Obamacare 2022 Rates for Butts County

Cigna HealthCare of Georgia, Inc.

Local: | Toll Free:

Toc - Plan #1 Cigna HealthCare of Georgia, Inc.

Bronze

(HMO) Cigna Connect 8700 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$272.16
$308.91
$347.82
$486.08
$738.65

$480.36
$517.11
$556.02
$694.28

$688.56
$725.31
$764.22
$902.48

$896.76
$933.51
$972.42
$1,110.68

$208.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$544.32
$617.82
$695.64
$972.16
$1,477.30

$752.52
$826.02
$903.84
$1,180.36

$960.72
$1,034.22
$1,112.04
$1,388.56

$1,168.92
$1,242.42
$1,320.24
$1,596.76

$208.20

Toc - Plan #2 Cigna HealthCare of Georgia, Inc.

Expanded Bronze

(HMO) Cigna Connect 7800 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,800 $15,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$279.71
$317.48
$357.47
$499.57
$759.14

$493.69
$531.46
$571.45
$713.55

$707.67
$745.44
$785.43
$927.53

$921.65
$959.42
$999.41
$1,141.51

$213.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$559.42
$634.96
$714.94
$999.14
$1,518.28

$773.40
$848.94
$928.92
$1,213.12

$987.38
$1,062.92
$1,142.90
$1,427.10

$1,201.36
$1,276.90
$1,356.88
$1,641.08

$213.98

Toc - Plan #3 Cigna HealthCare of Georgia, Inc.

Expanded Bronze

(HMO) Cigna Connect 6500 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$282.82
$321.00
$361.44
$505.11
$767.57

$499.18
$537.36
$577.80
$721.47

$715.54
$753.72
$794.16
$937.83

$931.90
$970.08
$1,010.52
$1,154.19

$216.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$565.64
$642.00
$722.88
$1,010.22
$1,535.14

$782.00
$858.36
$939.24
$1,226.58

$998.36
$1,074.72
$1,155.60
$1,442.94

$1,214.72
$1,291.08
$1,371.96
$1,659.30

$216.36

Toc - Plan #4 Cigna HealthCare of Georgia, Inc.

Expanded Bronze

(HMO) Cigna Connect HSA 7000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 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

$284.24
$322.61
$363.25
$507.65
$771.42

$501.68
$540.05
$580.69
$725.09

$719.12
$757.49
$798.13
$942.53

$936.56
$974.93
$1,015.57
$1,159.97

$217.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$568.48
$645.22
$726.50
$1,015.30
$1,542.84

$785.92
$862.66
$943.94
$1,232.74

$1,003.36
$1,080.10
$1,161.38
$1,450.18

$1,220.80
$1,297.54
$1,378.82
$1,667.62

$217.44

Toc - Plan #5 Cigna HealthCare of Georgia, Inc.

Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care ($0 Preferred Insulin)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,800 $13,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$285.88
$324.48
$365.36
$510.59
$775.89

$504.58
$543.18
$584.06
$729.29

$723.28
$761.88
$802.76
$947.99

$941.98
$980.58
$1,021.46
$1,166.69

$218.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$571.76
$648.96
$730.72
$1,021.18
$1,551.78

$790.46
$867.66
$949.42
$1,239.88

$1,009.16
$1,086.36
$1,168.12
$1,458.58

$1,227.86
$1,305.06
$1,386.82
$1,677.28

$218.70

Toc - Plan #6 Cigna HealthCare of Georgia, Inc.

Silver

(HMO) Cigna Connect 3600 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,600 $7,200 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

$341.11
$387.16
$435.94
$609.23
$925.78

$602.06
$648.11
$696.89
$870.18

$863.01
$909.06
$957.84
$1,131.13

$1,123.96
$1,170.01
$1,218.79
$1,392.08

$260.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$682.22
$774.32
$871.88
$1,218.46
$1,851.56

$943.17
$1,035.27
$1,132.83
$1,479.41

$1,204.12
$1,296.22
$1,393.78
$1,740.36

$1,465.07
$1,557.17
$1,654.73
$2,001.31

$260.95

Toc - Plan #7 Cigna HealthCare of Georgia, Inc.

Silver

(HMO) Cigna Connect 4500 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 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

$340.04
$385.95
$434.57
$607.31
$922.87

$600.17
$646.08
$694.70
$867.44

$860.30
$906.21
$954.83
$1,127.57

$1,120.43
$1,166.34
$1,214.96
$1,387.70

$260.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$680.08
$771.90
$869.14
$1,214.62
$1,845.74

$940.21
$1,032.03
$1,129.27
$1,474.75

$1,200.34
$1,292.16
$1,389.40
$1,734.88

$1,460.47
$1,552.29
$1,649.53
$1,995.01

$260.13

Toc - Plan #8 Cigna HealthCare of Georgia, Inc.

Silver

(HMO) Cigna Connect 6000 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$337.89
$383.51
$431.83
$603.48
$917.05

$596.38
$642.00
$690.32
$861.97

$854.87
$900.49
$948.81
$1,120.46

$1,113.36
$1,158.98
$1,207.30
$1,378.95

$258.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.78
$767.02
$863.66
$1,206.96
$1,834.10

$934.27
$1,025.51
$1,122.15
$1,465.45

$1,192.76
$1,284.00
$1,380.64
$1,723.94

$1,451.25
$1,542.49
$1,639.13
$1,982.43

$258.49

Toc - Plan #9 Cigna HealthCare of Georgia, Inc.

Silver

(HMO) Cigna Connect 7300 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,300 $14,600 Annual Deductible

$7,300 $14,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$341.15
$387.21
$435.99
$609.30
$925.89

$602.13
$648.19
$696.97
$870.28

$863.11
$909.17
$957.95
$1,131.26

$1,124.09
$1,170.15
$1,218.93
$1,392.24

$260.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$682.30
$774.42
$871.98
$1,218.60
$1,851.78

$943.28
$1,035.40
$1,132.96
$1,479.58

$1,204.26
$1,296.38
$1,393.94
$1,740.56

$1,465.24
$1,557.36
$1,654.92
$2,001.54

$260.98

Toc - Plan #10 Cigna HealthCare of Georgia, Inc.

Silver

(HMO) Cigna Connect 3500 Enhanced Diabetes Care ($0 Preferred Insulin)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 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

$341.57
$387.69
$436.53
$610.05
$927.03

$602.87
$648.99
$697.83
$871.35

$864.17
$910.29
$959.13
$1,132.65

$1,125.47
$1,171.59
$1,220.43
$1,393.95

$261.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$683.14
$775.38
$873.06
$1,220.10
$1,854.06

$944.44
$1,036.68
$1,134.36
$1,481.40

$1,205.74
$1,297.98
$1,395.66
$1,742.70

$1,467.04
$1,559.28
$1,656.96
$2,004.00

$261.30

Toc - Plan #11 Cigna HealthCare of Georgia, Inc.

Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,200 $8,400 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

$340.08
$385.99
$434.62
$607.38
$922.98

$600.24
$646.15
$694.78
$867.54

$860.40
$906.31
$954.94
$1,127.70

$1,120.56
$1,166.47
$1,215.10
$1,387.86

$260.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$680.16
$771.98
$869.24
$1,214.76
$1,845.96

$940.32
$1,032.14
$1,129.40
$1,474.92

$1,200.48
$1,292.30
$1,389.56
$1,735.08

$1,460.64
$1,552.46
$1,649.72
$1,995.24

$260.16

Toc - Plan #12 Cigna HealthCare of Georgia, Inc.

Gold

(HMO) Cigna Connect 1600 ($0 Telehealth)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,600 $3,200 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$403.36
$457.81
$515.49
$720.40
$1,094.71

$711.93
$766.38
$824.06
$1,028.97

$1,020.50
$1,074.95
$1,132.63
$1,337.54

$1,329.07
$1,383.52
$1,441.20
$1,646.11

$308.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$806.72
$915.62
$1,030.98
$1,440.80
$2,189.42

$1,115.29
$1,224.19
$1,339.55
$1,749.37

$1,423.86
$1,532.76
$1,648.12
$2,057.94

$1,732.43
$1,841.33
$1,956.69
$2,366.51

$308.57

Toc - Plan #13 Cigna HealthCare of Georgia, Inc.

Gold

(HMO) Cigna Connect 1250 Enhanced Diabetes Care ($0 Preferred Insulin)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,250 $2,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$417.85
$474.26
$534.01
$746.27
$1,134.03

$737.50
$793.91
$853.66
$1,065.92

$1,057.15
$1,113.56
$1,173.31
$1,385.57

$1,376.80
$1,433.21
$1,492.96
$1,705.22

$319.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$835.70
$948.52
$1,068.02
$1,492.54
$2,268.06

$1,155.35
$1,268.17
$1,387.67
$1,812.19

$1,475.00
$1,587.82
$1,707.32
$2,131.84

$1,794.65
$1,907.47
$2,026.97
$2,451.49

$319.65

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Local: 1-855-738-6652 | Toll Free: 1-855-738-6652

Toc - Plan #14 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 0 for HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$297.17
$337.29
$379.78
$530.75
$806.52

$524.51
$564.63
$607.12
$758.09

$751.85
$791.97
$834.46
$985.43

$979.19
$1,019.31
$1,061.80
$1,212.77

$227.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.34
$674.58
$759.56
$1,061.50
$1,613.04

$821.68
$901.92
$986.90
$1,288.84

$1,049.02
$1,129.26
$1,214.24
$1,516.18

$1,276.36
$1,356.60
$1,441.58
$1,743.52

$227.34

Toc - Plan #15 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 3000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$7,700 $15,400 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

$365.43
$414.76
$467.02
$652.66
$991.78

$644.98
$694.31
$746.57
$932.21

$924.53
$973.86
$1,026.12
$1,211.76

$1,204.08
$1,253.41
$1,305.67
$1,491.31

$279.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$730.86
$829.52
$934.04
$1,305.32
$1,983.56

$1,010.41
$1,109.07
$1,213.59
$1,584.87

$1,289.96
$1,388.62
$1,493.14
$1,864.42

$1,569.51
$1,668.17
$1,772.69
$2,143.97

$279.55

Toc - Plan #16 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 5500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$349.34
$396.50
$446.46
$623.92
$948.11

