Obamacare 2022 Rates for Seminole County

Obamacare > Rates > Georgia > Seminole 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 Seminole 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, 76 Plans and 2022 Rates for Seminole County, Georgia

Below, you’ll find a summary of the 76 plans for Seminole 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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Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

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

Toc - Plan #1 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Catastrophic

(HMO) Anthem Catastrophic Pathway X 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 		$185.18
$210.18
$236.66
$330.73
$502.58 		$326.84
$351.84
$378.32
$472.39 		$468.50
$493.50
$519.98
$614.05 		$610.16
$635.16
$661.64
$755.71 		$141.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$370.36
$420.36
$473.32
$661.46
$1,005.16 		$512.02
$562.02
$614.98
$803.12 		$653.68
$703.68
$756.64
$944.78 		$795.34
$845.34
$898.30
$1,086.44 		$141.66
Toc - Plan #2 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$258.15
$293.00
$329.92
$461.06
$700.62 		$455.63
$490.48
$527.40
$658.54 		$653.11
$687.96
$724.88
$856.02 		$850.59
$885.44
$922.36
$1,053.50 		$197.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$516.30
$586.00
$659.84
$922.12
$1,401.24 		$713.78
$783.48
$857.32
$1,119.60 		$911.26
$980.96
$1,054.80
$1,317.08 		$1,108.74
$1,178.44
$1,252.28
$1,514.56 		$197.48
Toc - Plan #3 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$255.02
$289.45
$325.92
$455.47
$692.12 		$450.11
$484.54
$521.01
$650.56 		$645.20
$679.63
$716.10
$845.65 		$840.29
$874.72
$911.19
$1,040.74 		$195.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510.04
$578.90
$651.84
$910.94
$1,384.24 		$705.13
$773.99
$846.93
$1,106.03 		$900.22
$969.08
$1,042.02
$1,301.12 		$1,095.31
$1,164.17
$1,237.11
$1,496.21 		$195.09
Toc - Plan #4 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$252.54
$286.63
$322.75
$451.04
$685.39 		$445.73
$479.82
$515.94
$644.23 		$638.92
$673.01
$709.13
$837.42 		$832.11
$866.20
$902.32
$1,030.61 		$193.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$505.08
$573.26
$645.50
$902.08
$1,370.78 		$698.27
$766.45
$838.69
$1,095.27 		$891.46
$959.64
$1,031.88
$1,288.46 		$1,084.65
$1,152.83
$1,225.07
$1,481.65 		$193.19
Toc - Plan #5 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$317.46
$360.32
$405.71
$566.98
$861.59 		$560.32
$603.18
$648.57
$809.84 		$803.18
$846.04
$891.43
$1,052.70 		$1,046.04
$1,088.90
$1,134.29
$1,295.56 		$242.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.92
$720.64
$811.42
$1,133.96
$1,723.18 		$877.78
$963.50
$1,054.28
$1,376.82 		$1,120.64
$1,206.36
$1,297.14
$1,619.68 		$1,363.50
$1,449.22
$1,540.00
$1,862.54 		$242.86
Toc - Plan #6 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$303.49
$344.46
$387.86
$542.03
$823.67 		$535.66
$576.63
$620.03
$774.20 		$767.83
$808.80
$852.20
$1,006.37 		$1,000.00
$1,040.97
$1,084.37
$1,238.54 		$232.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.98
$688.92
$775.72
$1,084.06
$1,647.34 		$839.15
$921.09
$1,007.89
$1,316.23 		$1,071.32
$1,153.26
$1,240.06
$1,548.40 		$1,303.49
$1,385.43
$1,472.23
$1,780.57 		$232.17
Toc - Plan #7 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Bronze

