Obamacare 2022 Rates for Gwinnett County

Obamacare > Rates > Georgia > Gwinnett County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Gwinnett County, GA.

The health insurance rates listed below are for calendar year 2022.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 156 Plans and 2022 Rates for Gwinnett County, Georgia

Below, you’ll find a summary of the 156 plans for Gwinnett County, Georgia and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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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

ADVERTISEMENT

Bright HealthCare

Local: 1-855-827-4448 | Toll Free: 1-855-827-4448 | TTY: 1-855-827-4448
Toc - Plan #14 Bright HealthCare
Gold

(HMO) Gold 1000 ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$356.35
$404.45
$455.41
$636.43
$967.12 		$628.95
$677.05
$728.01
$909.03 		$901.55
$949.65
$1,000.61
$1,181.63 		$1,174.15
$1,222.25
$1,273.21
$1,454.23 		$272.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.70
$808.90
$910.82
$1,272.86
$1,934.24 		$985.30
$1,081.50
$1,183.42
$1,545.46 		$1,257.90
$1,354.10
$1,456.02
$1,818.06 		$1,530.50
$1,626.70
$1,728.62
$2,090.66 		$272.60
Toc - Plan #15 Bright HealthCare
Gold

(HMO) Gold $0 Deductible + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription L

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$399.39
$453.31
$510.43
$713.32
$1,083.96 		$704.93
$758.85
$815.97
$1,018.86 		$1,010.47
$1,064.39
$1,121.51
$1,324.40 		$1,316.01
$1,369.93
$1,427.05
$1,629.94 		$305.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.78
$906.62
$1,020.86
$1,426.64
$2,167.92 		$1,104.32
$1,212.16
$1,326.40
$1,732.18 		$1,409.86
$1,517.70
$1,631.94
$2,037.72 		$1,715.40
$1,823.24
$1,937.48
$2,343.26 		$305.54
Toc - Plan #16 Bright HealthCare
Silver

(HMO) Silver 5000 ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$321.42
$364.81
$410.78
$574.06
$872.34 		$567.31
$610.70
$656.67
$819.95 		$813.20
$856.59
$902.56
$1,065.84 		$1,059.09
$1,102.48
$1,148.45
$1,311.73 		$245.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.84
$729.62
$821.56
$1,148.12
$1,744.68 		$888.73
$975.51
$1,067.45
$1,394.01 		$1,134.62
$1,221.40
$1,313.34
$1,639.90 		$1,380.51
$1,467.29
$1,559.23
$1,885.79 		$245.89
Toc - Plan #17 Bright HealthCare
Silver

(HMO) Silver 3000 ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$324.49
$368.29
$414.70
$579.54
$880.66 		$572.72
$616.52
$662.93
$827.77 		$820.95
$864.75
$911.16
$1,076.00 		$1,069.18
$1,112.98
$1,159.39
$1,324.23 		$248.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.98
$736.58
$829.40
$1,159.08
$1,761.32 		$897.21
$984.81
$1,077.63
$1,407.31 		$1,145.44
$1,233.04
$1,325.86
$1,655.54 		$1,393.67
$1,481.27
$1,574.09
$1,903.77 		$248.23
Toc - Plan #18 Bright HealthCare
Silver

(HMO) Silver 6700 ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$327.11
$371.27
$418.04
$584.22
$887.77 		$577.35
$621.51
$668.28
$834.46 		$827.59
$871.75
$918.52
$1,084.70 		$1,077.83
$1,121.99
$1,168.76
$1,334.94 		$250.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.22
$742.54
$836.08
$1,168.44
$1,775.54 		$904.46
$992.78
$1,086.32
$1,418.68 		$1,154.70
$1,243.02
$1,336.56
$1,668.92 		$1,404.94
$1,493.26
$1,586.80
$1,919.16 		$250.24
Toc - Plan #19 Bright HealthCare
Silver

(HMO) Silver 6700 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Presc

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$340.67
$386.66
$435.37
$608.43
$924.57 		$601.28
$647.27
$695.98
$869.04 		$861.89
$907.88
$956.59
$1,129.65 		$1,122.50
$1,168.49
$1,217.20
$1,390.26 		$260.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.34
$773.32
$870.74
$1,216.86
$1,849.14 		$941.95
$1,033.93
$1,131.35
$1,477.47 		$1,202.56
$1,294.54
$1,391.96
$1,738.08 		$1,463.17
$1,555.15
$1,652.57
$1,998.69 		$260.61
Toc - Plan #20 Bright HealthCare
Silver