$616.59
$663.75
$713.71
$891.17

$883.84
$931.00
$980.96
$1,158.42

$1,151.09
$1,198.25
$1,248.21
$1,425.67

$267.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$698.68
$793.00
$892.92
$1,247.84
$1,896.22

$965.93
$1,060.25
$1,160.17
$1,515.09

$1,233.18
$1,327.50
$1,427.42
$1,782.34

$1,500.43
$1,594.75
$1,694.67
$2,049.59

$267.25

Toc - Plan #17 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5600

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,600 $11,200 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

$293.52
$333.15
$375.12
$524.23
$796.61

$518.06
$557.69
$599.66
$748.77

$742.60
$782.23
$824.20
$973.31

$967.14
$1,006.77
$1,048.74
$1,197.85

$224.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$587.04
$666.30
$750.24
$1,048.46
$1,593.22

$811.58
$890.84
$974.78
$1,273.00

$1,036.12
$1,115.38
$1,199.32
$1,497.54

$1,260.66
$1,339.92
$1,423.86
$1,722.08

$224.54

Toc - Plan #18 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 6000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$290.71
$329.96
$371.53
$519.21
$788.99

$513.10
$552.35
$593.92
$741.60

$735.49
$774.74
$816.31
$963.99

$957.88
$997.13
$1,038.70
$1,186.38

$222.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$581.42
$659.92
$743.06
$1,038.42
$1,577.98

$803.81
$882.31
$965.45
$1,260.81

$1,026.20
$1,104.70
$1,187.84
$1,483.20

$1,248.59
$1,327.09
$1,410.23
$1,705.59

$222.39

Toc - Plan #19 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Catastrophic

(HMO) Anthem Catastrophic Pathway X Guided Access HMO 8700

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$213.17
$241.95
$272.43
$380.72
$578.54

$376.25
$405.03
$435.51
$543.80

$539.33
$568.11
$598.59
$706.88

$702.41
$731.19
$761.67
$869.96

$163.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$426.34
$483.90
$544.86
$761.44
$1,157.08

$589.42
$646.98
$707.94
$924.52

$752.50
$810.06
$871.02
$1,087.60

$915.58
$973.14
$1,034.10
$1,250.68

$163.08

Toc - Plan #20 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 8000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$280.20
$318.03
$358.10
$500.44
$760.46

$494.55
$532.38
$572.45
$714.79

$708.90
$746.73
$786.80
$929.14

$923.25
$961.08
$1,001.15
$1,143.49

$214.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$560.40
$636.06
$716.20
$1,000.88
$1,520.92

$774.75
$850.41
$930.55
$1,215.23

$989.10
$1,064.76
$1,144.90
$1,429.58

$1,203.45
$1,279.11
$1,359.25
$1,643.93

$214.35

Toc - Plan #21 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 4950

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$4,950 $9,900 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

$361.92
$410.78
$462.53
$646.39
$982.25

$638.79
$687.65
$739.40
$923.26

$915.66
$964.52
$1,016.27
$1,200.13

$1,192.53
$1,241.39
$1,293.14
$1,477.00

$276.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$723.84
$821.56
$925.06
$1,292.78
$1,964.50

$1,000.71
$1,098.43
$1,201.93
$1,569.65

$1,277.58
$1,375.30
$1,478.80
$1,846.52

$1,554.45
$1,652.17
$1,755.67
$2,123.39

$276.87

Toc - Plan #22 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Gold

(HMO) Anthem Gold Pathway X Guided Access HMO 1900

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 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

$413.70
$469.55
$528.71
$738.87
$1,122.78

$730.18
$786.03
$845.19
$1,055.35

$1,046.66
$1,102.51
$1,161.67
$1,371.83

$1,363.14
$1,418.99
$1,478.15
$1,688.31

$316.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$827.40
$939.10
$1,057.42
$1,477.74
$2,245.56

$1,143.88
$1,255.58
$1,373.90
$1,794.22

$1,460.36
$1,572.06
$1,690.38
$2,110.70

$1,776.84
$1,888.54
$2,006.86
$2,427.18

$316.48

Toc - Plan #23 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$305.36
$346.58
$390.25
$545.37
$828.75

$538.96
$580.18
$623.85
$778.97

$772.56
$813.78
$857.45
$1,012.57

$1,006.16
$1,047.38
$1,091.05
$1,246.17

$233.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$610.72
$693.16
$780.50
$1,090.74
$1,657.50

$844.32
$926.76
$1,014.10
$1,324.34

$1,077.92
$1,160.36
$1,247.70
$1,557.94

$1,311.52
$1,393.96
$1,481.30
$1,791.54

$233.60

Toc - Plan #24 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 2600

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$2,600 $5,200 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

$393.60
$446.74
$503.02
$702.97
$1,068.23

$694.70
$747.84
$804.12
$1,004.07

$995.80
$1,048.94
$1,105.22
$1,305.17

$1,296.90
$1,350.04
$1,406.32
$1,606.27

$301.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$787.20
$893.48
$1,006.04
$1,405.94
$2,136.46

$1,088.30
$1,194.58
$1,307.14
$1,707.04

$1,389.40
$1,495.68
$1,608.24
$2,008.14

$1,690.50
$1,796.78
$1,909.34
$2,309.24

$301.10

Toc - Plan #25 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 6000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$348.18
$395.18
$444.97
$621.85
$944.96

$614.54
$661.54
$711.33
$888.21

$880.90
$927.90
$977.69
$1,154.57

$1,147.26
$1,194.26
$1,244.05
$1,420.93

$266.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$696.36
$790.36
$889.94
$1,243.70
$1,889.92

$962.72
$1,056.72
$1,156.30
$1,510.06

$1,229.08
$1,323.08
$1,422.66
$1,776.42

$1,495.44
$1,589.44
$1,689.02
$2,042.78

$266.36

Oscar Health Plan of Georgia

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

Toc - Plan #26 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$265.49
$301.32
$339.28
$474.14
$720.51

$468.58
$504.41
$542.37
$677.23

$671.67
$707.50
$745.46
$880.32

$874.76
$910.59
$948.55
$1,083.41

$203.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$530.98
$602.64
$678.56
$948.28
$1,441.02

$734.07
$805.73
$881.65
$1,151.37

$937.16
$1,008.82
$1,084.74
$1,354.46

$1,140.25
$1,211.91
$1,287.83
$1,557.55

$203.09

Toc - Plan #27 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 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

$260.77
$295.97
$333.25
$465.72
$707.71

$460.25
$495.45
$532.73
$665.20

$659.73
$694.93
$732.21
$864.68

$859.21
$894.41
$931.69
$1,064.16

$199.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$521.54
$591.94
$666.50
$931.44
$1,415.42

$721.02
$791.42
$865.98
$1,130.92

$920.50
$990.90
$1,065.46
$1,330.40

$1,119.98
$1,190.38
$1,264.94
$1,529.88

$199.48

Toc - Plan #28 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Elite- $0 Ded+PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$300.35
$340.89
$383.84
$536.41
$815.12

$530.11
$570.65
$613.60
$766.17

$759.87
$800.41
$843.36
$995.93

$989.63
$1,030.17
$1,073.12
$1,225.69

$229.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$600.70
$681.78
$767.68
$1,072.82
$1,630.24

$830.46
$911.54
$997.44
$1,302.58

$1,060.22
$1,141.30
$1,227.20
$1,532.34

$1,289.98
$1,371.06
$1,456.96
$1,762.10

$229.76

Toc - Plan #29 Oscar Health Plan of Georgia

Silver

(HMO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,750 $11,500 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

$325.49
$369.42
$415.96
$581.30
$883.35

$574.48
$618.41
$664.95
$830.29

$823.47
$867.40
$913.94
$1,079.28

$1,072.46
$1,116.39
$1,162.93
$1,328.27

$248.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$650.98
$738.84
$831.92
$1,162.60
$1,766.70

$899.97
$987.83
$1,080.91
$1,411.59

$1,148.96
$1,236.82
$1,329.90
$1,660.58

$1,397.95
$1,485.81
$1,578.89
$1,909.57

$248.99

Toc - Plan #30 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,450 $12,900 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

$320.58
$363.84
$409.68
$572.53
$870.02

$565.81
$609.07
$654.91
$817.76

$811.04
$854.30
$900.14
$1,062.99

$1,056.27
$1,099.53
$1,145.37
$1,308.22

$245.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$641.16
$727.68
$819.36
$1,145.06
$1,740.04

$886.39
$972.91
$1,064.59
$1,390.29

$1,131.62
$1,218.14
$1,309.82
$1,635.52

$1,376.85
$1,463.37
$1,555.05
$1,880.75

$245.23

Toc - Plan #31 Oscar Health Plan of Georgia

Catastrophic

(HMO) Secure

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$227.41
$258.10
$290.62
$406.14
$617.17

$401.37
$432.06
$464.58
$580.10

$575.33
$606.02
$638.54
$754.06

$749.29
$779.98
$812.50
$928.02

$173.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$454.82
$516.20
$581.24
$812.28
$1,234.34

$628.78
$690.16
$755.20
$986.24

$802.74
$864.12
$929.16
$1,160.20

$976.70
$1,038.08
$1,103.12
$1,334.16

$173.96

Toc - Plan #32 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Elite- $0 Ded+Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$300.47
$341.02
$383.98
$536.61
$815.44

$530.32
$570.87
$613.83
$766.46

$760.17
$800.72
$843.68
$996.31

$990.02
$1,030.57
$1,073.53
$1,226.16

$229.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$600.94
$682.04
$767.96
$1,073.22
$1,630.88

$830.79
$911.89
$997.81
$1,303.07

$1,060.64
$1,141.74
$1,227.66
$1,532.92

$1,290.49
$1,371.59
$1,457.51
$1,762.77

$229.85

Toc - Plan #33 Oscar Health Plan of Georgia

Gold

(HMO) Gold Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$6,000 $12,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$352.17
$399.70
$450.06
$628.96
$955.76

$621.57
$669.10
$719.46
$898.36

$890.97
$938.50
$988.86
$1,167.76

$1,160.37
$1,207.90
$1,258.26
$1,437.16

$269.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$704.34
$799.40
$900.12
$1,257.92
$1,911.52