(HMO) Anthem Bronze Pathway X 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 		$243.41
$276.27
$311.08
$434.73
$660.61 		$429.62
$462.48
$497.29
$620.94 		$615.83
$648.69
$683.50
$807.15 		$802.04
$834.90
$869.71
$993.36 		$186.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.82
$552.54
$622.16
$869.46
$1,321.22 		$673.03
$738.75
$808.37
$1,055.67 		$859.24
$924.96
$994.58
$1,241.88 		$1,045.45
$1,111.17
$1,180.79
$1,428.09 		$186.21
Toc - Plan #8 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$314.40
$356.84
$401.80
$561.52
$853.28 		$554.92
$597.36
$642.32
$802.04 		$795.44
$837.88
$882.84
$1,042.56 		$1,035.96
$1,078.40
$1,123.36
$1,283.08 		$240.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.80
$713.68
$803.60
$1,123.04
$1,706.56 		$869.32
$954.20
$1,044.12
$1,363.56 		$1,109.84
$1,194.72
$1,284.64
$1,604.08 		$1,350.36
$1,435.24
$1,525.16
$1,844.60 		$240.52
Toc - Plan #9 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$302.50
$343.34
$386.60
$540.27
$820.99 		$533.91
$574.75
$618.01
$771.68 		$765.32
$806.16
$849.42
$1,003.09 		$996.73
$1,037.57
$1,080.83
$1,234.50 		$231.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.00
$686.68
$773.20
$1,080.54
$1,641.98 		$836.41
$918.09
$1,004.61
$1,311.95 		$1,067.82
$1,149.50
$1,236.02
$1,543.36 		$1,299.23
$1,380.91
$1,467.43
$1,774.77 		$231.41
Toc - Plan #10 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Gold

(HMO) Anthem Gold Pathway X 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 		$359.41
$407.93
$459.33
$641.91
$975.44 		$634.36
$682.88
$734.28
$916.86 		$909.31
$957.83
$1,009.23
$1,191.81 		$1,184.26
$1,232.78
$1,284.18
$1,466.76 		$274.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.82
$815.86
$918.66
$1,283.82
$1,950.88 		$993.77
$1,090.81
$1,193.61
$1,558.77 		$1,268.72
$1,365.76
$1,468.56
$1,833.72 		$1,543.67
$1,640.71
$1,743.51
$2,108.67 		$274.95
Toc - Plan #11 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$265.26
$301.07
$339.00
$473.75
$719.92 		$468.18
$503.99
$541.92
$676.67 		$671.10
$706.91
$744.84
$879.59 		$874.02
$909.83
$947.76
$1,082.51 		$202.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.52
$602.14
$678.00
$947.50
$1,439.84 		$733.44
$805.06
$880.92
$1,150.42 		$936.36
$1,007.98
$1,083.84
$1,353.34 		$1,139.28
$1,210.90
$1,286.76
$1,556.26 		$202.92
Toc - Plan #12 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$341.94
$388.10
$437.00
$610.70
$928.03 		$603.52
$649.68
$698.58
$872.28 		$865.10
$911.26
$960.16
$1,133.86 		$1,126.68
$1,172.84
$1,221.74
$1,395.44 		$261.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.88
$776.20
$874.00
$1,221.40
$1,856.06 		$945.46
$1,037.78
$1,135.58
$1,482.98 		$1,207.04
$1,299.36
$1,397.16
$1,744.56 		$1,468.62
$1,560.94
$1,658.74
$2,006.14 		$261.58

