.99
$1104.02
$1155.96
$1340.44
$230.61

Plan: (PPO) BlueCross Platinum P02S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $1,500 : Family: $3,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$369.16
$419.00
$471.78
$659.32
$1001.90
$738.32
$838.00
$943.56
$1318.64
$2003.80
$972.74
$1072.42
$1177.98
$1553.06
$1207.16
$1306.84
$1412.40
$1787.48
$1441.58
$1541.26
$1646.82
$2021.90
$603.58
$653.42
$706.20
$893.74
$838.00
$887.84
$940.62
$1128.16
$1072.42
$1122.26
$1175.04
$1362.58
$234.42

Plan: (PPO) BlueCross Platinum P03S

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$399.06
$452.92
$509.99
$712.72
$1083.03
$798.12
$905.84
$1019.98
$1425.44
$2166.06
$1051.52
$1159.24
$1273.38
$1678.84
$1304.92
$1412.64
$1526.78
$1932.24
$1558.32
$1666.04
$1780.18
$2185.64
$652.46
$706.32
$763.39
$966.12
$905.86
$959.72
$1016.79
$1219.52
$1159.26
$1213.12
$1270.19
$1472.92
$253.40

Plan: (PPO) BlueCross Platinum P01E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $1,800 : Family: $3,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$308.69
$350.36
$394.51
$551.32
$837.78
$617.38
$700.72
$789.02
$1102.64
$1675.56
$813.40
$896.74
$985.04
$1298.66
$1009.42
$1092.76
$1181.06
$1494.68
$1205.44
$1288.78
$1377.08
$1690.70
$504.71
$546.38
$590.53
$747.34
$700.73
$742.40
$786.55
$943.36
$896.75
$938.42
$982.57
$1139.38
$196.02

Plan: (PPO) BlueCross Platinum P02E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $1,500 : Family: $3,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$313.79
$356.15
$401.02
$560.42
$851.61
$627.58
$712.30
$802.04
$1120.84
$1703.22
$826.84
$911.56
$1001.30
$1320.10
$1026.10
$1110.82
$1200.56
$1519.36
$1225.36
$1310.08
$1399.82
$1718.62
$513.05
$555.41
$600.28
$759.68
$712.31
$754.67
$799.54
$958.94
$911.57
$953.93
$998.80
$1158.20
$199.26

Plan: (PPO) BlueCross Platinum P03E

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-743-0455 - Provider Directory for This Plan: (BlueCross BlueShield of Tennessee)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $3,000 : Family: $6,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$339.20
$384.99
$433.49
$605.81
$920.58
$678.40
$769.98
$866.98
$1211.62
$1841.16
$893.79
$985.37
$1082.37
$1427.01
$1109.18
$1200.76
$1297.76
$1642.40
$1324.57
$1416.15
$1513.15
$1857.79
$554.59
$600.38
$648.88
$821.20
$769.98
$815.77
$864.27
$1036.59
$985.37
$1031.16
$1079.66
$1251.98
$215.39

Assurant Health

Local: 1-414-271-3011 | Toll Free: 1-800-800-1212

Plan: (PPO) Assurant Health Bronze Plan 001

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-800-1212 - Provider Directory for This Plan: (Assurant Health)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$248.82
$282.41
$317.99
$444.39
$675.30
$497.64
$564.82
$635.98
$888.78
$1350.60
$655.64
$722.82
$793.98
$1046.78
$813.64
$880.82
$951.98
$1204.78
$971.64
$1038.82
$1109.98
$1362.78
$406.82
$440.41
$475.99
$602.39
$564.82
$598.41
$633.99
$760.39
$722.82
$756.41
$791.99
$918.39
$158.00