(HMO) Silver $0 Deductible ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$336.49
$381.91
$430.03
$600.97
$913.23 		$593.90
$639.32
$687.44
$858.38 		$851.31
$896.73
$944.85
$1,115.79 		$1,108.72
$1,154.14
$1,202.26
$1,373.20 		$257.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.98
$763.82
$860.06
$1,201.94
$1,826.46 		$930.39
$1,021.23
$1,117.47
$1,459.35 		$1,187.80
$1,278.64
$1,374.88
$1,716.76 		$1,445.21
$1,536.05
$1,632.29
$1,974.17 		$257.41
Toc - Plan #21 Bright HealthCare
Expanded Bronze

(HMO) Bronze 8700 + $0 Mental Health ($0 Telehealth + $0 Primary Care + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$237.60
$269.68
$303.65
$424.35
$644.84 		$419.36
$451.44
$485.41
$606.11 		$601.12
$633.20
$667.17
$787.87 		$782.88
$814.96
$848.93
$969.63 		$181.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475.20
$539.36
$607.30
$848.70
$1,289.68 		$656.96
$721.12
$789.06
$1,030.46 		$838.72
$902.88
$970.82
$1,212.22 		$1,020.48
$1,084.64
$1,152.58
$1,393.98 		$181.76
Toc - Plan #22 Bright HealthCare
Expanded Bronze

(HMO) Bronze 7200 ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$245.43
$278.57
$313.66
$438.34
$666.10 		$433.19
$466.33
$501.42
$626.10 		$620.95
$654.09
$689.18
$813.86 		$808.71
$841.85
$876.94
$1,001.62 		$187.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$490.86
$557.14
$627.32
$876.68
$1,332.20 		$678.62
$744.90
$815.08
$1,064.44 		$866.38
$932.66
$1,002.84
$1,252.20 		$1,054.14
$1,120.42
$1,190.60
$1,439.96 		$187.76
Toc - Plan #23 Bright HealthCare
Expanded Bronze

(HMO) Bronze 7200 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$258.99
$293.96
$330.99
$462.56
$702.90 		$457.12
$492.09
$529.12
$660.69 		$655.25
$690.22
$727.25
$858.82 		$853.38
$888.35
$925.38
$1,056.95 		$198.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.98
$587.92
$661.98
$925.12
$1,405.80 		$716.11
$786.05
$860.11
$1,123.25 		$914.24
$984.18
$1,058.24
$1,321.38 		$1,112.37
$1,182.31
$1,256.37
$1,519.51 		$198.13
Toc - Plan #24 Bright HealthCare
Expanded Bronze

(HMO) Bronze $0 Medical Deductible ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$274.30
$311.33
$350.55
$489.90
$744.45 		$484.14
$521.17
$560.39
$699.74 		$693.98
$731.01
$770.23
$909.58 		$903.82
$940.85
$980.07
$1,119.42 		$209.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.60
$622.66
$701.10
$979.80
$1,488.90 		$758.44
$832.50
$910.94
$1,189.64 		$968.28
$1,042.34
$1,120.78
$1,399.48 		$1,178.12
$1,252.18
$1,330.62
$1,609.32 		$209.84
Toc - Plan #25 Bright HealthCare
Expanded Bronze

(HMO) Bronze 5300 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 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 		$258.55
$293.46
$330.43
$461.77
$701.71 		$456.34
$491.25
$528.22
$659.56 		$654.13
$689.04
$726.01
$857.35 		$851.92
$886.83
$923.80
$1,055.14 		$197.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.10
$586.92
$660.86
$923.54
$1,403.42 		$714.89
$784.71
$858.65
$1,121.33 		$912.68
$982.50
$1,056.44
$1,319.12 		$1,110.47
$1,180.29
$1,254.23
$1,516.91 		$197.79
Toc - Plan #26 Bright HealthCare
Catastrophic