$973.74
$1,068.80
$1,169.52
$1,527.32

$1,243.14
$1,338.20
$1,438.92
$1,796.72

$1,512.54
$1,607.60
$1,708.32
$2,066.12

$269.40

Toc - Plan #34 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,200 $10,400 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

$279.38
$317.09
$357.04
$498.96
$758.22

$493.10
$530.81
$570.76
$712.68

$706.82
$744.53
$784.48
$926.40

$920.54
$958.25
$998.20
$1,140.12

$213.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$558.76
$634.18
$714.08
$997.92
$1,516.44

$772.48
$847.90
$927.80
$1,211.64

$986.20
$1,061.62
$1,141.52
$1,425.36

$1,199.92
$1,275.34
$1,355.24
$1,639.08

$213.72

Toc - Plan #35 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,200 $8,400 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

$320.28
$363.50
$409.30
$572.00
$869.20

$565.28
$608.50
$654.30
$817.00

$810.28
$853.50
$899.30
$1,062.00

$1,055.28
$1,098.50
$1,144.30
$1,307.00

$245.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$640.56
$727.00
$818.60
$1,144.00
$1,738.40

$885.56
$972.00
$1,063.60
$1,389.00

$1,130.56
$1,217.00
$1,308.60
$1,634.00

$1,375.56
$1,462.00
$1,553.60
$1,879.00

$245.00

Toc - Plan #36 Oscar Health Plan of Georgia

Silver

(HMO) Silver Classic- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$335.90
$381.24
$429.27
$599.90
$911.61

$592.86
$638.20
$686.23
$856.86

$849.82
$895.16
$943.19
$1,113.82

$1,106.78
$1,152.12
$1,200.15
$1,370.78

$256.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$671.80
$762.48
$858.54
$1,199.80
$1,823.22

$928.76
$1,019.44
$1,115.50
$1,456.76

$1,185.72
$1,276.40
$1,372.46
$1,713.72

$1,442.68
$1,533.36
$1,629.42
$1,970.68

$256.96

Toc - Plan #37 Oscar Health Plan of Georgia

Gold

(HMO) Gold Classic- Low Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,250 $2,500 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

$352.43
$399.99
$450.39
$629.42
$956.46

$622.03
$669.59
$719.99
$899.02

$891.63
$939.19
$989.59
$1,168.62

$1,161.23
$1,208.79
$1,259.19
$1,438.22

$269.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$704.86
$799.98
$900.78
$1,258.84
$1,912.92

$974.46
$1,069.58
$1,170.38
$1,528.44

$1,244.06
$1,339.18
$1,439.98
$1,798.04

$1,513.66
$1,608.78
$1,709.58
$2,067.64

$269.60

Toc - Plan #38 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$273.08
$309.93
$348.98
$487.70
$741.11

$481.98
$518.83
$557.88
$696.60

$690.88
$727.73
$766.78
$905.50

$899.78
$936.63
$975.68
$1,114.40

$208.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$546.16
$619.86
$697.96
$975.40
$1,482.22

$755.06
$828.76
$906.86
$1,184.30

$963.96
$1,037.66
$1,115.76
$1,393.20

$1,172.86
$1,246.56
$1,324.66
$1,602.10

$208.90

Toc - Plan #39 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 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

$288.62
$327.58
$368.85
$515.47
$783.30

$509.41
$548.37
$589.64
$736.26

$730.20
$769.16
$810.43
$957.05

$950.99
$989.95
$1,031.22
$1,177.84

$220.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$577.24
$655.16
$737.70
$1,030.94
$1,566.60

$798.03
$875.95
$958.49
$1,251.73

$1,018.82
$1,096.74
$1,179.28
$1,472.52

$1,239.61
$1,317.53
$1,400.07
$1,693.31

$220.79

Toc - Plan #40 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- $3000 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 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

$291.90
$331.29
$373.03
$521.31
$792.18

$515.19
$554.58
$596.32
$744.60

$738.48
$777.87
$819.61
$967.89

$961.77
$1,001.16
$1,042.90
$1,191.18

$223.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$583.80
$662.58
$746.06
$1,042.62
$1,584.36

$807.09
$885.87
$969.35
$1,265.91

$1,030.38
$1,109.16
$1,192.64
$1,489.20

$1,253.67
$1,332.45
$1,415.93
$1,712.49

$223.29

Toc - Plan #41 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,700 $9,400 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

$275.99
$313.24
$352.70
$492.90
$749.01

$487.11
$524.36
$563.82
$704.02

$698.23
$735.48
$774.94
$915.14

$909.35
$946.60
$986.06
$1,126.26

$211.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$551.98
$626.48
$705.40
$985.80
$1,498.02

$763.10
$837.60
$916.52
$1,196.92

$974.22
$1,048.72
$1,127.64
$1,408.04

$1,185.34
$1,259.84
$1,338.76
$1,619.16

$211.12

Toc - Plan #42 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,375 $16,750 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

$316.70
$359.45
$404.73
$565.61
$859.50

$558.97
$601.72
$647.00
$807.88

$801.24
$843.99
$889.27
$1,050.15

$1,043.51
$1,086.26
$1,131.54
$1,292.42

$242.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$633.40
$718.90
$809.46
$1,131.22
$1,719.00

$875.67
$961.17
$1,051.73
$1,373.49

$1,117.94
$1,203.44
$1,294.00
$1,615.76

$1,360.21
$1,445.71
$1,536.27
$1,858.03

$242.27

Toc - Plan #43 Oscar Health Plan of Georgia

Silver

(HMO) Silver Elite- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$333.48
$378.48
$426.17
$595.57
$905.03

$588.58
$633.58
$681.27
$850.67

$843.68
$888.68
$936.37
$1,105.77

$1,098.78
$1,143.78
$1,191.47
$1,360.87

$255.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$666.96
$756.96
$852.34
$1,191.14
$1,810.06

$922.06
$1,012.06
$1,107.44
$1,446.24

$1,177.16
$1,267.16
$1,362.54
$1,701.34

$1,432.26
$1,522.26
$1,617.64
$1,956.44

$255.10

Toc - Plan #44 Oscar Health Plan of Georgia

Silver

(HMO) Silver Classic- Low Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$325.87
$369.85
$416.44
$581.98
$884.37

$575.15
$619.13
$665.72
$831.26

$824.43
$868.41
$915.00
$1,080.54

$1,073.71
$1,117.69
$1,164.28
$1,329.82

$249.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$651.74
$739.70
$832.88
$1,163.96
$1,768.74

$901.02
$988.98
$1,082.16
$1,413.24

$1,150.30
$1,238.26
$1,331.44
$1,662.52

$1,399.58
$1,487.54
$1,580.72
$1,911.80

$249.28

Toc - Plan #45 Oscar Health Plan of Georgia

Silver

(HMO) Silver Elite- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$333.30
$378.28
$425.94
$595.25
$904.54

$588.26
$633.24
$680.90
$850.21

$843.22
$888.20
$935.86
$1,105.17

$1,098.18
$1,143.16
$1,190.82
$1,360.13

$254.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$666.60
$756.56
$851.88
$1,190.50
$1,809.08

$921.56
$1,011.52
$1,106.84
$1,445.46

$1,176.52
$1,266.48
$1,361.80
$1,700.42

$1,431.48
$1,521.44
$1,616.76
$1,955.38

$254.96

Toc - Plan #46 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 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

$332.12
$376.95
$424.44
$593.15
$901.35

$586.19
$631.02
$678.51
$847.22

$840.26
$885.09
$932.58
$1,101.29

$1,094.33
$1,139.16
$1,186.65
$1,355.36

$254.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.24
$753.90
$848.88
$1,186.30
$1,802.70

$918.31
$1,007.97
$1,102.95
$1,440.37

$1,172.38
$1,262.04
$1,357.02
$1,694.44

$1,426.45
$1,516.11
$1,611.09
$1,948.51

$254.07

Toc - Plan #47 Oscar Health Plan of Georgia

Silver

(HMO) Silver Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$328.67
$373.02
$420.02
$586.98
$891.97

$580.09
$624.44
$671.44
$838.40

$831.51
$875.86
$922.86
$1,089.82

$1,082.93
$1,127.28
$1,174.28
$1,341.24

$251.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$657.34
$746.04
$840.04
$1,173.96
$1,783.94

$908.76
$997.46
$1,091.46
$1,425.38

$1,160.18
$1,248.88
$1,342.88
$1,676.80

$1,411.60
$1,500.30
$1,594.30
$1,928.22

$251.42

Toc - Plan #48 Oscar Health Plan of Georgia

Gold

(HMO) Gold Simple

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,550 $13,100 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

$340.42
$386.37
$435.05
$607.98
$923.88

$600.84
$646.79
$695.47
$868.40

$861.26
$907.21
$955.89
$1,128.82

$1,121.68
$1,167.63
$1,216.31
$1,389.24

$260.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$680.84
$772.74
$870.10
$1,215.96
$1,847.76

$941.26
$1,033.16
$1,130.52
$1,476.38

$1,201.68
$1,293.58
$1,390.94
$1,736.80

$1,462.10
$1,554.00
$1,651.36
$1,997.22

$260.42

Toc - Plan #49 Oscar Health Plan of Georgia

Gold

(HMO) Gold Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$6,750 $13,500 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

$344.56
$391.06
$440.33
$615.36
$935.10

$608.14
$654.64
$703.91
$878.94

$871.72
$918.22
$967.49
$1,142.52

$1,135.30
$1,181.80
$1,231.07
$1,406.10

$263.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$689.12
$782.12
$880.66
$1,230.72
$1,870.20

$952.70
$1,045.70
$1,144.24
$1,494.30

$1,216.28
$1,309.28
$1,407.82
$1,757.88

$1,479.86
$1,572.86
$1,671.40
$2,021.46

$263.58

Toc - Plan #50 Oscar Health Plan of Georgia

Gold

(HMO) Gold Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$375.38
$426.05
$479.72
$670.41
$1,018.76

$662.54
$713.21
$766.88
$957.57

$949.70
$1,000.37
$1,054.04
$1,244.73

$1,236.86
$1,287.53
$1,341.20
$1,531.89

$287.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$750.76
$852.10
$959.44
$1,340.82
$2,037.52