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 #13 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 		$232.89
$264.32
$297.62
$415.92
$632.03 		$411.04
$442.47
$475.77
$594.07 		$589.19
$620.62
$653.92
$772.22 		$767.34
$798.77
$832.07
$950.37 		$178.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$465.78
$528.64
$595.24
$831.84
$1,264.06 		$643.93
$706.79
$773.39
$1,009.99 		$822.08
$884.94
$951.54
$1,188.14 		$1,000.23
$1,063.09
$1,129.69
$1,366.29 		$178.15
Toc - Plan #14 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 		$304.78
$345.92
$389.50
$544.33
$827.16 		$537.93
$579.07
$622.65
$777.48 		$771.08
$812.22
$855.80
$1,010.63 		$1,004.23
$1,045.37
$1,088.95
$1,243.78 		$233.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.56
$691.84
$779.00
$1,088.66
$1,654.32 		$842.71
$924.99
$1,012.15
$1,321.81 		$1,075.86
$1,158.14
$1,245.30
$1,554.96 		$1,309.01
$1,391.29
$1,478.45
$1,788.11 		$233.15
Toc - Plan #15 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 		$294.85
$334.64
$376.80
$526.58
$800.19 		$520.40
$560.19
$602.35
$752.13 		$745.95
$785.74
$827.90
$977.68 		$971.50
$1,011.29
$1,053.45
$1,203.23 		$225.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.70
$669.28
$753.60
$1,053.16
$1,600.38 		$815.25
$894.83
$979.15
$1,278.71 		$1,040.80
$1,120.38
$1,204.70
$1,504.26 		$1,266.35
$1,345.93
$1,430.25
$1,729.81 		$225.55
Toc - Plan #16 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 		$311.34
$353.36
$397.88
$556.03
$844.94 		$549.51
$591.53
$636.05
$794.20 		$787.68
$829.70
$874.22
$1,032.37 		$1,025.85
$1,067.87
$1,112.39
$1,270.54 		$238.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.68
$706.72
$795.76
$1,112.06
$1,689.88 		$860.85
$944.89
$1,033.93
$1,350.23 		$1,099.02
$1,183.06
$1,272.10
$1,588.40 		$1,337.19
$1,421.23
$1,510.27
$1,826.57 		$238.17
Toc - Plan #17 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 		$291.19
$330.49
$372.13
$520.05
$790.27 		$513.94
$553.24
$594.88
$742.80 		$736.69
$775.99
$817.63
$965.55 		$959.44
$998.74
$1,040.38
$1,188.30 		$222.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.38
$660.98
$744.26
$1,040.10
$1,580.54 		$805.13
$883.73
$967.01
$1,262.85 		$1,027.88
$1,106.48
$1,189.76
$1,485.60 		$1,250.63
$1,329.23
$1,412.51
$1,708.35 		$222.75
Toc - Plan #18 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 		$287.53
$326.34
$367.46
$513.52
$780.34 		$507.49
$546.30
$587.42
$733.48 		$727.45
$766.26
$807.38
$953.44 		$947.41
$986.22
$1,027.34
$1,173.40 		$219.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.06
$652.68
$734.92
$1,027.04
$1,560.68 		$795.02
$872.64
$954.88
$1,247.00 		$1,014.98
$1,092.60
$1,174.84
$1,466.96 		$1,234.94
$1,312.56
$1,394.80
$1,686.92 		$219.96
Toc - Plan #19 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 		$312.71
$354.91
$399.63
$558.48
$848.66 		$551.92
$594.12
$638.84
$797.69 		$791.13
$833.33
$878.05
$1,036.90 		$1,030.34
$1,072.54
$1,117.26
$1,276.11 		$239.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.42
$709.82
$799.26
$1,116.96
$1,697.32 		$864.63
$949.03
$1,038.47
$1,356.17 		$1,103.84
$1,188.24
$1,277.68
$1,595.38 		$1,343.05
$1,427.45
$1,516.89
$1,834.59 		$239.21
Toc - Plan #20 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 		$254.92
$289.33
$325.78
$455.28
$691.83 		$449.93
$484.34
$520.79
$650.29 		$644.94
$679.35
$715.80
$845.30 		$839.95
$874.36
$910.81
$1,040.31 		$195.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$509.84
$578.66
$651.56
$910.56
$1,383.66 		$704.85
$773.67
$846.57
$1,105.57 		$899.86
$968.68
$1,041.58
$1,300.58 		$1,094.87
$1,163.69
$1,236.59
$1,495.59 		$195.01
Toc - Plan #21 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 		$252.33
$286.39
$322.47
$450.65
$684.80 		$445.36
$479.42
$515.50
$643.68 		$638.39
$672.45
$708.53
$836.71 		$831.42
$865.48
$901.56
$1,029.74 		$193.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.66
$572.78
$644.94
$901.30
$1,369.60 		$697.69
$765.81
$837.97
$1,094.33 		$890.72
$958.84
$1,031.00
$1,287.36 		$1,083.75
$1,151.87
$1,224.03
$1,480.39 		$193.03
Toc - Plan #22 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 		$268.27
$304.48
$342.84
$479.12
$728.06 		$473.49
$509.70
$548.06
$684.34 		$678.71
$714.92
$753.28
$889.56 		$883.93
$920.14
$958.50
$1,094.78 		$205.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.54
$608.96
$685.68
$958.24
$1,456.12 		$741.76
$814.18
$890.90
$1,163.46 		$946.98
$1,019.40
$1,096.12
$1,368.68 		$1,152.20
$1,224.62
$1,301.34
$1,573.90 		$205.22
Toc - Plan #23 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 		$274.49
$311.53
$350.79
$490.22
$744.94 		$484.47