Plan: (PPO) Assurant Health Silver Plan 001

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-800-1212 - Provider Directory for This Plan: (Assurant Health)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$296.40
$336.41
$378.80
$529.37
$804.43
$592.80
$672.82
$757.60
$1058.74
$1608.86
$781.01
$861.03
$945.81
$1246.95
$969.22
$1049.24
$1134.02
$1435.16
$1157.43
$1237.45
$1322.23
$1623.37
$484.61
$524.62
$567.01
$717.58
$672.82
$712.83
$755.22
$905.79
$861.03
$901.04
$943.43
$1094.00
$188.21

Plan: (PPO) Assurant Health Bronze Plan 002

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-800-1212 - Provider Directory for This Plan: (Assurant Health)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$257.85
$292.66
$329.53
$460.52
$699.80
$515.70
$585.32
$659.06
$921.04
$1399.60
$679.43
$749.05
$822.79
$1084.77
$843.16
$912.78
$986.52
$1248.50
$1006.89
$1076.51
$1150.25
$1412.23
$421.58
$456.39
$493.26
$624.25
$585.31
$620.12
$656.99
$787.98
$749.04
$783.85
$820.72
$951.71
$163.73

Plan: (PPO) Assurant Health Silver Plan 002

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-800-1212 - Provider Directory for This Plan: (Assurant Health)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$302.13
$342.92
$386.12
$539.60
$819.98
$604.26
$685.84
$772.24
$1079.20
$1639.96
$796.11
$877.69
$964.09
$1271.05
$987.96
$1069.54
$1155.94
$1462.90
$1179.81
$1261.39
$1347.79
$1654.75
$493.98
$534.77
$577.97
$731.45
$685.83
$726.62
$769.82
$923.30
$877.68
$918.47
$961.67
$1115.15
$191.85

Plan: (PPO) Assurant Health Gold Plan 002

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-800-1212 - Provider Directory for This Plan: (Assurant Health)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$363.88
$413.00
$465.04
$649.89
$987.57
$727.76
$826.00
$930.08
$1299.78
$1975.14
$958.82
$1057.06
$1161.14
$1530.84
$1189.88
$1288.12
$1392.20
$1761.90
$1420.94
$1519.18
$1623.26
$1992.96
$594.94
$644.06
$696.10
$880.95
$826.00
$875.12
$927.16
$1112.01
$1057.06
$1106.18
$1158.22
$1343.07
$231.06

Plan: (PPO) Assurant Health Platinum Plan 002

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-800-1212 - Provider Directory for This Plan: (Assurant Health)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $2,000 : Family: $4,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$415.69
$471.81
$531.25
$742.42
$1128.18
$831.38
$943.62
$1062.50
$1484.84
$2256.36
$1095.34
$1207.58
$1326.46
$1748.80
$1359.30
$1471.54
$1590.42
$2012.76
$1623.26
$1735.50
$1854.38
$2276.72
$679.65
$735.77
$795.21
$1006.38
$943.61
$999.73
$1059.17
$1270.34
$1207.57
$1263.69
$1323.13
$1534.30
$263.96

Community Health Alliance

Local: 1-800-580-8574 | Toll Free: 1-800-580-8574

TTY: 1-800-545-8279

Plan: (PPO) Community Health Choice B Silver 10

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$187.66
$212.98
$239.82
$335.14
$509.28
$375.32
$425.96
$479.64
$670.28
$1018.56
$494.48
$545.12
$598.80
$789.44
$613.64
$664.28
$717.96
$908.60
$732.80
$783.44
$837.12
$1027.76
$306.82
$332.14
$358.98
$454.30
$425.98
$451.30
$478.14
$573.46
$545.14
$570.46
$597.30
$692.62
$119.16

Plan: (PPO) Community Health Select Nash Silver 10

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$162.06
$183.93
$207.10
$289.42
$439.80
$324.12
$367.86
$414.20
$578.84
$879.60
$427.02
$470.76
$517.10
$681.74
$529.92
$573.66
$620.00
$784.64
$632.82
$676.56
$722.90
$887.54
$264.96
$286.83
$310.00
$392.32
$367.86
$389.73
$412.90
$495.22
$470.76
$492.63
$515.80
$598.12
$102.90