$1,037.92
$1,139.26
$1,246.60
$1,627.98

$1,325.08
$1,426.42
$1,533.76
$1,915.14

$1,612.24
$1,713.58
$1,820.92
$2,202.30

$287.16

Toc - Plan #51 Oscar Health Plan of Georgia

Gold

(HMO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$360.25
$408.87
$460.39
$643.39
$977.69

$635.83
$684.45
$735.97
$918.97

$911.41
$960.03
$1,011.55
$1,194.55

$1,186.99
$1,235.61
$1,287.13
$1,470.13

$275.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$720.50
$817.74
$920.78
$1,286.78
$1,955.38

$996.08
$1,093.32
$1,196.36
$1,562.36

$1,271.66
$1,368.90
$1,471.94
$1,837.94

$1,547.24
$1,644.48
$1,747.52
$2,113.52

$275.58

Toc - Plan #52 Oscar Health Plan of Georgia

Gold

(HMO) Gold Classic- HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,850 $5,700 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

$342.20
$388.38
$437.31
$611.14
$928.69

$603.97
$650.15
$699.08
$872.91

$865.74
$911.92
$960.85
$1,134.68

$1,127.51
$1,173.69
$1,222.62
$1,396.45

$261.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$684.40
$776.76
$874.62
$1,222.28
$1,857.38

$946.17
$1,038.53
$1,136.39
$1,484.05

$1,207.94
$1,300.30
$1,398.16
$1,745.82

$1,469.71
$1,562.07
$1,659.93
$2,007.59

$261.77

Toc - Plan #53 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Super Simple

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$260.07
$295.17
$332.36
$464.47
$705.81

$459.02
$494.12
$531.31
$663.42

$657.97
$693.07
$730.26
$862.37

$856.92
$892.02
$929.21
$1,061.32

$198.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$520.14
$590.34
$664.72
$928.94
$1,411.62

$719.09
$789.29
$863.67
$1,127.89

$918.04
$988.24
$1,062.62
$1,326.84

$1,116.99
$1,187.19
$1,261.57
$1,525.79

$198.95

Toc - Plan #54 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- $5000 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

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

$290.80
$330.04
$371.62
$519.34
$789.19

$513.25
$552.49
$594.07
$741.79

$735.70
$774.94
$816.52
$964.24

$958.15
$997.39
$1,038.97
$1,186.69

$222.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$581.60
$660.08
$743.24
$1,038.68
$1,578.38

$804.05
$882.53
$965.69
$1,261.13

$1,026.50
$1,104.98
$1,188.14
$1,483.58

$1,248.95
$1,327.43
$1,410.59
$1,706.03

$222.45

Toc - Plan #55 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$297.10
$337.19
$379.68
$530.60
$806.29

$524.37
$564.46
$606.95
$757.87

$751.64
$791.73
$834.22
$985.14

$978.91
$1,019.00
$1,061.49
$1,212.41

$227.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.20
$674.38
$759.36
$1,061.20
$1,612.58

$821.47
$901.65
$986.63
$1,288.47

$1,048.74
$1,128.92
$1,213.90
$1,515.74

$1,276.01
$1,356.19
$1,441.17
$1,743.01

$227.27

Toc - Plan #56 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Elite- $1000 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 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

$297.33
$337.46
$379.98
$531.02
$806.93

$524.78
$564.91
$607.43
$758.47

$752.23
$792.36
$834.88
$985.92

$979.68
$1,019.81
$1,062.33
$1,213.37

$227.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.66
$674.92
$759.96
$1,062.04
$1,613.86

$822.11
$902.37
$987.41
$1,289.49

$1,049.56
$1,129.82
$1,214.86
$1,516.94

$1,277.01
$1,357.27
$1,442.31
$1,744.39

$227.45

Toc - Plan #57 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,450 $12,900 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

$322.10
$365.57
$411.63
$575.25
$874.15

$568.50
$611.97
$658.03
$821.65

$814.90
$858.37
$904.43
$1,068.05

$1,061.30
$1,104.77
$1,150.83
$1,314.45

$246.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$644.20
$731.14
$823.26
$1,150.50
$1,748.30

$890.60
$977.54
$1,069.66
$1,396.90

$1,137.00
$1,223.94
$1,316.06
$1,643.30

$1,383.40
$1,470.34
$1,562.46
$1,889.70

$246.40

CareSource

Local: 1-833-230-2030 | Toll Free: 1-833-230-2030 | TTY: 1-800-255-0056

Toc - Plan #58 CareSource

Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$7,700 $15,400 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

$266.74
$302.75
$340.89
$476.40
$723.93

$470.80
$506.81
$544.95
$680.46

$674.86
$710.87
$749.01
$884.52

$878.92
$914.93
$953.07
$1,088.58

$204.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$533.48
$605.50
$681.78
$952.80
$1,447.86

$737.54
$809.56
$885.84
$1,156.86

$941.60
$1,013.62
$1,089.90
$1,360.92

$1,145.66
$1,217.68
$1,293.96
$1,564.98

$204.06

Toc - Plan #59 CareSource

Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$372.77
$423.09
$476.40
$665.76
$1,011.69

$657.94
$708.26
$761.57
$950.93

$943.11
$993.43
$1,046.74
$1,236.10

$1,228.28
$1,278.60
$1,331.91
$1,521.27

$285.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$745.54
$846.18
$952.80
$1,331.52
$2,023.38

$1,030.71
$1,131.35
$1,237.97
$1,616.69

$1,315.88
$1,416.52
$1,523.14
$1,901.86

$1,601.05
$1,701.69
$1,808.31
$2,187.03

$285.17

Toc - Plan #60 CareSource

Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$374.65
$425.23
$478.80
$669.12
$1,016.80

$661.26
$711.84
$765.41
$955.73

$947.87
$998.45
$1,052.02
$1,242.34

$1,234.48
$1,285.06
$1,338.63
$1,528.95

$286.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$749.30
$850.46
$957.60
$1,338.24
$2,033.60

$1,035.91
$1,137.07
$1,244.21
$1,624.85

$1,322.52
$1,423.68
$1,530.82
$1,911.46

$1,609.13
$1,710.29
$1,817.43
$2,198.07

$286.61

Toc - Plan #61 CareSource

Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$7,900 $15,800 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

$395.45
$448.84
$505.39
$706.27
$1,073.25

$697.97
$751.36
$807.91
$1,008.79

$1,000.49
$1,053.88
$1,110.43
$1,311.31

$1,303.01
$1,356.40
$1,412.95
$1,613.83

$302.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$790.90
$897.68
$1,010.78
$1,412.54
$2,146.50

$1,093.42
$1,200.20
$1,313.30
$1,715.06

$1,395.94
$1,502.72
$1,615.82
$2,017.58

$1,698.46
$1,805.24
$1,918.34
$2,320.10

$302.52

Toc - Plan #62 CareSource

Silver

(HMO) CareSource Marketplace Low Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$5,100 $10,200 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

$408.56
$463.71
$522.14
$729.68
$1,108.83

$721.11
$776.26
$834.69
$1,042.23

$1,033.66
$1,088.81
$1,147.24
$1,354.78

$1,346.21
$1,401.36
$1,459.79
$1,667.33

$312.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$817.12
$927.42
$1,044.28
$1,459.36
$2,217.66

$1,129.67
$1,239.97
$1,356.83
$1,771.91

$1,442.22
$1,552.52
$1,669.38
$2,084.46

$1,754.77
$1,865.07
$1,981.93
$2,397.01

$312.55

Toc - Plan #63 CareSource

Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$5,400 $10,800 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

$298.06
$338.30
$380.92
$532.33
$808.93

$526.08
$566.32
$608.94
$760.35

$754.10
$794.34
$836.96
$988.37

$982.12
$1,022.36
$1,064.98
$1,216.39

$228.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$596.12
$676.60
$761.84
$1,064.66
$1,617.86

$824.14
$904.62
$989.86
$1,292.68

$1,052.16
$1,132.64
$1,217.88
$1,520.70

$1,280.18
$1,360.66
$1,445.90
$1,748.72

$228.02

Toc - Plan #64 CareSource

Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$255.54
$290.03
$326.58
$456.39
$693.53

$451.03
$485.52
$522.07
$651.88

$646.52
$681.01
$717.56
$847.37

$842.01
$876.50
$913.05
$1,042.86

$195.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$511.08
$580.06
$653.16
$912.78
$1,387.06

$706.57
$775.55
$848.65
$1,108.27

$902.06
$971.04
$1,044.14
$1,303.76

$1,097.55
$1,166.53
$1,239.63
$1,499.25

$195.49

Toc - Plan #65 CareSource

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$7,700 $15,400 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

$273.71
$310.66
$349.80
$488.84
$742.84

$483.10
$520.05
$559.19
$698.23

$692.49
$729.44
$768.58
$907.62

$901.88
$938.83
$977.97
$1,117.01

$209.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$547.42
$621.32
$699.60
$977.68
$1,485.68

$756.81
$830.71
$908.99
$1,187.07

$966.20
$1,040.10
$1,118.38
$1,396.46

$1,175.59
$1,249.49
$1,327.77
$1,605.85

$209.39

Toc - Plan #66 CareSource

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$379.99
$431.29
$485.63
$678.66
$1,031.29

$670.68
$721.98
$776.32
$969.35

$961.37
$1,012.67
$1,067.01
$1,260.04

$1,252.06
$1,303.36
$1,357.70
$1,550.73

$290.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$759.98
$862.58
$971.26
$1,357.32
$2,062.58

$1,050.67
$1,153.27
$1,261.95
$1,648.01

$1,341.36
$1,443.96
$1,552.64
$1,938.70

$1,632.05
$1,734.65
$1,843.33
$2,229.39

$290.69

Toc - Plan #67 CareSource

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$381.88
$433.43
$488.03
$682.02
$1,036.40

$674.01
$725.56
$780.16
$974.15

$966.14
$1,017.69
$1,072.29
$1,266.28

$1,258.27
$1,309.82
$1,364.42
$1,558.41

$292.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.76
$866.86
$976.06
$1,364.04
$2,072.80

$1,055.89
$1,158.99
$1,268.19
$1,656.17

$1,348.02
$1,451.12
$1,560.32
$1,948.30

$1,640.15
$1,743.25
$1,852.45
$2,240.43

$292.13

Toc - Plan #68 CareSource

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$7,900 $15,800 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