$521.51
$560.77
$700.20 		$694.45
$731.49
$770.75
$910.18 		$904.43
$941.47
$980.73
$1,120.16 		$209.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.98
$623.06
$701.58
$980.44
$1,489.88 		$758.96
$833.04
$911.56
$1,190.42 		$968.94
$1,043.02
$1,121.54
$1,400.40 		$1,178.92
$1,253.00
$1,331.52
$1,610.38 		$209.98
Toc - Plan #24 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 		$288.63
$327.59
$368.86
$515.48
$783.32 		$509.43
$548.39
$589.66
$736.28 		$730.23
$769.19
$810.46
$957.08 		$951.03
$989.99
$1,031.26
$1,177.88 		$220.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.26
$655.18
$737.72
$1,030.96
$1,566.64 		$798.06
$875.98
$958.52
$1,251.76 		$1,018.86
$1,096.78
$1,179.32
$1,472.56 		$1,239.66
$1,317.58
$1,400.12
$1,693.36 		$220.80
Toc - Plan #25 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 		$275.77
$312.99
$352.42
$492.51
$748.41 		$486.73
$523.95
$563.38
$703.47 		$697.69
$734.91
$774.34
$914.43 		$908.65
$945.87
$985.30
$1,125.39 		$210.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.54
$625.98
$704.84
$985.02
$1,496.82 		$762.50
$836.94
$915.80
$1,195.98 		$973.46
$1,047.90
$1,126.76
$1,406.94 		$1,184.42
$1,258.86
$1,337.72
$1,617.90 		$210.96
Toc - Plan #26 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 		$275.86
$313.09
$352.54
$492.67
$748.66 		$486.89
$524.12
$563.57
$703.70 		$697.92
$735.15
$774.60
$914.73 		$908.95
$946.18
$985.63
$1,125.76 		$211.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.72
$626.18
$705.08
$985.34
$1,497.32 		$762.75
$837.21
$916.11
$1,196.37 		$973.78
$1,048.24
$1,127.14
$1,407.40 		$1,184.81
$1,259.27
$1,338.17
$1,618.43 		$211.03
Toc - Plan #27 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 		$282.35
$320.46
$360.83
$504.26
$766.28 		$498.34
$536.45
$576.82
$720.25 		$714.33
$752.44
$792.81
$936.24 		$930.32
$968.43
$1,008.80
$1,152.23 		$215.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.70
$640.92
$721.66
$1,008.52
$1,532.56 		$780.69
$856.91
$937.65
$1,224.51 		$996.68
$1,072.90
$1,153.64
$1,440.50 		$1,212.67
$1,288.89
$1,369.63
$1,656.49 		$215.99
Toc - Plan #28 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 		$291.65
$331.01
$372.71
$520.87
$791.51 		$514.75
$554.11
$595.81
$743.97 		$737.85
$777.21
$818.91
$967.07 		$960.95
$1,000.31
$1,042.01
$1,190.17 		$223.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.30
$662.02
$745.42
$1,041.74
$1,583.02 		$806.40
$885.12
$968.52
$1,264.84 		$1,029.50
$1,108.22
$1,191.62
$1,487.94 		$1,252.60
$1,331.32
$1,414.72
$1,711.04 		$223.10
Toc - Plan #29 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 		$303.45
$344.40
$387.79
$541.94
$823.52 		$535.58
$576.53
$619.92
$774.07 		$767.71
$808.66
$852.05
$1,006.20 		$999.84
$1,040.79
$1,084.18
$1,238.33 		$232.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.90
$688.80
$775.58
$1,083.88
$1,647.04 		$839.03
$920.93
$1,007.71
$1,316.01 		$1,071.16
$1,153.06
$1,239.84
$1,548.14 		$1,303.29
$1,385.19
$1,471.97
$1,780.27 		$232.13
Toc - Plan #30 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 		$317.61
$360.48
$405.89
$567.23
$861.97 		$560.57
$603.44
$648.85
$810.19 		$803.53
$846.40
$891.81
$1,053.15 		$1,046.49
$1,089.36
$1,134.77
$1,296.11 		$242.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.22
$720.96
$811.78
$1,134.46
$1,723.94 		$878.18
$963.92
$1,054.74
$1,377.42 		$1,121.14
$1,206.88
$1,297.70
$1,620.38 		$1,364.10
$1,449.84
$1,540.66
$1,863.34 		$242.96
Toc - Plan #31 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 		$307.26
$348.72
$392.66
$548.74
$833.87 		$542.30
$583.76
$627.70
$783.78 		$777.34
$818.80
$862.74
$1,018.82 		$1,012.38
$1,053.84
$1,097.78
$1,253.86 		$235.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.52
$697.44
$785.32
$1,097.48
$1,667.74 		$849.56
$932.48
$1,020.36
$1,332.52 		$1,084.60
$1,167.52
$1,255.40
$1,567.56 		$1,319.64
$1,402.56
$1,490.44
$1,802.60 		$235.04
Toc - Plan #32 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 		$242.69
$275.44
$310.14
$433.42
$658.63 		$428.34
$461.09
$495.79
$619.07 		$613.99
$646.74
$681.44
$804.72 		$799.64
$832.39
$867.09
$990.37 		$185.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$485.38
$550.88
$620.28
$866.84
$1,317.26 		$671.03
$736.53
$805.93
$1,052.49 		$856.68
$922.18
$991.58
$1,238.14 		$1,042.33
$1,107.83
$1,177.23
$1,423.79 		$185.65
Toc - Plan #33 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 		$324.44
$368.23
$414.62
$579.43
$880.50 		$572.63
$616.42
$662.81
$827.62 		$820.82
$864.61
$911.00
$1,075.81 		$1,069.01
$1,112.80
$1,159.19
$1,324.00 		$248.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.88