Plan: (PPO) Community Health Choice B Silver 11

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$199.01
$225.86
$254.32
$355.41
$540.08
$398.02
$451.72
$508.64
$710.82
$1080.16
$524.38
$578.08
$635.00
$837.18
$650.74
$704.44
$761.36
$963.54
$777.10
$830.80
$887.72
$1089.90
$325.37
$352.22
$380.68
$481.77
$451.73
$478.58
$507.04
$608.13
$578.09
$604.94
$633.40
$734.49
$126.36

Plan: (PPO) Community Health Select Nash Silver 11

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $6,450 : Family: $12,900

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$171.88
$195.08
$219.65
$306.97
$466.47
$343.76
$390.16
$439.30
$613.94
$932.94
$452.90
$499.30
$548.44
$723.08
$562.04
$608.44
$657.58
$832.22
$671.18
$717.58
$766.72
$941.36
$281.02
$304.22
$328.79
$416.11
$390.16
$413.36
$437.93
$525.25
$499.30
$522.50
$547.07
$634.39
$109.14

Plan: (PPO) Community Health Choice B Silver 12

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,600 : Family: $5,200
Out of Pocket Maximum per year: Individual: $4,400 : Family: $8,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$187.11
$212.35
$239.11
$334.15
$507.78
$374.22
$424.70
$478.22
$668.30
$1015.56
$493.03
$543.51
$597.03
$787.11
$611.84
$662.32
$715.84
$905.92
$730.65
$781.13
$834.65
$1024.73
$305.92
$331.16
$357.92
$452.96
$424.73
$449.97
$476.73
$571.77
$543.54
$568.78
$595.54
$690.58
$118.81

Plan: (PPO) Community Health Select Nash Silver 12

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,600 : Family: $5,200
Out of Pocket Maximum per year: Individual: $4,400 : Family: $8,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$161.51
$183.30
$206.39
$288.43
$438.30
$323.02
$366.60
$412.78
$576.86
$876.60
$425.57
$469.15
$515.33
$679.41
$528.12
$571.70
$617.88
$781.96
$630.67
$674.25
$720.43
$884.51
$264.06
$285.85
$308.94
$390.98
$366.61
$388.40
$411.49
$493.53
$469.16
$490.95
$514.04
$596.08
$102.55

Plan: (PPO) Community Health Choice B Silver 13

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $3,600 : Family: $7,200
Out of Pocket Maximum per year: Individual: $3,600 : Family: $7,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$199.15
$226.02
$254.50
$355.66
$540.45
$398.30
$452.04
$509.00
$711.32
$1080.90
$524.75
$578.49
$635.45
$837.77
$651.20
$704.94
$761.90
$964.22
$777.65
$831.39
$888.35
$1090.67
$325.60
$352.47
$380.95
$482.11
$452.05
$478.92
$507.40
$608.56
$578.50
$605.37
$633.85
$735.01
$126.45

Plan: (PPO) Community Health Select Nash Silver 13

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $3,600 : Family: $7,200
Out of Pocket Maximum per year: Individual: $3,600 : Family: $7,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$172.02
$195.23
$219.83
$307.21
$466.84
$344.04
$390.46
$439.66
$614.42
$933.68
$453.27
$499.69
$548.89
$723.65
$562.50
$608.92
$658.12
$832.88
$671.73
$718.15
$767.35
$942.11
$281.25
$304.46
$329.06
$416.44
$390.48
$413.69
$438.29
$525.67
$499.71
$522.92
$547.52
$634.90
$109.23

Plan: (PPO) Community Health Choice B Silver 14

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$206.62
$234.50
$264.05
$369.00
$560.74
$413.24
$469.00
$528.10
$738.00
$1121.48
$544.44
$600.20
$659.30
$869.20
$675.64
$731.40
$790.50
$1000.40
$806.84
$862.60
$921.70
$1131.60
$337.82
$365.70
$395.25
$500.20
$469.02
$496.90
$526.45
$631.40
$600.22
$628.10
$657.65
$762.60
$131.20