$402.67
$457.02
$514.60
$719.16
$1,092.83

$710.71
$765.06
$822.64
$1,027.20

$1,018.75
$1,073.10
$1,130.68
$1,335.24

$1,326.79
$1,381.14
$1,438.72
$1,643.28

$308.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$805.34
$914.04
$1,029.20
$1,438.32
$2,185.66

$1,113.38
$1,222.08
$1,337.24
$1,746.36

$1,421.42
$1,530.12
$1,645.28
$2,054.40

$1,729.46
$1,838.16
$1,953.32
$2,362.44

$308.04

Toc - Plan #69 CareSource

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$5,100 $10,200 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

$415.78
$471.91
$531.37
$742.58
$1,128.43

$733.85
$789.98
$849.44
$1,060.65

$1,051.92
$1,108.05
$1,167.51
$1,378.72

$1,369.99
$1,426.12
$1,485.58
$1,696.79

$318.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$831.56
$943.82
$1,062.74
$1,485.16
$2,256.86

$1,149.63
$1,261.89
$1,380.81
$1,803.23

$1,467.70
$1,579.96
$1,698.88
$2,121.30

$1,785.77
$1,898.03
$2,016.95
$2,439.37

$318.07

Toc - Plan #70 CareSource

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2030

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$262.22
$297.61
$335.11
$468.31
$711.65

$462.81
$498.20
$535.70
$668.90

$663.40
$698.79
$736.29
$869.49

$863.99
$899.38
$936.88
$1,070.08

$200.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$524.44
$595.22
$670.22
$936.62
$1,423.30

$725.03
$795.81
$870.81
$1,137.21

$925.62
$996.40
$1,071.40
$1,337.80

$1,126.21
$1,196.99
$1,271.99
$1,538.39

$200.59

Ambetter from Peach State Health Plan

Local: 1-877-687-1180 | Toll Free: 1-877-687-1180 | TTY: 1-877-941-9231

Toc - Plan #71 Ambetter from Peach State Health Plan

Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$289.77
$328.88
$370.32
$517.52
$786.42

$511.44
$550.55
$591.99
$739.19

$733.11
$772.22
$813.66
$960.86

$954.78
$993.89
$1,035.33
$1,182.53

$221.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$579.54
$657.76
$740.64
$1,035.04
$1,572.84

$801.21
$879.43
$962.31
$1,256.71

$1,022.88
$1,101.10
$1,183.98
$1,478.38

$1,244.55
$1,322.77
$1,405.65
$1,700.05

$221.67

Toc - Plan #72 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 4

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$7,200 $14,400 Annual Deductible

$7,200 $14,400 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

$379.23
$430.42
$484.64
$677.29
$1,029.20

$669.33
$720.52
$774.74
$967.39

$959.43
$1,010.62
$1,064.84
$1,257.49

$1,249.53
$1,300.72
$1,354.94
$1,547.59

$290.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$758.46
$860.84
$969.28
$1,354.58
$2,058.40

$1,048.56
$1,150.94
$1,259.38
$1,644.68

$1,338.66
$1,441.04
$1,549.48
$1,934.78

$1,628.76
$1,731.14
$1,839.58
$2,224.88

$290.10

Toc - Plan #73 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$366.87
$416.38
$468.84
$655.21
$995.65

$647.52
$697.03
$749.49
$935.86

$928.17
$977.68
$1,030.14
$1,216.51

$1,208.82
$1,258.33
$1,310.79
$1,497.16

$280.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$733.74
$832.76
$937.68
$1,310.42
$1,991.30

$1,014.39
$1,113.41
$1,218.33
$1,591.07

$1,295.04
$1,394.06
$1,498.98
$1,871.72

$1,575.69
$1,674.71
$1,779.63
$2,152.37

$280.65

Toc - Plan #74 Ambetter from Peach State Health Plan

Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$1,450 $2,900 Annual Deductible

$6,300 $12,600 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

$387.38
$439.67
$495.06
$691.85
$1,051.33

$683.72
$736.01
$791.40
$988.19

$980.06
$1,032.35
$1,087.74
$1,284.53

$1,276.40
$1,328.69
$1,384.08
$1,580.87

$296.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$774.76
$879.34
$990.12
$1,383.70
$2,102.66

$1,071.10
$1,175.68
$1,286.46
$1,680.04

$1,367.44
$1,472.02
$1,582.80
$1,976.38

$1,663.78
$1,768.36
$1,879.14
$2,272.72

$296.34

Toc - Plan #75 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$362.32
$411.22
$463.03
$647.08
$983.30

$639.49
$688.39
$740.20
$924.25

$916.66
$965.56
$1,017.37
$1,201.42

$1,193.83
$1,242.73
$1,294.54
$1,478.59

$277.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$724.64
$822.44
$926.06
$1,294.16
$1,966.60

$1,001.81
$1,099.61
$1,203.23
$1,571.33

$1,278.98
$1,376.78
$1,480.40
$1,848.50

$1,556.15
$1,653.95
$1,757.57
$2,125.67

$277.17

Toc - Plan #76 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 29

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$5,450 $10,900 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$357.77
$406.05
$457.21
$638.95
$970.95

$631.45
$679.73
$730.89
$912.63

$905.13
$953.41
$1,004.57
$1,186.31

$1,178.81
$1,227.09
$1,278.25
$1,459.99

$273.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.54
$812.10
$914.42
$1,277.90
$1,941.90

$989.22
$1,085.78
$1,188.10
$1,551.58

$1,262.90
$1,359.46
$1,461.78
$1,825.26

$1,536.58
$1,633.14
$1,735.46
$2,098.94

$273.68

Toc - Plan #77 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 28

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 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

$389.09
$441.61
$497.24
$694.90
$1,055.96

$686.74
$739.26
$794.89
$992.55

$984.39
$1,036.91
$1,092.54
$1,290.20

$1,282.04
$1,334.56
$1,390.19
$1,587.85

$297.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$778.18
$883.22
$994.48
$1,389.80
$2,111.92

$1,075.83
$1,180.87
$1,292.13
$1,687.45

$1,373.48
$1,478.52
$1,589.78
$1,985.10

$1,671.13
$1,776.17
$1,887.43
$2,282.75

$297.65

Toc - Plan #78 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$317.19
$360.00
$405.36
$566.48
$860.83

$559.83
$602.64
$648.00
$809.12

$802.47
$845.28
$890.64
$1,051.76

$1,045.11
$1,087.92
$1,133.28
$1,294.40

$242.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$634.38
$720.00
$810.72
$1,132.96
$1,721.66

$877.02
$962.64
$1,053.36
$1,375.60

$1,119.66
$1,205.28
$1,296.00
$1,618.24

$1,362.30
$1,447.92
$1,538.64
$1,860.88

$242.64

Toc - Plan #79 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$313.97
$356.34
$401.24
$560.73
$852.08

$554.15
$596.52
$641.42
$800.91

$794.33
$836.70
$881.60
$1,041.09

$1,034.51
$1,076.88
$1,121.78
$1,281.27

$240.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$627.94
$712.68
$802.48
$1,121.46
$1,704.16

$868.12
$952.86
$1,042.66
$1,361.64

$1,108.30
$1,193.04
$1,282.84
$1,601.82

$1,348.48
$1,433.22
$1,523.02
$1,842.00

$240.18

Toc - Plan #80 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 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

$333.80
$378.85
$426.58
$596.15
$905.91

$589.15
$634.20
$681.93
$851.50

$844.50
$889.55
$937.28
$1,106.85

$1,099.85
$1,144.90
$1,192.63
$1,362.20

$255.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$667.60
$757.70
$853.16
$1,192.30
$1,811.82

$922.95
$1,013.05
$1,108.51
$1,447.65

$1,178.30
$1,268.40
$1,363.86
$1,703.00

$1,433.65
$1,523.75
$1,619.21
$1,958.35

$255.35

Toc - Plan #81 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$341.54
$387.63
$436.47
$609.97
$926.90

$602.81
$648.90
$697.74
$871.24

$864.08
$910.17
$959.01
$1,132.51

$1,125.35
$1,171.44
$1,220.28
$1,393.78

$261.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$683.08
$775.26
$872.94
$1,219.94
$1,853.80

$944.35
$1,036.53
$1,134.21
$1,481.21

$1,205.62
$1,297.80
$1,395.48
$1,742.48

$1,466.89
$1,559.07
$1,656.75
$2,003.75

$261.27

Toc - Plan #82 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$359.13
$407.60
$458.96
$641.39
$974.66

$633.86
$682.33
$733.69
$916.12

$908.59
$957.06
$1,008.42
$1,190.85

$1,183.32
$1,231.79
$1,283.15
$1,465.58

$274.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$718.26
$815.20
$917.92
$1,282.78
$1,949.32

$992.99
$1,089.93
$1,192.65
$1,557.51

$1,267.72
$1,364.66
$1,467.38
$1,832.24

$1,542.45
$1,639.39
$1,742.11
$2,106.97

$274.73

Toc - Plan #83 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

$6,100 $12,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$343.13
$389.44
$438.51
$612.81
$931.22

$605.62
$651.93
$701.00
$875.30

$868.11
$914.42
$963.49
$1,137.79

$1,130.60
$1,176.91
$1,225.98
$1,400.28

$262.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$686.26
$778.88
$877.02
$1,225.62
$1,862.44

$948.75
$1,041.37
$1,139.51
$1,488.11

$1,211.24
$1,303.86
$1,402.00
$1,750.60

$1,473.73
$1,566.35
$1,664.49
$2,013.09

$262.49

Toc - Plan #84 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$5,450 $10,900 Annual Deductible

$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$343.24
$389.57
$438.65
$613.01
$931.53

$605.81
$652.14
$701.22
$875.58

$868.38
$914.71
$963.79
$1,138.15

$1,130.95
$1,177.28
$1,226.36
$1,400.72

$262.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$686.48
$779.14
$877.30
$1,226.02
$1,863.06

$949.05
$1,041.71
$1,139.87
$1,488.59

$1,211.62
$1,304.28
$1,402.44
$1,751.16

$1,474.19
$1,566.85
$1,665.01
$2,013.73

$262.57

Toc - Plan #85 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,100 $16,200 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