$736.46
$829.24
$1,158.86
$1,761.00 		$897.07
$984.65
$1,077.43
$1,407.05 		$1,145.26
$1,232.84
$1,325.62
$1,655.24 		$1,393.45
$1,481.03
$1,573.81
$1,903.43 		$248.19
Toc - Plan #34 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 		$325.87
$369.85
$416.45
$581.98
$884.38 		$575.15
$619.13
$665.73
$831.26 		$824.43
$868.41
$915.01
$1,080.54 		$1,073.71
$1,117.69
$1,164.29
$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
$832.90
$1,163.96
$1,768.76 		$901.02
$988.98
$1,082.18
$1,413.24 		$1,150.30
$1,238.26
$1,331.46
$1,662.52 		$1,399.58
$1,487.54
$1,580.74
$1,911.80 		$249.28
Toc - Plan #35 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 		$299.63
$340.07
$382.92
$535.13
$813.18 		$528.84
$569.28
$612.13
$764.34 		$758.05
$798.49
$841.34
$993.55 		$987.26
$1,027.70
$1,070.55
$1,222.76 		$229.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.26
$680.14
$765.84
$1,070.26
$1,626.36 		$828.47
$909.35
$995.05
$1,299.47 		$1,057.68
$1,138.56
$1,224.26
$1,528.68 		$1,286.89
$1,367.77
$1,453.47
$1,757.89 		$229.21
Toc - Plan #36 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 		$265.65
$301.50
$339.49
$474.43
$720.95 		$468.87
$504.72
$542.71
$677.65 		$672.09
$707.94
$745.93
$880.87 		$875.31
$911.16
$949.15
$1,084.09 		$203.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531.30
$603.00
$678.98
$948.86
$1,441.90 		$734.52
$806.22
$882.20
$1,152.08 		$937.74
$1,009.44
$1,085.42
$1,355.30 		$1,140.96
$1,212.66
$1,288.64
$1,558.52 		$203.22
Toc - Plan #37 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 		$262.95
$298.44
$336.04
$469.61
$713.62 		$464.10
$499.59
$537.19
$670.76 		$665.25
$700.74
$738.34
$871.91 		$866.40
$901.89
$939.49
$1,073.06 		$201.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.90
$596.88
$672.08
$939.22
$1,427.24 		$727.05
$798.03
$873.23
$1,140.37 		$928.20
$999.18
$1,074.38
$1,341.52 		$1,129.35
$1,200.33
$1,275.53
$1,542.67 		$201.15
Toc - Plan #38 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 		$279.56
$317.29
$357.27
$499.28
$758.70 		$493.42
$531.15
$571.13
$713.14 		$707.28
$745.01
$784.99
$927.00 		$921.14
$958.87
$998.85
$1,140.86 		$213.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559.12
$634.58
$714.54
$998.56
$1,517.40 		$772.98
$848.44
$928.40
$1,212.42 		$986.84
$1,062.30
$1,142.26
$1,426.28 		$1,200.70
$1,276.16
$1,356.12
$1,640.14 		$213.86
Toc - Plan #39 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 		$286.04
$324.64
$365.55
$510.85
$776.29 		$504.85
$543.45
$584.36
$729.66 		$723.66
$762.26
$803.17
$948.47 		$942.47
$981.07
$1,021.98
$1,167.28 		$218.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.08
$649.28
$731.10
$1,021.70
$1,552.58 		$790.89
$868.09
$949.91
$1,240.51 		$1,009.70
$1,086.90
$1,168.72
$1,459.32 		$1,228.51
$1,305.71
$1,387.53
$1,678.13 		$218.81
Toc - Plan #40 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 		$300.78
$341.37
$384.38
$537.17
$816.28 		$530.87
$571.46
$614.47
$767.26 		$760.96
$801.55
$844.56
$997.35 		$991.05
$1,031.64
$1,074.65
$1,227.44 		$230.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.56
$682.74
$768.76
$1,074.34
$1,632.56 		$831.65
$912.83
$998.85
$1,304.43 		$1,061.74
$1,142.92
$1,228.94
$1,534.52 		$1,291.83
$1,373.01
$1,459.03
$1,764.61 		$230.09
Toc - Plan #41 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 		$287.47
$326.27
$367.37
$513.40
$780.17 		$507.38
$546.18
$587.28
$733.31 		$727.29
$766.09
$807.19
$953.22 		$947.20
$986.00
$1,027.10
$1,173.13 		$219.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.94
$652.54
$734.74
$1,026.80
$1,560.34 		$794.85
$872.45
$954.65
$1,246.71 		$1,014.76
$1,092.36
$1,174.56
$1,466.62 		$1,234.67
$1,312.27
$1,394.47
$1,686.53 		$219.91
Toc - Plan #42 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 		$294.23
$333.95
$376.02
$525.49
$798.53 		$519.31
$559.03
$601.10
$750.57 		$744.39
$784.11
$826.18
$975.65 		$969.47
$1,009.19
$1,051.26
$1,200.73 		$225.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.46
$667.90
$752.04
$1,050.98
$1,597.06 		$813.54
$892.98
$977.12
$1,276.06 		$1,038.62
$1,118.06
$1,202.20
$1,501.14 		$1,263.70
$1,343.14
$1,427.28
$1,726.22 		$225.08
Toc - Plan #43 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 		$303.92
$344.94
$388.40
$542.79
$824.82 		$536.41
$577.43
$620.89
$775.28 		$768.90
$809.92
$853.38
$1,007.77 		$1,001.39
$1,042.41
$1,085.87
$1,240.26 		$232.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.84
$689.88
$776.80
$1,085.58
$1,649.64 		$840.33
$922.37
$1,009.29
$1,318.07 		$1,072.82
$1,154.86
$1,241.78
$1,550.56 		$1,305.31
$1,387.35
$1,474.27
$1,783.05 		$232.49