Plan: (PPO) Community Health Select Nash Silver 14

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $0 : Family: $0
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$178.39
$202.46
$227.97
$318.58
$484.12
$356.78
$404.92
$455.94
$637.16
$968.24
$470.05
$518.19
$569.21
$750.43
$583.32
$631.46
$682.48
$863.70
$696.59
$744.73
$795.75
$976.97
$291.66
$315.73
$341.24
$431.85
$404.93
$429.00
$454.51
$545.12
$518.20
$542.27
$567.78
$658.39
$113.27

Plan: (PPO) Community Health Choice B Silver 15

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$175.62
$199.32
$224.43
$313.64
$476.61
$351.24
$398.64
$448.86
$627.28
$953.22
$462.75
$510.15
$560.37
$738.79
$574.26
$621.66
$671.88
$850.30
$685.77
$733.17
$783.39
$961.81
$287.13
$310.83
$335.94
$425.15
$398.64
$422.34
$447.45
$536.66
$510.15
$533.85
$558.96
$648.17
$111.51

Plan: (PPO) Community Health Select Nash Silver 15

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $4,000 : Family: $8,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$151.68
$172.15
$193.83
$270.88
$411.63
$303.36
$344.30
$387.66
$541.76
$823.26
$399.67
$440.61
$483.97
$638.07
$495.98
$536.92
$580.28
$734.38
$592.29
$633.23
$676.59
$830.69
$247.99
$268.46
$290.14
$367.19
$344.30
$364.77
$386.45
$463.50
$440.61
$461.08
$482.76
$559.81
$96.31

Plan: (PPO) Community Health Choice B Silver 16

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $5,600 : Family: $11,200
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$196.10
$222.56
$250.60
$350.22
$532.19
$392.20
$445.12
$501.20
$700.44
$1064.38
$516.72
$569.64
$625.72
$824.96
$641.24
$694.16
$750.24
$949.48
$765.76
$818.68
$874.76
$1074.00
$320.62
$347.08
$375.12
$474.74
$445.14
$471.60
$499.64
$599.26
$569.66
$596.12
$624.16
$723.78
$124.52

Plan: (PPO) Community Health Select Nash Silver 16

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $5,600 : Family: $11,200
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$169.25
$192.09
$216.29
$302.27
$459.33
$338.50
$384.18
$432.58
$604.54
$918.66
$445.97
$491.65
$540.05
$712.01
$553.44
$599.12
$647.52
$819.48
$660.91
$706.59
$754.99
$926.95
$276.72
$299.56
$323.76
$409.74
$384.19
$407.03
$431.23
$517.21
$491.66
$514.50
$538.70
$624.68
$107.47

Plan: (PPO) Community Health Choice B Silver 17

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$183.79
$208.58
$234.86
$328.22
$498.77
$367.58
$417.16
$469.72
$656.44
$997.54
$484.28
$533.86
$586.42
$773.14
$600.98
$650.56
$703.12
$889.84
$717.68
$767.26
$819.82
$1006.54
$300.49
$325.28
$351.56
$444.92
$417.19
$441.98
$468.26
$561.62
$533.89
$558.68
$584.96
$678.32
$116.70

Plan: (PPO) Community Health Select Nash Silver 17

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$158.74
$180.16
$202.85
$283.49
$430.79
$317.48
$360.32
$405.70
$566.98
$861.58
$418.27
$461.11
$506.49
$667.77
$519.06
$561.90
$607.28
$768.56
$619.85
$662.69
$708.07
$869.35
$259.53
$280.95
$303.64
$384.28
$360.32
$381.74
$404.43
$485.07
$461.11
$482.53
$505.22
$585.86
$100.79