$351.32
$398.74
$448.97
$627.44
$953.45

$620.07
$667.49
$717.72
$896.19

$888.82
$936.24
$986.47
$1,164.94

$1,157.57
$1,204.99
$1,255.22
$1,433.69

$268.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$702.64
$797.48
$897.94
$1,254.88
$1,906.90

$971.39
$1,066.23
$1,166.69
$1,523.63

$1,240.14
$1,334.98
$1,435.44
$1,792.38

$1,508.89
$1,603.73
$1,704.19
$2,061.13

$268.75

Toc - Plan #86 Ambetter from Peach State Health Plan

Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$750 $1,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$362.89
$411.86
$463.76
$648.10
$984.85

$640.49
$689.46
$741.36
$925.70

$918.09
$967.06
$1,018.96
$1,203.30

$1,195.69
$1,244.66
$1,296.56
$1,480.90

$277.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$725.78
$823.72
$927.52
$1,296.20
$1,969.70

$1,003.38
$1,101.32
$1,205.12
$1,573.80

$1,280.98
$1,378.92
$1,482.72
$1,851.40

$1,558.58
$1,656.52
$1,760.32
$2,129.00

$277.60

Toc - Plan #87 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 12 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$377.56
$428.52
$482.51
$674.31
$1,024.68

$666.39
$717.35
$771.34
$963.14

$955.22
$1,006.18
$1,060.17
$1,251.97

$1,244.05
$1,295.01
$1,349.00
$1,540.80

$288.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$755.12
$857.04
$965.02
$1,348.62
$2,049.36

$1,043.95
$1,145.87
$1,253.85
$1,637.45

$1,332.78
$1,434.70
$1,542.68
$1,926.28

$1,621.61
$1,723.53
$1,831.51
$2,215.11

$288.83

Toc - Plan #88 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 4 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$7,200 $14,400 Annual Deductible

$7,200 $14,400 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

$395.19
$448.53
$505.04
$705.79
$1,072.52

$697.50
$750.84
$807.35
$1,008.10

$999.81
$1,053.15
$1,109.66
$1,310.41

$1,302.12
$1,355.46
$1,411.97
$1,612.72

$302.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$790.38
$897.06
$1,010.08
$1,411.58
$2,145.04

$1,092.69
$1,199.37
$1,312.39
$1,713.89

$1,395.00
$1,501.68
$1,614.70
$2,016.20

$1,697.31
$1,803.99
$1,917.01
$2,318.51

$302.31

Toc - Plan #89 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 11 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$382.31
$433.91
$488.57
$682.78
$1,037.55

$674.77
$726.37
$781.03
$975.24

$967.23
$1,018.83
$1,073.49
$1,267.70

$1,259.69
$1,311.29
$1,365.95
$1,560.16

$292.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$764.62
$867.82
$977.14
$1,365.56
$2,075.10

$1,057.08
$1,160.28
$1,269.60
$1,658.02

$1,349.54
$1,452.74
$1,562.06
$1,950.48

$1,642.00
$1,745.20
$1,854.52
$2,242.94

$292.46

Toc - Plan #90 Ambetter from Peach State Health Plan

Bronze

(HMO) Ambetter Essential Care 1 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$301.97
$342.72
$385.90
$539.29
$819.51

$532.97
$573.72
$616.90
$770.29

$763.97
$804.72
$847.90
$1,001.29

$994.97
$1,035.72
$1,078.90
$1,232.29

$231.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$603.94
$685.44
$771.80
$1,078.58
$1,639.02

$834.94
$916.44
$1,002.80
$1,309.58

$1,065.94
$1,147.44
$1,233.80
$1,540.58

$1,296.94
$1,378.44
$1,464.80
$1,771.58

$231.00

Toc - Plan #91 Ambetter from Peach State Health Plan

Gold

(HMO) Ambetter Secure Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$1,450 $2,900 Annual Deductible

$6,300 $12,600 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

$403.69
$458.17
$515.90
$720.96
$1,095.58

$712.50
$766.98
$824.71
$1,029.77

$1,021.31
$1,075.79
$1,133.52
$1,338.58

$1,330.12
$1,384.60
$1,442.33
$1,647.39

$308.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$807.38
$916.34
$1,031.80
$1,441.92
$2,191.16

$1,116.19
$1,225.15
$1,340.61
$1,750.73

$1,425.00
$1,533.96
$1,649.42
$2,059.54

$1,733.81
$1,842.77
$1,958.23
$2,368.35

$308.81

Toc - Plan #92 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 28 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 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

$405.46
$460.19
$518.17
$724.14
$1,100.40

$715.63
$770.36
$828.34
$1,034.31

$1,025.80
$1,080.53
$1,138.51
$1,344.48

$1,335.97
$1,390.70
$1,448.68
$1,654.65

$310.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$810.92
$920.38
$1,036.34
$1,448.28
$2,200.80

$1,121.09
$1,230.55
$1,346.51
$1,758.45

$1,431.26
$1,540.72
$1,656.68
$2,068.62

$1,741.43
$1,850.89
$1,966.85
$2,378.79

$310.17

Toc - Plan #93 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 29 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$5,450 $10,900 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$372.82
$423.14
$476.45
$665.84
$1,011.81

$658.02
$708.34
$761.65
$951.04

$943.22
$993.54
$1,046.85
$1,236.24

$1,228.42
$1,278.74
$1,332.05
$1,521.44

$285.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$745.64
$846.28
$952.90
$1,331.68
$2,023.62

$1,030.84
$1,131.48
$1,238.10
$1,616.88

$1,316.04
$1,416.68
$1,523.30
$1,902.08

$1,601.24
$1,701.88
$1,808.50
$2,187.28

$285.20

Toc - Plan #94 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$330.54
$375.15
$422.41
$590.32
$897.05

$583.39
$628.00
$675.26
$843.17

$836.24
$880.85
$928.11
$1,096.02

$1,089.09
$1,133.70
$1,180.96
$1,348.87

$252.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.08
$750.30
$844.82
$1,180.64
$1,794.10

$913.93
$1,003.15
$1,097.67
$1,433.49

$1,166.78
$1,256.00
$1,350.52
$1,686.34

$1,419.63
$1,508.85
$1,603.37
$1,939.19

$252.85

Toc - Plan #95 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$327.18
$371.34
$418.12
$584.32
$887.94

$577.46
$621.62
$668.40
$834.60

$827.74
$871.90
$918.68
$1,084.88

$1,078.02
$1,122.18
$1,168.96
$1,335.16

$250.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$654.36
$742.68
$836.24
$1,168.64
$1,775.88

$904.64
$992.96
$1,086.52
$1,418.92

$1,154.92
$1,243.24
$1,336.80
$1,669.20

$1,405.20
$1,493.52
$1,587.08
$1,919.48

$250.28

Toc - Plan #96 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care 22 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 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

$347.85
$394.79
$444.54
$621.24
$944.03

$613.95
$660.89
$710.64
$887.34

$880.05
$926.99
$976.74
$1,153.44

$1,146.15
$1,193.09
$1,242.84
$1,419.54

$266.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$695.70
$789.58
$889.08
$1,242.48
$1,888.06

$961.80
$1,055.68
$1,155.18
$1,508.58

$1,227.90
$1,321.78
$1,421.28
$1,774.68

$1,494.00
$1,587.88
$1,687.38
$2,040.78

$266.10

Toc - Plan #97 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$355.91
$403.94
$454.84
$635.63
$965.91

$628.17
$676.20
$727.10
$907.89

$900.43
$948.46
$999.36
$1,180.15

$1,172.69
$1,220.72
$1,271.62
$1,452.41

$272.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$711.82
$807.88
$909.68
$1,271.26
$1,931.82

$984.08
$1,080.14
$1,181.94
$1,543.52

$1,256.34
$1,352.40
$1,454.20
$1,815.78

$1,528.60
$1,624.66
$1,726.46
$2,088.04

$272.26

Toc - Plan #98 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$374.24
$424.76
$478.27
$668.38
$1,015.67

$660.53
$711.05
$764.56
$954.67

$946.82
$997.34
$1,050.85
$1,240.96

$1,233.11
$1,283.63
$1,337.14
$1,527.25

$286.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$748.48
$849.52
$956.54
$1,336.76
$2,031.34

$1,034.77
$1,135.81
$1,242.83
$1,623.05

$1,321.06
$1,422.10
$1,529.12
$1,909.34

$1,607.35
$1,708.39
$1,815.41
$2,195.63

$286.29

Toc - Plan #99 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 31 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$5,450 $10,900 Annual Deductible

$6,450 $12,900 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

$357.69
$405.96
$457.11
$638.81
$970.73

$631.31
$679.58
$730.73
$912.43

$904.93
$953.20
$1,004.35
$1,186.05

$1,178.55
$1,226.82
$1,277.97
$1,459.67

$273.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.38
$811.92
$914.22
$1,277.62
$1,941.46

$989.00
$1,085.54
$1,187.84
$1,551.24

$1,262.62
$1,359.16
$1,461.46
$1,824.86

$1,536.24
$1,632.78
$1,735.08
$2,098.48

$273.62

Toc - Plan #100 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Balanced Care 32 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,100 $16,200 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$366.10
$415.52
$467.87
$653.84
$993.58

$646.16
$695.58
$747.93
$933.90

$926.22
$975.64
$1,027.99
$1,213.96

$1,206.28
$1,255.70
$1,308.05
$1,494.02

$280.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$732.20
$831.04
$935.74
$1,307.68
$1,987.16

$1,012.26
$1,111.10
$1,215.80
$1,587.74

$1,292.32
$1,391.16
$1,495.86
$1,867.80

$1,572.38
$1,671.22
$1,775.92
$2,147.86

$280.06

Toc - Plan #101 Ambetter from Peach State Health Plan

Gold

(HMO) Ambetter Secure Care 20 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$750 $1,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$378.16
$429.20
$483.27
$675.37
$1,026.29

$667.44
$718.48
$772.55
$964.65

$956.72
$1,007.76
$1,061.83
$1,253.93

$1,246.00
$1,297.04
$1,351.11
$1,543.21

$289.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$756.32
$858.40
$966.54
$1,350.74
$2,052.58