(HMO) Catastrophic 8700 ($0 Primary Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$202.12
$229.41
$258.31
$360.99
$548.55 		$356.74
$384.03
$412.93
$515.61 		$511.36
$538.65
$567.55
$670.23 		$665.98
$693.27
$722.17
$824.85 		$154.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$404.24
$458.82
$516.62
$721.98
$1,097.10 		$558.86
$613.44
$671.24
$876.60 		$713.48
$768.06
$825.86
$1,031.22 		$868.10
$922.68
$980.48
$1,185.84 		$154.62
Toc - Plan #27 Bright HealthCare
Expanded Bronze

(HMO) Bronze 8700 ($25 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$234.46
$266.11
$299.64
$418.75
$636.33 		$413.82
$445.47
$479.00
$598.11 		$593.18
$624.83
$658.36
$777.47 		$772.54
$804.19
$837.72
$956.83 		$179.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$468.92
$532.22
$599.28
$837.50
$1,272.66 		$648.28
$711.58
$778.64
$1,016.86 		$827.64
$890.94
$958.00
$1,196.22 		$1,007.00
$1,070.30
$1,137.36
$1,375.58 		$179.36
Toc - Plan #28 Bright HealthCare
Silver

(HMO) Silver 4000 ($35 Primary Care + $15 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$316.95
$359.74
$405.07
$566.08
$860.21 		$559.42
$602.21
$647.54
$808.55 		$801.89
$844.68
$890.01
$1,051.02 		$1,044.36
$1,087.15
$1,132.48
$1,293.49 		$242.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.90
$719.48
$810.14
$1,132.16
$1,720.42 		$876.37
$961.95
$1,052.61
$1,374.63 		$1,118.84
$1,204.42
$1,295.08
$1,617.10 		$1,361.31
$1,446.89
$1,537.55
$1,859.57 		$242.47

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-609-9754 | Toll Free: 1-800-609-9754 | TTY: 1-800-609-9754
Toc - Plan #29 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($2 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$456.43
$518.04
$583.31
$815.18
$1,238.74 		$805.60
$867.21
$932.48
$1,164.35 		$1,154.77
$1,216.38
$1,281.65
$1,513.52 		$1,503.94
$1,565.55
$1,630.82
$1,862.69 		$349.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912.86
$1,036.08
$1,166.62
$1,630.36
$2,477.48 		$1,262.03
$1,385.25
$1,515.79
$1,979.53 		$1,611.20
$1,734.42
$1,864.96
$2,328.70 		$1,960.37
$2,083.59
$2,214.13
$2,677.87 		$349.17
Toc - Plan #30 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($2 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$475.63
$539.84
$607.86
$849.48
$1,290.86 		$839.49
$903.70
$971.72
$1,213.34 		$1,203.35
$1,267.56
$1,335.58
$1,577.20 		$1,567.21
$1,631.42
$1,699.44
$1,941.06 		$363.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$951.26
$1,079.68
$1,215.72
$1,698.96
$2,581.72 		$1,315.12
$1,443.54
$1,579.58
$2,062.82 		$1,678.98
$1,807.40
$1,943.44
$2,426.68 		$2,042.84
$2,171.26
$2,307.30
$2,790.54 		$363.86
Toc - Plan #31 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($2 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,250 $4,500 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 		$453.34
$514.54
$579.37
$809.67
$1,230.37 		$800.15
$861.35
$926.18
$1,156.48 		$1,146.96
$1,208.16
$1,272.99
$1,503.29 		$1,493.77
$1,554.97
$1,619.80
$1,850.10 		$346.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$906.68
$1,029.08
$1,158.74
$1,619.34
$2,460.74 		$1,253.49
$1,375.89
$1,505.55
$1,966.15 		$1,600.30
$1,722.70
$1,852.36
$2,312.96 		$1,947.11
$2,069.51
$2,199.17
$2,659.77 		$346.81
Toc - Plan #32 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($2 Rx + Dental + Vision + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$474.26
$538.28
$606.10
$847.03
$1,287.14 		$837.07
$901.09
$968.91
$1,209.84 		$1,199.88
$1,263.90
$1,331.72
$1,572.65 		$1,562.69
$1,626.71
$1,694.53
$1,935.46 		$362.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$948.52
$1,076.56
$1,212.20
$1,694.06
$2,574.28 		$1,311.33
$1,439.37
$1,575.01
$2,056.87 		$1,674.14
$1,802.18
$1,937.82
$2,419.68 		$2,036.95
$2,164.99
$2,300.63
$2,782.49 		$362.81
Toc - Plan #33 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($2 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