ADVERTISEMENT

Alliant Health Plans

Local: 1-800-811-4793 | Toll Free: 1-800-811-4793

Toc - Plan #44 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits) 40002

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$276.34
$313.63
$353.15
$493.52
$749.95 		$487.73
$525.02
$564.54
$704.91 		$699.12
$736.41
$775.93
$916.30 		$910.51
$947.80
$987.32
$1,127.69 		$211.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.68
$627.26
$706.30
$987.04
$1,499.90 		$764.07
$838.65
$917.69
$1,198.43 		$975.46
$1,050.04
$1,129.08
$1,409.82 		$1,186.85
$1,261.43
$1,340.47
$1,621.21 		$211.39
Toc - Plan #45 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40017

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$262.57
$298.00
$335.55
$468.93
$712.59 		$463.43
$498.86
$536.41
$669.79 		$664.29
$699.72
$737.27
$870.65 		$865.15
$900.58
$938.13
$1,071.51 		$200.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.14
$596.00
$671.10
$937.86
$1,425.18 		$726.00
$796.86
$871.96
$1,138.72 		$926.86
$997.72
$1,072.82
$1,339.58 		$1,127.72
$1,198.58
$1,273.68
$1,540.44 		$200.86
Toc - Plan #46 Alliant Health Plans
Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits) 40184

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$344.13
$390.57
$439.78
$614.59
$933.93 		$607.38
$653.82
$703.03
$877.84 		$870.63
$917.07
$966.28
$1,141.09 		$1,133.88
$1,180.32
$1,229.53
$1,404.34 		$263.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.26
$781.14
$879.56
$1,229.18
$1,867.86 		$951.51
$1,044.39
$1,142.81
$1,492.43 		$1,214.76
$1,307.64
$1,406.06
$1,755.68 		$1,478.01
$1,570.89
$1,669.31
$2,018.93 		$263.25
Toc - Plan #47 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits) 40330

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$6,800 $13,600 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 		$285.97
$324.57
$365.46
$510.73
$776.11 		$504.73
$543.33
$584.22
$729.49 		$723.49
$762.09
$802.98
$948.25 		$942.25
$980.85
$1,021.74
$1,167.01 		$218.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.94
$649.14
$730.92
$1,021.46
$1,552.22 		$790.70
$867.90
$949.68
$1,240.22 		$1,009.46
$1,086.66
$1,168.44
$1,458.98 		$1,228.22
$1,305.42
$1,387.20
$1,677.74 		$218.76
Toc - Plan #48 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40331