Plan: (PPO) Community Health Choice B Bronze 10

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$148.91
$169.00
$190.30
$265.94
$404.12
$297.82
$338.00
$380.60
$531.88
$808.24
$392.37
$432.55
$475.15
$626.43
$486.92
$527.10
$569.70
$720.98
$581.47
$621.65
$664.25
$815.53
$243.46
$263.55
$284.85
$360.49
$338.01
$358.10
$379.40
$455.04
$432.56
$452.65
$473.95
$549.59
$94.55

Plan: (PPO) Community Health Select Nash Bronze 10

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$130.09
$147.64
$166.24
$232.33
$353.04
$260.18
$295.28
$332.48
$464.66
$706.08
$342.78
$377.88
$415.08
$547.26
$425.38
$460.48
$497.68
$629.86
$507.98
$543.08
$580.28
$712.46
$212.69
$230.24
$248.84
$314.93
$295.29
$312.84
$331.44
$397.53
$377.89
$395.44
$414.04
$480.13
$82.60

Plan: (PPO) Community Health Choice B Bronze 11

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$146.84
$166.65
$187.64
$262.23
$398.49
$293.68
$333.30
$375.28
$524.46
$796.98
$386.91
$426.53
$468.51
$617.69
$480.14
$519.76
$561.74
$710.92
$573.37
$612.99
$654.97
$804.15
$240.07
$259.88
$280.87
$355.46
$333.30
$353.11
$374.10
$448.69
$426.53
$446.34
$467.33
$541.92
$93.23

Plan: (PPO) Community Health Select Nash Bronze 11

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$128.29
$145.60
$163.95
$229.11
$348.16
$256.58
$291.20
$327.90
$458.22
$696.32
$338.04
$372.66
$409.36
$539.68
$419.50
$454.12
$490.82
$621.14
$500.96
$535.58
$572.28
$702.60
$209.75
$227.06
$245.41
$310.57
$291.21
$308.52
$326.87
$392.03
$372.67
$389.98
$408.33
$473.49
$81.46

Plan: (PPO) Community Health Choice B Bronze 12

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $6,600 : Family: $13,200
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$136.87
$155.34
$174.91
$244.44
$371.45
$273.74
$310.68
$349.82
$488.88
$742.90
$360.65
$397.59
$436.73
$575.79
$447.56
$484.50
$523.64
$662.70
$534.47
$571.41
$610.55
$749.61
$223.78
$242.25
$261.82
$331.35
$310.69
$329.16
$348.73
$418.26
$397.60
$416.07
$435.64
$505.17
$86.91

Plan: (PPO) Community Health Select Nash Bronze 12

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $6,600 : Family: $13,200
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$119.57
$135.71
$152.80
$213.54
$324.50
$239.14
$271.42
$305.60
$427.08
$649.00
$315.06
$347.34
$381.52
$503.00
$390.98
$423.26
$457.44
$578.92
$466.90
$499.18
$533.36
$654.84
$195.49
$211.63
$228.72
$289.46
$271.41
$287.55
$304.64
$365.38
$347.33
$363.47
$380.56
$441.30
$75.92

Plan: (PPO) Community Health Choice B Bronze 13

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $6,300 : Family: $12,600
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$169.81
$192.72
$217.00
$303.26
$460.83
$339.62
$385.44
$434.00
$606.52
$921.66
$447.44
$493.26
$541.82
$714.34
$555.26
$601.08
$649.64
$822.16
$663.08
$708.90
$757.46
$929.98
$277.63
$300.54
$324.82
$411.08
$385.45
$408.36
$432.64
$518.90
$493.27
$516.18
$540.46
$626.72
$107.82