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 		$445.80
$505.98
$569.73
$796.19
$1,209.89 		$786.83
$847.01
$910.76
$1,137.22 		$1,127.86
$1,188.04
$1,251.79
$1,478.25 		$1,468.89
$1,529.07
$1,592.82
$1,819.28 		$341.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891.60
$1,011.96
$1,139.46
$1,592.38
$2,419.78 		$1,232.63
$1,352.99
$1,480.49
$1,933.41 		$1,573.66
$1,694.02
$1,821.52
$2,274.44 		$1,914.69
$2,035.05
$2,162.55
$2,615.47 		$341.03
Toc - Plan #34 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ Saver ($2 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

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 		$451.97
$512.98
$577.62
$807.22
$1,226.64 		$797.73
$858.74
$923.38
$1,152.98 		$1,143.49
$1,204.50
$1,269.14
$1,498.74 		$1,489.25
$1,550.26
$1,614.90
$1,844.50 		$345.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.94
$1,025.96
$1,155.24
$1,614.44
$2,453.28 		$1,249.70
$1,371.72
$1,501.00
$1,960.20 		$1,595.46
$1,717.48
$1,846.76
$2,305.96 		$1,941.22
$2,063.24
$2,192.52
$2,651.72 		$345.76
Toc - Plan #35 UnitedHealthcare
Gold

(HMO) UHC Gold Value+

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 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 		$454.71
$516.10
$581.12
$812.12
$1,234.09 		$802.56
$863.95
$928.97
$1,159.97 		$1,150.41
$1,211.80
$1,276.82
$1,507.82 		$1,498.26
$1,559.65
$1,624.67
$1,855.67 		$347.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.42
$1,032.20
$1,162.24
$1,624.24
$2,468.18 		$1,257.27
$1,380.05
$1,510.09
$1,972.09 		$1,605.12
$1,727.90
$1,857.94
$2,319.94 		$1,952.97
$2,075.75
$2,205.79
$2,667.79 		$347.85
Toc - Plan #36 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

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 		$380.64
$432.03
$486.46
$679.83
$1,033.06 		$671.83
$723.22
$777.65
$971.02 		$963.02
$1,014.41
$1,068.84
$1,262.21 		$1,254.21
$1,305.60
$1,360.03
$1,553.40 		$291.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.28
$864.06
$972.92
$1,359.66
$2,066.12 		$1,052.47
$1,155.25
$1,264.11
$1,650.85 		$1,343.66
$1,446.44
$1,555.30
$1,942.04 		$1,634.85
$1,737.63
$1,846.49
$2,233.23 		$291.19
Toc - Plan #37 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$398.13
$451.88
$508.81
$711.06
$1,080.53 		$702.70
$756.45
$813.38
$1,015.63 		$1,007.27
$1,061.02
$1,117.95
$1,320.20 		$1,311.84
$1,365.59
$1,422.52
$1,624.77 		$304.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.26
$903.76
$1,017.62
$1,422.12
$2,161.06 		$1,100.83
$1,208.33
$1,322.19
$1,726.69 		$1,405.40
$1,512.90
$1,626.76
$2,031.26 		$1,709.97
$1,817.47
$1,931.33
$2,335.83 		$304.57
Toc - Plan #38 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$417.68
$474.06
$533.79
$745.97
$1,133.57 		$737.20
$793.58
$853.31
$1,065.49 		$1,056.72
$1,113.10
$1,172.83
$1,385.01 		$1,376.24
$1,432.62
$1,492.35
$1,704.53 		$319.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.36
$948.12
$1,067.58
$1,491.94
$2,267.14 		$1,154.88
$1,267.64
$1,387.10
$1,811.46 		$1,474.40
$1,587.16
$1,706.62
$2,130.98 		$1,793.92
$1,906.68
$2,026.14
$2,450.50 		$319.52
Toc - Plan #39 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$399.16
$453.05
$510.13
$712.90
$1,083.32 		$704.52
$758.41
$815.49
$1,018.26 		$1,009.88
$1,063.77
$1,120.85
$1,323.62 		$1,315.24
$1,369.13
$1,426.21
$1,628.98 		$305.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.32
$906.10
$1,020.26
$1,425.80
$2,166.64 		$1,103.68
$1,211.46
$1,325.62
$1,731.16 		$1,409.04
$1,516.82
$1,630.98
$2,036.52 		$1,714.40
$1,822.18
$1,936.34
$2,341.88 		$305.36
Toc - Plan #40 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ Saver ($1 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