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$263.26
$298.79
$336.43
$470.16
$714.46 		$464.64
$500.17
$537.81
$671.54 		$666.02
$701.55
$739.19
$872.92 		$867.40
$902.93
$940.57
$1,074.30 		$201.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.52
$597.58
$672.86
$940.32
$1,428.92 		$727.90
$798.96
$874.24
$1,141.70 		$929.28
$1,000.34
$1,075.62
$1,343.08 		$1,130.66
$1,201.72
$1,277.00
$1,544.46 		$201.38
Toc - Plan #49 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40336

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$278.06
$315.58
$355.34
$496.59
$754.62 		$490.77
$528.29
$568.05
$709.30 		$703.48
$741.00
$780.76
$922.01 		$916.19
$953.71
$993.47
$1,134.72 		$212.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.12
$631.16
$710.68
$993.18
$1,509.24 		$768.83
$843.87
$923.39
$1,205.89 		$981.54
$1,056.58
$1,136.10
$1,418.60 		$1,194.25
$1,269.29
$1,348.81
$1,631.31 		$212.71
Toc - Plan #50 Alliant Health Plans
Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits + Dental) 40348

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$357.90
$406.20
$457.38
$639.18
$971.30 		$631.68
$679.98
$731.16
$912.96 		$905.46
$953.76
$1,004.94
$1,186.74 		$1,179.24
$1,227.54
$1,278.72
$1,460.52 		$273.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.80
$812.40
$914.76
$1,278.36
$1,942.60 		$989.58
$1,086.18
$1,188.54
$1,552.14 		$1,263.36
$1,359.96
$1,462.32
$1,825.92 		$1,537.14
$1,633.74
$1,736.10
$2,099.70 		$273.78
Toc - Plan #51 Alliant Health Plans
Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits + Chiro + Dental) 40349

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$361.68
$410.50
$462.22
$645.94
$981.57 		$638.36
$687.18
$738.90
$922.62 		$915.04
$963.86
$1,015.58
$1,199.30 		$1,191.72
$1,240.54
$1,292.26
$1,475.98 		$276.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.36
$821.00
$924.44
$1,291.88
$1,963.14 		$1,000.04
$1,097.68
$1,201.12
$1,568.56 		$1,276.72
$1,374.36
$1,477.80
$1,845.24 		$1,553.40
$1,651.04
$1,754.48
$2,121.92 		$276.68
Toc - Plan #52 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Dental) 40354

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$287.35
$326.13
$367.22
$513.19
$779.84 		$507.17
$545.95
$587.04
$733.01 		$726.99
$765.77
$806.86
$952.83 		$946.81
$985.59
$1,026.68
$1,172.65 		$219.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.70
$652.26
$734.44
$1,026.38
$1,559.68 		$794.52
$872.08
$954.26
$1,246.20 		$1,014.34
$1,091.90
$1,174.08
$1,466.02 		$1,234.16
$1,311.72
$1,393.90
$1,685.84 		$219.82
Toc - Plan #53 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Chiro + Dental) 40355

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$290.10
$329.25
$370.73
$518.10
$787.30 		$512.02
$551.17
$592.65
$740.02 		$733.94
$773.09
$814.57
$961.94 		$955.86
$995.01
$1,036.49
$1,183.86 		$221.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.20
$658.50
$741.46
$1,036.20
$1,574.60 		$802.12
$880.42
$963.38
$1,258.12 		$1,024.04
$1,102.34
$1,185.30
$1,480.04 		$1,245.96
$1,324.26
$1,407.22
$1,701.96 		$221.92
Toc - Plan #54 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Dental) 40357

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$6,800 $13,600 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 		$297.67
$337.84
$380.41
$531.62
$807.84 		$525.38
$565.55
$608.12
$759.33 		$753.09
$793.26
$835.83
$987.04 		$980.80
$1,020.97
$1,063.54
$1,214.75 		$227.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$595.34
$675.68
$760.82
$1,063.24
$1,615.68 		$823.05
$903.39
$988.53
$1,290.95 		$1,050.76
$1,131.10
$1,216.24
$1,518.66 		$1,278.47
$1,358.81
$1,443.95
$1,746.37 		$227.71
Toc - Plan #55 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Chiro + Dental) 40358