Plan: (PPO) Community Health Select Nash Bronze 13

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $6,300 : Family: $12,600
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$148.50
$168.53
$189.77
$265.20
$402.99
$297.00
$337.06
$379.54
$530.40
$805.98
$391.29
$431.35
$473.83
$624.69
$485.58
$525.64
$568.12
$718.98
$579.87
$619.93
$662.41
$813.27
$242.79
$262.82
$284.06
$359.49
$337.08
$357.11
$378.35
$453.78
$431.37
$451.40
$472.64
$548.07
$94.29

Plan: (PPO) Community Health Choice B Bronze 14

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,700 : Family: $5,400
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$153.62
$174.34
$196.31
$274.34
$416.89
$307.24
$348.68
$392.62
$548.68
$833.78
$404.78
$446.22
$490.16
$646.22
$502.32
$543.76
$587.70
$743.76
$599.86
$641.30
$685.24
$841.30
$251.16
$271.88
$293.85
$371.88
$348.70
$369.42
$391.39
$469.42
$446.24
$466.96
$488.93
$566.96
$97.54

Plan: (PPO) Community Health Select Nash Bronze 14

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,700 : Family: $5,400
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$134.24
$152.35
$171.55
$239.74
$364.31
$268.48
$304.70
$343.10
$479.48
$728.62
$353.72
$389.94
$428.34
$564.72
$438.96
$475.18
$513.58
$649.96
$524.20
$560.42
$598.82
$735.20
$219.48
$237.59
$256.79
$324.98
$304.72
$322.83
$342.03
$410.22
$389.96
$408.07
$427.27
$495.46
$85.24

Plan: (PPO) Community Health Choice B Gold 10

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$260.17
$295.29
$332.49
$464.65
$706.08
$520.34
$590.58
$664.98
$929.30
$1412.16
$685.54
$755.78
$830.18
$1094.50
$850.74
$920.98
$995.38
$1259.70
$1015.94
$1086.18
$1160.58
$1424.90
$425.37
$460.49
$497.69
$629.85
$590.57
$625.69
$662.89
$795.05
$755.77
$790.89
$828.09
$960.25
$165.20

Plan: (PPO) Community Health Select Nash Gold 10

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$231.53
$262.77
$295.88
$413.49
$628.34
$463.06
$525.54
$591.76
$826.98
$1256.68
$610.07
$672.55
$738.77
$973.99
$757.08
$819.56
$885.78
$1121.00
$904.09
$966.57
$1032.79
$1268.01
$378.54
$409.78
$442.89
$560.50
$525.55
$556.79
$589.90
$707.51
$672.56
$703.80
$736.91
$854.52
$147.01

Plan: (PPO) Community Health Choice B Gold 12

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $3,250 : Family: $6,500
Out of Pocket Maximum per year: Individual: $3,250 : Family: $6,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$242.46
$275.18
$309.85
$433.02
$658.01
$484.92
$550.36
$619.70
$866.04
$1316.02
$638.88
$704.32
$773.66
$1020.00
$792.84
$858.28
$927.62
$1173.96
$946.80
$1012.24
$1081.58
$1327.92
$396.42
$429.14
$463.81
$586.98
$550.38
$583.10
$617.77
$740.94
$704.34
$737.06
$771.73
$894.90
$153.96

Plan: (PPO) Community Health Select Nash Gold 12

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $3,250 : Family: $6,500
Out of Pocket Maximum per year: Individual: $3,250 : Family: $6,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$215.75
$244.87
$275.72
$385.32
$585.52
$431.50
$489.74
$551.44
$770.64
$1171.04
$568.50
$626.74
$688.44
$907.64
$705.50
$763.74
$825.44
$1044.64
$842.50
$900.74
$962.44
$1181.64
$352.75
$381.87
$412.72
$522.32
$489.75
$518.87
$549.72
$659.32
$626.75
$655.87
$686.72
$796.32
$137.00