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 		$402.59
$456.94
$514.51
$719.02
$1,092.62 		$710.57
$764.92
$822.49
$1,027.00 		$1,018.55
$1,072.90
$1,130.47
$1,334.98 		$1,326.53
$1,380.88
$1,438.45
$1,642.96 		$307.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.18
$913.88
$1,029.02
$1,438.04
$2,185.24 		$1,113.16
$1,221.86
$1,337.00
$1,746.02 		$1,421.14
$1,529.84
$1,644.98
$2,054.00 		$1,729.12
$1,837.82
$1,952.96
$2,361.98 		$307.98
Toc - Plan #41 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

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 		$400.87
$454.99
$512.32
$715.96
$1,087.97 		$707.54
$761.66
$818.99
$1,022.63 		$1,014.21
$1,068.33
$1,125.66
$1,329.30 		$1,320.88
$1,375.00
$1,432.33
$1,635.97 		$306.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.74
$909.98
$1,024.64
$1,431.92
$2,175.94 		$1,108.41
$1,216.65
$1,331.31
$1,738.59 		$1,415.08
$1,523.32
$1,637.98
$2,045.26 		$1,721.75
$1,829.99
$1,944.65
$2,351.93 		$306.67
Toc - Plan #42 UnitedHealthcare
Expanded Bronze

(HMO) UHC Value+ Bronze ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,650 $15,300 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 		$368.30
$418.02
$470.68
$657.78
$999.56 		$650.05
$699.77
$752.43
$939.53 		$931.80
$981.52
$1,034.18
$1,221.28 		$1,213.55
$1,263.27
$1,315.93
$1,503.03 		$281.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.60
$836.04
$941.36
$1,315.56
$1,999.12 		$1,018.35
$1,117.79
$1,223.11
$1,597.31 		$1,300.10
$1,399.54
$1,504.86
$1,879.06 		$1,581.85
$1,681.29
$1,786.61
$2,160.81 		$281.75
Toc - Plan #43 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

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 		$342.92
$389.21
$438.25
$612.46
$930.68 		$605.25
$651.54
$700.58
$874.79 		$867.58
$913.87
$962.91
$1,137.12 		$1,129.91
$1,176.20
$1,225.24
$1,399.45 		$262.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.84
$778.42
$876.50
$1,224.92
$1,861.36 		$948.17
$1,040.75
$1,138.83
$1,487.25 		$1,210.50
$1,303.08
$1,401.16
$1,749.58 		$1,472.83
$1,565.41
$1,663.49
$2,011.91 		$262.33
Toc - Plan #44 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First ($3 Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 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 		$347.38
$394.27
$443.95
$620.42
$942.78 		$613.12
$660.01
$709.69
$886.16 		$878.86
$925.75
$975.43
$1,151.90 		$1,144.60
$1,191.49
$1,241.17
$1,417.64 		$265.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.76
$788.54
$887.90
$1,240.84
$1,885.56 		$960.50
$1,054.28
$1,153.64
$1,506.58 		$1,226.24
$1,320.02
$1,419.38
$1,772.32 		$1,491.98
$1,585.76
$1,685.12
$2,038.06 		$265.74

ADVERTISEMENT

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

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

Toc - Plan #45 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 #46 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 #47 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 #48 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 #49 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 #50 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 #51 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 #52 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 #53 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 #54 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 #55 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 #56 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

ADVERTISEMENT

Oscar Health Plan of Georgia

Local: 1-855-672-2755 | Toll Free: 

Toc - Plan #57 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 #58 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 #59 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 #60 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 #61 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 #62 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 #63 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 #64 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 #65 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 #66 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 #67 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 #68 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 #69 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 #70 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 #71 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 #72 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 #73 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 #74 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 #75 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 #76 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 #77 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 #78 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 #79 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 #80 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 #81 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 #82 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 #83 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 #84 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 #85 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 #86 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 #87 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 #88 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