$1,045.60
$1,147.68
$1,255.82
$1,640.02

$1,334.88
$1,436.96
$1,545.10
$1,929.30

$1,624.16
$1,726.24
$1,834.38
$2,218.58

$289.28

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #102 Aetna CVS Health

Expanded Bronze

(HMO) Aetna CVS Bronze: Low-Cost Walk-in Clinic Visits, Telehealth, Atlanta

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$298.76
$339.09
$381.81
$533.58
$810.83

$527.31
$567.64
$610.36
$762.13

$755.86
$796.19
$838.91
$990.68

$984.41
$1,024.74
$1,067.46
$1,219.23

$228.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$597.52
$678.18
$763.62
$1,067.16
$1,621.66

$826.07
$906.73
$992.17
$1,295.71

$1,054.62
$1,135.28
$1,220.72
$1,524.26

$1,283.17
$1,363.83
$1,449.27
$1,752.81

$228.55

Toc - Plan #103 Aetna CVS Health

Bronze

(HMO) Aetna CVS Bronze: $0 Walk-In Clinic Visits, Telehealth, Atlanta

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$290.56
$329.78
$371.33
$518.94
$788.58

$512.84
$552.06
$593.61
$741.22

$735.12
$774.34
$815.89
$963.50

$957.40
$996.62
$1,038.17
$1,185.78

$222.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$581.12
$659.56
$742.66
$1,037.88
$1,577.16

$803.40
$881.84
$964.94
$1,260.16

$1,025.68
$1,104.12
$1,187.22
$1,482.44

$1,247.96
$1,326.40
$1,409.50
$1,704.72

$222.28

Toc - Plan #104 Aetna CVS Health

Gold

(HMO) Aetna CVS Gold: $0 Walk-In Clinic Visits, Telehealth, Atlanta

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$1,450 $2,900 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

$395.65
$449.07
$505.65
$706.64
$1,073.80

$698.32
$751.74
$808.32
$1,009.31

$1,000.99
$1,054.41
$1,110.99
$1,311.98

$1,303.66
$1,357.08
$1,413.66
$1,614.65

$302.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$791.30
$898.14
$1,011.30
$1,413.28
$2,147.60

$1,093.97
$1,200.81
$1,313.97
$1,715.95

$1,396.64
$1,503.48
$1,616.64
$2,018.62

$1,699.31
$1,806.15
$1,919.31
$2,321.29

$302.67

Toc - Plan #105 Aetna CVS Health

Silver

(HMO) Aetna CVS Silver 2: $0 Walk-In Clinic Visits, Telehealth, Atlanta

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$359.17
$407.66
$459.02
$641.48
$974.80

$633.94
$682.43
$733.79
$916.25

$908.71
$957.20
$1,008.56
$1,191.02

$1,183.48
$1,231.97
$1,283.33
$1,465.79

$274.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$718.34
$815.32
$918.04
$1,282.96
$1,949.60

$993.11
$1,090.09
$1,192.81
$1,557.73

$1,267.88
$1,364.86
$1,467.58
$1,832.50

$1,542.65
$1,639.63
$1,742.35
$2,107.27

$274.77

Toc - Plan #106 Aetna CVS Health

Silver

(HMO) Aetna CVS Silver 1: $0 Walk-In Clinic Visits, Telehealth, Atlanta

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 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

$416.47
$472.70
$532.25
$743.82
$1,130.30

$735.07
$791.30
$850.85
$1,062.42

$1,053.67
$1,109.90
$1,169.45
$1,381.02

$1,372.27
$1,428.50
$1,488.05
$1,699.62

$318.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$832.94
$945.40
$1,064.50
$1,487.64
$2,260.60

$1,151.54
$1,264.00
$1,383.10
$1,806.24

$1,470.14
$1,582.60
$1,701.70
$2,124.84

$1,788.74
$1,901.20
$2,020.30
$2,443.44

$318.60

Kaiser Permanente

Local: 1-800-494-5314 | Toll Free: 1-800-494-5314

Toc - Plan #107 Kaiser Permanente

Gold

(HMO) KP GA Gold 500/20

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$380.19
$431.51
$485.88
$679.01
$1,031.83

$671.03
$722.35
$776.72
$969.85

$961.87
$1,013.19
$1,067.56
$1,260.69

$1,252.71
$1,304.03
$1,358.40
$1,551.53

$290.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$760.38
$863.02
$971.76
$1,358.02
$2,063.66

$1,051.22
$1,153.86
$1,262.60
$1,648.86

$1,342.06
$1,444.70
$1,553.44
$1,939.70

$1,632.90
$1,735.54
$1,844.28
$2,230.54

$290.84

Toc - Plan #108 Kaiser Permanente

Silver

(HMO) KP GA Silver 3000/30

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$388.65
$441.12
$496.70
$694.14
$1,054.81

$685.97
$738.44
$794.02
$991.46

$983.29
$1,035.76
$1,091.34
$1,288.78

$1,280.61
$1,333.08
$1,388.66
$1,586.10

$297.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$777.30
$882.24
$993.40
$1,388.28
$2,109.62

$1,074.62
$1,179.56
$1,290.72
$1,685.60

$1,371.94
$1,476.88
$1,588.04
$1,982.92

$1,669.26
$1,774.20
$1,885.36
$2,280.24

$297.32

Toc - Plan #109 Kaiser Permanente

Silver

(HMO) KP GA Silver 3500/20%/HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$371.42
$421.56
$474.68
$663.36
$1,008.03

$655.56
$705.70
$758.82
$947.50

$939.70
$989.84
$1,042.96
$1,231.64

$1,223.84
$1,273.98
$1,327.10
$1,515.78

$284.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$742.84
$843.12
$949.36
$1,326.72
$2,016.06

$1,026.98
$1,127.26
$1,233.50
$1,610.86

$1,311.12
$1,411.40
$1,517.64
$1,895.00

$1,595.26
$1,695.54
$1,801.78
$2,179.14

$284.14

Toc - Plan #110 Kaiser Permanente

Expanded Bronze

(HMO) KP GA Bronze Virtual Complete 5000/60

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$281.58
$319.59
$359.86
$502.90
$764.20

$496.99
$535.00
$575.27
$718.31

$712.40
$750.41
$790.68
$933.72

$927.81
$965.82
$1,006.09
$1,149.13

$215.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$563.16
$639.18
$719.72
$1,005.80
$1,528.40

$778.57
$854.59
$935.13
$1,221.21

$993.98
$1,070.00
$1,150.54
$1,436.62

$1,209.39
$1,285.41
$1,365.95
$1,652.03

$215.41

Toc - Plan #111 Kaiser Permanente

Expanded Bronze

(HMO) KP GA Bronze 6500/40%/HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$278.50
$316.09
$355.92
$497.39
$755.84

$491.55
$529.14
$568.97
$710.44

$704.60
$742.19
$782.02
$923.49

$917.65
$955.24
$995.07
$1,136.54

$213.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$557.00
$632.18
$711.84
$994.78
$1,511.68

$770.05
$845.23
$924.89
$1,207.83

$983.10
$1,058.28
$1,137.94
$1,420.88

$1,196.15
$1,271.33
$1,350.99
$1,633.93

$213.05

Toc - Plan #112 Kaiser Permanente

Catastrophic

(HMO) KP GA Catastrophic 8700/0

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 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

$243.88
$276.81
$311.68
$435.58
$661.90

$430.45
$463.38
$498.25
$622.15

$617.02
$649.95
$684.82
$808.72

$803.59
$836.52
$871.39
$995.29

$186.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$487.76
$553.62
$623.36
$871.16
$1,323.80

$674.33
$740.19
$809.93
$1,057.73

$860.90
$926.76
$996.50
$1,244.30

$1,047.47
$1,113.33
$1,183.07
$1,430.87

$186.57

Toc - Plan #113 Kaiser Permanente

Gold

(HMO) KP GA Gold 1500/20

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$365.55
$414.90
$467.17
$652.87
$992.10

$645.20
$694.55
$746.82
$932.52

$924.85
$974.20
$1,026.47
$1,212.17

$1,204.50
$1,253.85
$1,306.12
$1,491.82

$279.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$731.10
$829.80
$934.34
$1,305.74
$1,984.20

$1,010.75
$1,109.45
$1,213.99
$1,585.39

$1,290.40
$1,389.10
$1,493.64
$1,865.04

$1,570.05
$1,668.75
$1,773.29
$2,144.69

$279.65

Toc - Plan #114 Kaiser Permanente

Silver

(HMO) KP GA Silver 4500/35

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$367.79
$417.44
$470.04
$656.88
$998.19

$649.15
$698.80
$751.40
$938.24

$930.51
$980.16
$1,032.76
$1,219.60

$1,211.87
$1,261.52
$1,314.12
$1,500.96

$281.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$735.58
$834.88
$940.08
$1,313.76
$1,996.38

$1,016.94
$1,116.24
$1,221.44
$1,595.12

$1,298.30
$1,397.60
$1,502.80
$1,876.48

$1,579.66
$1,678.96
$1,784.16
$2,157.84

$281.36

Toc - Plan #115 Kaiser Permanente

Gold

(HMO) KP GA Gold 1700/25

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$1,700 $3,400 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

$352.45
$400.03
$450.44
$629.48
$956.56

$622.08
$669.66
$720.07
$899.11

$891.71
$939.29
$989.70
$1,168.74

$1,161.34
$1,208.92
$1,259.33
$1,438.37

$269.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$704.90
$800.06
$900.88
$1,258.96
$1,913.12

$974.53
$1,069.69
$1,170.51
$1,528.59

$1,244.16
$1,339.32
$1,440.14
$1,798.22

$1,513.79
$1,608.95
$1,709.77
$2,067.85

$269.63

Toc - Plan #116 Kaiser Permanente

Silver

(HMO) KP GA Silver Virtual Complete 4800/40

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$4,800 $9,600 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

$349.65
$396.86
$446.86
$624.48
$948.96

$617.13
$664.34
$714.34
$891.96

$884.61
$931.82
$981.82
$1,159.44

$1,152.09
$1,199.30
$1,249.30
$1,426.92

$267.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$699.30
$793.72
$893.72
$1,248.96
$1,897.92

$966.78
$1,061.20
$1,161.20
$1,516.44

$1,234.26
$1,328.68
$1,428.68
$1,783.92

$1,501.74
$1,596.16
$1,696.16
$2,051.40

$267.48

‡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 Butts County here.