Plan: (PPO) CO-OPtions Community Health Choice B Silver 18, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$202.05
$229.32
$258.21
$360.85
$548.34
$404.10
$458.64
$516.42
$721.70
$1096.68
$532.40
$586.94
$644.72
$850.00
$660.70
$715.24
$773.02
$978.30
$789.00
$843.54
$901.32
$1106.60
$330.35
$357.62
$386.51
$489.15
$458.65
$485.92
$514.81
$617.45
$586.95
$614.22
$643.11
$745.75
$128.30

Plan: (PPO) CO-OPtions Community Health Choice B Gold 11, a Multi-State Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-580-8574 - Provider Directory for This Plan: (Community Health Alliance)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$252.42
$286.49
$322.58
$450.81
$685.05
$504.84
$572.98
$645.16
$901.62
$1370.10
$665.12
$733.26
$805.44
$1061.90
$825.40
$893.54
$965.72
$1222.18
$985.68
$1053.82
$1126.00
$1382.46
$412.70
$446.77
$482.86
$611.09
$572.98
$607.05
$643.14
$771.37
$733.26
$767.33
$803.42
$931.65
$160.28

Humana Insurance Company

Local: 1-877-720-4854 | Toll Free: 1-877-720-4854

TTY: 1-800-325-2028

Plan: (PPO) Humana Basic 6600/Nashville PPOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Insurance Company)

Deductible: Individual: $6,600 : Family: $13,200
Out of Pocket Maximum per year: Individual: $6,600 : Family: $13,200

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$149.09
$169.22
$190.54
$266.27
$404.63
$298.18
$338.44
$381.08
$532.54
$809.26
$392.85
$433.11
$475.75
$627.21
$487.52
$527.78
$570.42
$721.88
$582.19
$622.45
$665.09
$816.55
$243.76
$263.89
$285.21
$360.94
$338.43
$358.56
$379.88
$455.61
$433.10
$453.23
$474.55
$550.28
$94.67

Plan: (PPO) Humana Bronze 6300/Nashville PPOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Insurance Company)

Deductible: Individual: $6,300 : Family: $12,600
Out of Pocket Maximum per year: Individual: $6,300 : Family: $12,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$193.54
$219.67
$247.34
$345.66
$525.27
$387.08
$439.34
$494.68
$691.32
$1050.54
$509.98
$562.24
$617.58
$814.22
$632.88
$685.14
$740.48
$937.12
$755.78
$808.04
$863.38
$1060.02
$316.44
$342.57
$370.24
$468.56
$439.34
$465.47
$493.14
$591.46
$562.24
$588.37
$616.04
$714.36
$122.90

Plan: (PPO) Humana Silver 4600/Nashville PPOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Insurance Company)

Deductible: Individual: $4,600 : Family: $9,200
Out of Pocket Maximum per year: Individual: $6,300 : Family: $12,600

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$228.14
$258.94
$291.56
$407.46
$619.17
$456.28
$517.88
$583.12
$814.92
$1238.34
$601.15
$662.75
$727.99
$959.79
$746.02
$807.62
$872.86
$1104.66
$890.89
$952.49
$1017.73
$1249.53
$373.01
$403.81
$436.43
$552.33
$517.88
$548.68
$581.30
$697.20
$662.75
$693.55
$726.17
$842.07
$144.87

Plan: (PPO) Humana Gold 2500/Nashville PPOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Insurance Company)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$260.10
$295.21
$332.41
$464.54
$705.91
$520.20
$590.42
$664.82
$929.08
$1411.82
$685.36
$755.58
$829.98
$1094.24
$850.52
$920.74
$995.14
$1259.40
$1015.68
$1085.90
$1160.30
$1424.56
$425.26
$460.37
$497.57
$629.70
$590.42
$625.53
$662.73
$794.86
$755.58
$790.69
$827.89
$960.02
$165.16