ADVERTISEMENT

CareSource

Local: 1-833-230-2030 | Toll Free: 1-833-230-2030 | TTY: 1-800-255-0056
Toc - Plan #89 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 #90 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 #91 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 #92 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 #93 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 #94 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 #95 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 #96 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 #97 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 #98 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 #99 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 #100 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 #101 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

ADVERTISEMENT

Ambetter from Peach State Health Plan

Local: 1-877-687-1180 | Toll Free: 1-877-687-1180 | TTY: 1-877-941-9231
Toc - Plan #102 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 #103 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 #104 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 #105 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 #106 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 #107 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 #108 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 #109 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 #110 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 #111 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 #112 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 #113 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 #114 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 #115 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 #116 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 #117 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 #118 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 #119 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 #120 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 #121 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 #122 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 #123 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 #124 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 #125 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 #126 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 #127 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 #128 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 #129 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 #130 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 #131 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 #132 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

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #133 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 #134 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 #135 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 #136 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 #137 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

ADVERTISEMENT

Kaiser Permanente

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

Toc - Plan #138 Kaiser Permanente
Gold

(HMO) KP GA Signature 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 		$345.95
$392.65
$442.12
$617.87
$938.91 		$610.60
$657.30
$706.77
$882.52 		$875.25
$921.95
$971.42
$1,147.17 		$1,139.90
$1,186.60
$1,236.07
$1,411.82 		$264.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.90
$785.30
$884.24
$1,235.74
$1,877.82 		$956.55
$1,049.95
$1,148.89
$1,500.39 		$1,221.20
$1,314.60
$1,413.54
$1,765.04 		$1,485.85
$1,579.25
$1,678.19
$2,029.69 		$264.65
Toc - Plan #139 Kaiser Permanente
Silver

(HMO) KP GA Signature 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 		$353.65
$401.40
$451.97
$631.62
$959.81 		$624.19
$671.94
$722.51
$902.16 		$894.73
$942.48
$993.05
$1,172.70 		$1,165.27
$1,213.02
$1,263.59
$1,443.24 		$270.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.30
$802.80
$903.94
$1,263.24
$1,919.62 		$977.84
$1,073.34
$1,174.48
$1,533.78 		$1,248.38
$1,343.88
$1,445.02
$1,804.32 		$1,518.92
$1,614.42
$1,715.56
$2,074.86 		$270.54
Toc - Plan #140 Kaiser Permanente
Silver

(HMO) KP GA Signature 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 		$337.97
$383.60
$431.93
$603.62
$917.26 		$596.52
$642.15
$690.48
$862.17 		$855.07
$900.70
$949.03
$1,120.72 		$1,113.62
$1,159.25
$1,207.58
$1,379.27 		$258.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.94
$767.20
$863.86
$1,207.24
$1,834.52 		$934.49
$1,025.75
$1,122.41
$1,465.79 		$1,193.04
$1,284.30
$1,380.96
$1,724.34 		$1,451.59
$1,542.85
$1,639.51
$1,982.89 		$258.55
Toc - Plan #141 Kaiser Permanente
Expanded Bronze

(HMO) KP GA Signature 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 		$256.22
$290.81
$327.45
$457.61
$695.38 		$452.23
$486.82
$523.46
$653.62 		$648.24
$682.83
$719.47
$849.63 		$844.25
$878.84
$915.48
$1,045.64 		$196.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512.44
$581.62
$654.90
$915.22
$1,390.76 		$708.45
$777.63
$850.91
$1,111.23 		$904.46
$973.64
$1,046.92
$1,307.24 		$1,100.47
$1,169.65
$1,242.93
$1,503.25 		$196.01
Toc - Plan #142 Kaiser Permanente
Expanded Bronze

(HMO) KP GA Signature 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 		$253.42
$287.63
$323.87
$452.60
$687.77 		$447.28
$481.49
$517.73
$646.46 		$641.14
$675.35
$711.59
$840.32 		$835.00
$869.21
$905.45
$1,034.18 		$193.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$506.84
$575.26
$647.74
$905.20
$1,375.54 		$700.70
$769.12
$841.60
$1,099.06 		$894.56
$962.98
$1,035.46
$1,292.92 		$1,088.42
$1,156.84
$1,229.32
$1,486.78 		$193.86
Toc - Plan #143 Kaiser Permanente
Catastrophic