Butts County is in “Rating Area 3” of Georgia.

Currently, there are 116 plans offered in Rating Area 3.

Top

2022 Obamacare Plans for Butts County, GA

Plan Browser: 116 Plans

Cigna HealthCare of Georgia, Inc.

Local: | Toll Free:

1. Bronze Cigna Connect 8700 ($0 Telehealth)

2. Expanded Bronze Cigna Connect 7800 ($0 Telehealth)

3. Expanded Bronze Cigna Connect 6500 ($0 Telehealth)

4. Expanded Bronze Cigna Connect HSA 7000

5. Expanded Bronze Cigna Connect 6800 Enhanced Diabetes Care ($0 Preferred Insulin)

6. Silver Cigna Connect 3600 ($0 Telehealth)

7. Silver Cigna Connect 4500 ($0 Telehealth)

8. Silver Cigna Connect 6000 ($0 Telehealth)

9. Silver Cigna Connect 7300 ($0 Telehealth)

10. Silver Cigna Connect 3500 Enhanced Diabetes Care ($0 Preferred Insulin)

11. Silver Cigna Connect 4200 Enhanced Asthma COPD Care ($0 Telehealth)

12. Gold Cigna Connect 1600 ($0 Telehealth)

13. Gold Cigna Connect 1250 Enhanced Diabetes Care ($0 Preferred Insulin)

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Local: 1-855-738-6652 | Toll Free: 1-855-738-6652

14. Expanded Bronze Anthem Bronze Pathway X Guided Access HMO 0 for HSA

15. Silver Anthem Silver Pathway X Guided Access HMO 3000

16. Silver Anthem Silver Pathway X Guided Access HMO 5500

17. Expanded Bronze Anthem Bronze Pathway X Guided Access HMO 5600

18. Expanded Bronze Anthem Bronze Pathway X Guided Access HMO 6000

19. Catastrophic Anthem Catastrophic Pathway X Guided Access HMO 8700

20. Bronze Anthem Bronze Pathway X Guided Access HMO 8000

21. Silver Anthem Silver Pathway X Guided Access HMO 4950

22. Gold Anthem Gold Pathway X Guided Access HMO 1900

23. Expanded Bronze Anthem Bronze Pathway X Guided Access HMO 5000

24. Silver Anthem Silver Pathway X Guided Access HMO 2600

25. Silver Anthem Silver Pathway X Guided Access HMO 6000

Oscar Health Plan of Georgia

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

26. Expanded Bronze Bronze Classic- PCP Saver

27. Expanded Bronze Bronze Classic

28. Expanded Bronze Bronze Elite- $0 Ded+PCP Saver

29. Silver Silver Classic

30. Silver Silver Simple- Specialist Saver

31. Catastrophic Secure

32. Expanded Bronze Bronze Elite- $0 Ded+Specialist Saver

33. Gold Gold Classic

34. Expanded Bronze Bronze Simple- HSA

35. Silver Silver Simple

36. Silver Silver Classic- $0 Ded

37. Gold Gold Classic- Low Ded

38. Expanded Bronze Bronze Classic- $0 PCP

39. Expanded Bronze Bronze Classic- Specialist Saver

40. Expanded Bronze Bronze Classic- $3000 Ded

41. Expanded Bronze Bronze Classic- $4700 Ded

42. Silver Silver Simple- PCP Saver

43. Silver Silver Elite- Specialist Saver

44. Silver Silver Classic- Low Ded

45. Silver Silver Elite- $0 PCP

46. Silver Silver Simple- HSA

47. Silver Silver Elite- $0 Ded

48. Gold Gold Simple

49. Gold Gold Classic- $0 PCP

50. Gold Gold Elite- $0 Ded

51. Gold Gold Elite

52. Gold Gold Classic- HSA

53. Expanded Bronze Bronze Super Simple

54. Expanded Bronze Bronze Classic- $5000 Ded

55. Expanded Bronze Bronze Elite

56. Expanded Bronze Bronze Elite- $1000 Ded

57. Silver Silver Simple- For Diabetes

CareSource

Local: 1-833-230-2030 | Toll Free: 1-833-230-2030 | TTY: 1-800-255-0056

58. Expanded Bronze CareSource Marketplace Bronze First

59. Gold CareSource Marketplace Gold

60. Silver CareSource Marketplace Low Premium Silver

61. Silver CareSource Marketplace Standard Silver

62. Silver CareSource Marketplace Low Deductible Silver

63. Expanded Bronze CareSource Marketplace HSA Eligible Bronze

64. Bronze CareSource Marketplace Bronze

65. Expanded Bronze CareSource Marketplace Bronze First Dental, Vision, & Fitness

66. Gold CareSource Marketplace Gold Dental, Vision, & Fitness

67. Silver CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

68. Silver CareSource Marketplace Standard Silver Dental, Vision, & Fitness

69. Silver CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness

70. Bronze CareSource Marketplace Bronze Dental, Vision, & Fitness

Ambetter from Peach State Health Plan

Local: 1-877-687-1180 | Toll Free: 1-877-687-1180 | TTY: 1-877-941-9231

71. Bronze Ambetter Essential Care 1

72. Silver Ambetter Balanced Care 4

73. Silver Ambetter Balanced Care 11

74. Gold Ambetter Secure Care 5

75. Silver Ambetter Balanced Care 12

76. Silver Ambetter Balanced Care 29

77. Silver Ambetter Balanced Care 28

78. Expanded Bronze Ambetter Essential Care 2 HSA

79. Expanded Bronze Ambetter Essential Care 5

80. Expanded Bronze Ambetter Essential Care 22

81. Expanded Bronze Ambetter Essential Care: $1,500 Medical Deductible

82. Expanded Bronze Ambetter Essential Care: $0 Medical Deductible

83. Silver Ambetter Balanced Care 30

84. Silver Ambetter Balanced Care 31

85. Silver Ambetter Balanced Care 32

86. Gold Ambetter Secure Care 20

87. Silver Ambetter Balanced Care 12 + Vision + Adult Dental

88. Silver Ambetter Balanced Care 4 + Vision + Adult Dental

89. Silver Ambetter Balanced Care 11 + Vision + Adult Dental

90. Bronze Ambetter Essential Care 1 + Vision + Adult Dental

91. Gold Ambetter Secure Care 5 + Vision + Adult Dental

92. Silver Ambetter Balanced Care 28 + Vision + Adult Dental

93. Silver Ambetter Balanced Care 29 + Vision + Adult Dental

94. Expanded Bronze Ambetter Essential Care 2 HSA + Vision + Adult Dental

95. Expanded Bronze Ambetter Essential Care 5 + Vision + Adult Dental

96. Expanded Bronze Ambetter Essential Care 22 + Vision + Adult Dental

97. Expanded Bronze Ambetter Essential Care: $1,500 Medical Deductible + Vision + Adult Dental

98. Expanded Bronze Ambetter Essential Care: $0 Medical Deductible + Vision + Adult Dental

99. Silver Ambetter Balanced Care 31 + Vision + Adult Dental

100. Silver Ambetter Balanced Care 32 + Vision + Adult Dental

101. Gold Ambetter Secure Care 20 + Vision + Adult Dental

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

102. Expanded Bronze Aetna CVS Bronze: Low-Cost Walk-in Clinic Visits, Telehealth, Atlanta

103. Bronze Aetna CVS Bronze: $0 Walk-In Clinic Visits, Telehealth, Atlanta

104. Gold Aetna CVS Gold: $0 Walk-In Clinic Visits, Telehealth, Atlanta

105. Silver Aetna CVS Silver 2: $0 Walk-In Clinic Visits, Telehealth, Atlanta

106. Silver Aetna CVS Silver 1: $0 Walk-In Clinic Visits, Telehealth, Atlanta

Kaiser Permanente

Local: 1-800-494-5314 | Toll Free: 1-800-494-5314

107. Gold KP GA Gold 500/20

108. Silver KP GA Silver 3000/30

109. Silver KP GA Silver 3500/20%/HSA

110. Expanded Bronze KP GA Bronze Virtual Complete 5000/60

111. Expanded Bronze KP GA Bronze 6500/40%/HSA

112. Catastrophic KP GA Catastrophic 8700/0

113. Gold KP GA Gold 1500/20

114. Silver KP GA Silver 4500/35

115. Gold KP GA Gold 1700/25

116. Silver KP GA Silver Virtual Complete 4800/40

scroll down for more

Ambetter from Peach State Health Plan

Aetna CVS Health

Kaiser Permanente

Annual Out of Pocket Expenses:

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

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $7,800 $15,600 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $6,500 $13,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $6,800 $13,600 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $3,600 $7,200 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $4,500 $9,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $7,300 $14,600 Annual Deductible $7,300 $14,600 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $3,500 $7,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $4,200 $8,400 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $1,600 $3,200 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $1,250 $2,500 Annual Deductible $7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

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:

Annual Out of Pocket Expenses:

Individual Family $3,000 $6,000 Annual Deductible $7,700 $15,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $5,500 $11,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $5,600 $11,200 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $8,000 $16,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $4,950 $9,900 Annual Deductible $7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $1,900 $3,800 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

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:

Annual Out of Pocket Expenses:

Individual Family $2,600 $5,200 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

Annual Out of Pocket Expenses:

Individual Family $7,500 $15,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$8,700 $17,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,800 $15,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,500 $13,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,000 $14,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$6,800 $13,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$3,600 $7,200 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$4,500 $9,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,300 $14,600 Annual Deductible

$7,300 $14,600 Maximum Out of Pocket Per Year

Individual Family

$3,500 $7,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$4,200 $8,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$1,600 $3,200 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$1,250 $2,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$7,050 $14,100 Annual Deductible

$7,050 $14,100 Maximum Out of Pocket Per Year

Individual Family

$3,000 $6,000 Annual Deductible

$7,700 $15,400 Maximum Out of Pocket Per Year

Individual Family

$5,500 $11,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,600 $11,200 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$8,700 $17,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$4,950 $9,900 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$1,900 $3,800 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,000 $10,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$2,600 $5,200 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,750 $11,500 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,450 $12,900 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year