Plan: (PPO) Humana Platinum 1000/Nashville PPOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Insurance Company)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $1,500 : Family: $3,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Platinum 21
30
40
50
60
$351.74
$399.22
$449.52
$628.21
$954.62
$703.48
$798.44
$899.04
$1256.42
$1909.24
$926.83
$1021.79
$1122.39
$1479.77
$1150.18
$1245.14
$1345.74
$1703.12
$1373.53
$1468.49
$1569.09
$1926.47
$575.09
$622.57
$672.87
$851.56
$798.44
$845.92
$896.22
$1074.91
$1021.79
$1069.27
$1119.57
$1298.26
$223.35

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237

Plan: (PPO) myCigna Health Savings 6100

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Healthcare)

Deductible: Individual: $6,100 : Family: $12,200
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$196.98
$223.56
$251.73
$351.79
$534.58
$393.96
$447.12
$503.46
$703.58
$1069.16
$519.03
$572.19
$628.53
$828.65
$644.10
$697.26
$753.60
$953.72
$769.17
$822.33
$878.67
$1078.79
$322.05
$348.63
$376.80
$476.86
$447.12
$473.70
$501.87
$601.93
$572.19
$598.77
$626.94
$727.00
$125.07

Plan: (PPO) myCigna Health Flex 5500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Healthcare)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$205.80
$233.57
$262.99
$367.54
$558.51
$411.60
$467.14
$525.98
$735.08
$1117.02
$542.27
$597.81
$656.65
$865.75
$672.94
$728.48
$787.32
$996.42
$803.61
$859.15
$917.99
$1127.09
$336.47
$364.24
$393.66
$498.21
$467.14
$494.91
$524.33
$628.88
$597.81
$625.58
$655.00
$759.55
$130.67

Plan: (PPO) myCigna Health Savings 3400

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Healthcare)

Deductible: Individual: $3,400 : Family: $6,800
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$240.09
$272.49
$306.82
$428.78
$651.58
$480.18
$544.98
$613.64
$857.56
$1303.16
$632.63
$697.43
$766.09
$1010.01
$785.08
$849.88
$918.54
$1162.46
$937.53
$1002.33
$1070.99
$1314.91
$392.54
$424.94
$459.27
$581.23
$544.99
$577.39
$611.72
$733.68
$697.44
$729.84
$764.17
$886.13
$152.45

Plan: (PPO) myCigna Health Flex 1500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Healthcare)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$235.67
$267.47
$301.17
$420.88
$639.57
$471.34
$534.94
$602.34
$841.76
$1279.14
$620.98
$684.58
$751.98
$991.40
$770.62
$834.22
$901.62
$1141.04
$920.26
$983.86
$1051.26
$1290.68
$385.31
$417.11
$450.81
$570.52
$534.95
$566.75
$600.45
$720.16
$684.59
$716.39
$750.09
$869.80
$149.64

Plan: (PPO) myCigna Health Flex 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Healthcare)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$236.96
$268.94
$302.82
$423.19
$643.09
$473.92
$537.88
$605.64
$846.38
$1286.18
$624.38
$688.34
$756.10
$996.84
$774.84
$838.80
$906.56
$1147.30
$925.30
$989.26
$1057.02
$1297.76
$387.42
$419.40
$453.28
$573.65
$537.88
$569.86
$603.74
$724.11
$688.34
$720.32
$754.20
$874.57
$150.46

Plan: (PPO) myCigna Health Flex 1250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-900-1237 - Provider Directory for This Plan: (Cigna Healthcare)

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$288.69
$327.65
$368.93
$515.59
$783.48
$577.38
$655.30
$737.86
$1031.18
$1566.96
$760.69
$838.61
$921.17
$1214.49
$944.00
$1021.92
$1104.48
$1397.80
$1127.31
$1205.23
$1287.79
$1581.11
$472.00
$510.96
$552.24
$698.90
$655.31
$694.27
$735.55
$882.21
$838.62
$877.58
$918.86
$1065.52
$183.31

†Source: Our summary of lowest costs and numbers of providers is based on a government report released September 25, 2013. For more detailed information about specific plans and providers, see HealthCare.gov.

‡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 Sumner County here.

 

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