(HMO) KP GA Signature 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 		$221.92
$251.88
$283.61
$396.35
$602.29 		$391.69
$421.65
$453.38
$566.12 		$561.46
$591.42
$623.15
$735.89 		$731.23
$761.19
$792.92
$905.66 		$169.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$443.84
$503.76
$567.22
$792.70
$1,204.58 		$613.61
$673.53
$736.99
$962.47 		$783.38
$843.30
$906.76
$1,132.24 		$953.15
$1,013.07
$1,076.53
$1,302.01 		$169.77
Toc - Plan #144 Kaiser Permanente
Gold

(HMO) KP GA Signature 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 		$332.63
$377.53
$425.10
$594.08
$902.76 		$587.09
$631.99
$679.56
$848.54 		$841.55
$886.45
$934.02
$1,103.00 		$1,096.01
$1,140.91
$1,188.48
$1,357.46 		$254.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.26
$755.06
$850.20
$1,188.16
$1,805.52 		$919.72
$1,009.52
$1,104.66
$1,442.62 		$1,174.18
$1,263.98
$1,359.12
$1,697.08 		$1,428.64
$1,518.44
$1,613.58
$1,951.54 		$254.46
Toc - Plan #145 Kaiser Permanente
Silver

(HMO) KP GA Signature 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 		$334.67
$379.85
$427.71
$597.72
$908.30 		$590.69
$635.87
$683.73
$853.74 		$846.71
$891.89
$939.75
$1,109.76 		$1,102.73
$1,147.91
$1,195.77
$1,365.78 		$256.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.34
$759.70
$855.42
$1,195.44
$1,816.60 		$925.36
$1,015.72
$1,111.44
$1,451.46 		$1,181.38
$1,271.74
$1,367.46
$1,707.48 		$1,437.40
$1,527.76
$1,623.48
$1,963.50 		$256.02
Toc - Plan #146 Kaiser Permanente
Gold

(HMO) KP GA Signature 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 		$320.71
$364.01
$409.87
$572.79
$870.41 		$566.06
$609.36
$655.22
$818.14 		$811.41
$854.71
$900.57
$1,063.49 		$1,056.76
$1,100.06
$1,145.92
$1,308.84 		$245.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.42
$728.02
$819.74
$1,145.58
$1,740.82 		$886.77
$973.37
$1,065.09
$1,390.93 		$1,132.12
$1,218.72
$1,310.44
$1,636.28 		$1,377.47
$1,464.07
$1,555.79
$1,881.63 		$245.35
Toc - Plan #147 Kaiser Permanente
Silver

(HMO) KP GA Signature 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 		$318.16
$361.12
$406.61
$568.24
$863.50 		$561.56
$604.52
$650.01
$811.64 		$804.96
$847.92
$893.41
$1,055.04 		$1,048.36
$1,091.32
$1,136.81
$1,298.44 		$243.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.32
$722.24
$813.22
$1,136.48
$1,727.00 		$879.72
$965.64
$1,056.62
$1,379.88 		$1,123.12
$1,209.04
$1,300.02
$1,623.28 		$1,366.52
$1,452.44
$1,543.42
$1,866.68 		$243.40

ADVERTISEMENT

Friday Health Plans

Local: 1-844-521-7999 | Toll Free: 1-844-521-7999 | TTY: 1-800-659-2656
Toc - Plan #148 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$225.87
$256.36
$288.66
$403.40
$613.00 		$398.66
$429.15
$461.45
$576.19 		$571.45
$601.94
$634.24
$748.98 		$744.24
$774.73
$807.03
$921.77 		$172.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$451.74
$512.72
$577.32
$806.80
$1,226.00 		$624.53
$685.51
$750.11
$979.59 		$797.32
$858.30
$922.90
$1,152.38 		$970.11
$1,031.09
$1,095.69
$1,325.17 		$172.79
Toc - Plan #149 Friday Health Plans
Bronze

(HMO) Friday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$246.54
$279.83
$315.08
$440.33
$669.12 		$435.15
$468.44
$503.69
$628.94 		$623.76
$657.05
$692.30
$817.55 		$812.37
$845.66
$880.91
$1,006.16 		$188.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$493.08
$559.66
$630.16
$880.66
$1,338.24 		$681.69
$748.27
$818.77
$1,069.27 		$870.30
$936.88
$1,007.38
$1,257.88 		$1,058.91
$1,125.49
$1,195.99
$1,446.49 		$188.61
Toc - Plan #150 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$252.22
$286.27
$322.33
$450.46
$684.52 		$445.17
$479.22
$515.28
$643.41 		$638.12
$672.17
$708.23
$836.36 		$831.07
$865.12
$901.18
$1,029.31 		$192.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.44
$572.54
$644.66
$900.92
$1,369.04 		$697.39
$765.49
$837.61
$1,093.87 		$890.34
$958.44
$1,030.56
$1,286.82 		$1,083.29
$1,151.39
$1,223.51
$1,479.77 		$192.95
Toc - Plan #151 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$260.12
$295.24
$332.44
$464.58
$705.98 		$459.12
$494.24
$531.44
$663.58 		$658.12
$693.24
$730.44
$862.58 		$857.12
$892.24
$929.44
$1,061.58 		$199.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520.24
$590.48
$664.88
$929.16
$1,411.96 		$719.24
$789.48
$863.88
$1,128.16 		$918.24
$988.48
$1,062.88
$1,327.16 		$1,117.24
$1,187.48
$1,261.88
$1,526.16 		$199.00
Toc - Plan #152 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$319.58
$362.72
$408.42
$570.77
$867.33 		$564.06
$607.20
$652.90
$815.25 		$808.54
$851.68
$897.38
$1,059.73 		$1,053.02
$1,096.16
$1,141.86
$1,304.21 		$244.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.16
$725.44
$816.84
$1,141.54
$1,734.66 		$883.64
$969.92
$1,061.32
$1,386.02 		$1,128.12
$1,214.40
$1,305.80
$1,630.50 		$1,372.60
$1,458.88
$1,550.28
$1,874.98 		$244.48
Toc - Plan #153 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.63
$365.05
$411.04
$574.42
$872.89 		$567.67
$611.09
$657.08
$820.46 		$813.71
$857.13
$903.12
$1,066.50 		$1,059.75
$1,103.17
$1,149.16
$1,312.54 		$246.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.26
$730.10
$822.08
$1,148.84
$1,745.78 		$889.30
$976.14
$1,068.12
$1,394.88 		$1,135.34
$1,222.18
$1,314.16
$1,640.92 		$1,381.38
$1,468.22
$1,560.20
$1,886.96 		$246.04
Toc - Plan #154 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$254.68
$289.06
$325.48
$454.86
$691.21 		$449.51
$483.89
$520.31
$649.69 		$644.34
$678.72
$715.14
$844.52 		$839.17
$873.55
$909.97
$1,039.35 		$194.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$509.36
$578.12
$650.96
$909.72
$1,382.42 		$704.19
$772.95
$845.79
$1,104.55 		$899.02
$967.78
$1,040.62
$1,299.38 		$1,093.85
$1,162.61
$1,235.45
$1,494.21 		$194.83
Toc - Plan #155 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$327.96
$372.24
$419.13
$585.74
$890.09 		$578.85
$623.13
$670.02
$836.63 		$829.74
$874.02
$920.91
$1,087.52 		$1,080.63
$1,124.91
$1,171.80
$1,338.41 		$250.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.92
$744.48
$838.26
$1,171.48
$1,780.18 		$906.81
$995.37
$1,089.15
$1,422.37 		$1,157.70
$1,246.26
$1,340.04
$1,673.26 		$1,408.59
$1,497.15
$1,590.93
$1,924.15 		$250.89
Toc - Plan #156 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336.39
$381.81
$429.91
$600.80
$912.97 		$593.73
$639.15
$687.25
$858.14 		$851.07
$896.49
$944.59
$1,115.48 		$1,108.41
$1,153.83
$1,201.93
$1,372.82 		$257.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.78
$763.62
$859.82
$1,201.60
$1,825.94 		$930.12
$1,020.96
$1,117.16
$1,458.94 		$1,187.46
$1,278.30
$1,374.50
$1,716.28 		$1,444.80
$1,535.64
$1,631.84
$1,973.62 		$257.34

‡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 Gwinnett County here.

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

Currently, there are 156 plans offered in Rating Area 3.

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2022 Obamacare Plans for Gwinnett County, GA

Plan Browser: 156 Plans
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