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$6,800 $13,600 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 		$300.42
$340.97
$383.93
$536.54
$815.32 		$530.24
$570.79
$613.75
$766.36 		$760.06
$800.61
$843.57
$996.18 		$989.88
$1,030.43
$1,073.39
$1,226.00 		$229.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.84
$681.94
$767.86
$1,073.08
$1,630.64 		$830.66
$911.76
$997.68
$1,302.90 		$1,060.48
$1,141.58
$1,227.50
$1,532.72 		$1,290.30
$1,371.40
$1,457.32
$1,762.54 		$229.82
Toc - Plan #56 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay) 40367

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$264.64
$300.35
$338.19
$472.62
$718.19 		$467.08
$502.79
$540.63
$675.06 		$669.52
$705.23
$743.07
$877.50 		$871.96
$907.67
$945.51
$1,079.94 		$202.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$529.28
$600.70
$676.38
$945.24
$1,436.38 		$731.72
$803.14
$878.82
$1,147.68 		$934.16
$1,005.58
$1,081.26
$1,350.12 		$1,136.60
$1,208.02
$1,283.70
$1,552.56 		$202.44
Toc - Plan #57 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits +$225 Specialty Drug Copay + Dental) 40368

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$273.58
$310.50
$349.63
$488.60
$742.48 		$482.86
$519.78
$558.91
$697.88 		$692.14
$729.06
$768.19
$907.16 		$901.42
$938.34
$977.47
$1,116.44 		$209.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.16
$621.00
$699.26
$977.20
$1,484.96 		$756.44
$830.28
$908.54
$1,186.48 		$965.72
$1,039.56
$1,117.82
$1,395.76 		$1,175.00
$1,248.84
$1,327.10
$1,605.04 		$209.28
Toc - Plan #58 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40369

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$275.30
$312.45
$351.82
$491.67
$747.14 		$485.90
$523.05
$562.42
$702.27 		$696.50
$733.65
$773.02
$912.87 		$907.10
$944.25
$983.62
$1,123.47 		$210.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.60
$624.90
$703.64
$983.34
$1,494.28 		$761.20
$835.50
$914.24
$1,193.94 		$971.80
$1,046.10
$1,124.84
$1,404.54 		$1,182.40
$1,256.70
$1,335.44
$1,615.14 		$210.60
Toc - Plan #59 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay) 40371

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$265.32
$301.13
$339.07
$473.85
$720.06 		$468.29
$504.10
$542.04
$676.82 		$671.26
$707.07
$745.01
$879.79 		$874.23
$910.04
$947.98
$1,082.76 		$202.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.64
$602.26
$678.14
$947.70
$1,440.12 		$733.61
$805.23
$881.11
$1,150.67 		$936.58
$1,008.20
$1,084.08
$1,353.64 		$1,139.55
$1,211.17
$1,287.05
$1,556.61 		$202.97
Toc - Plan #60 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay + Dental) 40372

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$273.93
$310.90
$350.07
$489.22
$743.42 		$483.48
$520.45
$559.62
$698.77 		$693.03
$730.00
$769.17
$908.32 		$902.58
$939.55
$978.72
$1,117.87 		$209.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.86
$621.80
$700.14
$978.44
$1,486.84 		$757.41
$831.35
$909.69
$1,187.99 		$966.96
$1,040.90
$1,119.24
$1,397.54 		$1,176.51
$1,250.45
$1,328.79
$1,607.09 		$209.55
Toc - Plan #61 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40373

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$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 #62 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay) 40374

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$280.12
$317.93
$357.98
$500.28
$760.23 		$494.41
$532.22
$572.27
$714.57 		$708.70
$746.51
$786.56
$928.86 		$922.99
$960.80
$1,000.85
$1,143.15 		$214.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.24
$635.86
$715.96
$1,000.56
$1,520.46 		$774.53
$850.15
$930.25
$1,214.85 		$988.82
$1,064.44
$1,144.54
$1,429.14 		$1,203.11
$1,278.73
$1,358.83
$1,643.43 		$214.29
Toc - Plan #63 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay + Dental) 40375

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$289.07
$328.08
$369.42
$516.26
$784.51 		$510.20
$549.21
$590.55
$737.39 		$731.33
$770.34
$811.68
$958.52 		$952.46
$991.47
$1,032.81
$1,179.65 		$221.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.14
$656.16
$738.84
$1,032.52
$1,569.02 		$799.27
$877.29
$959.97
$1,253.65 		$1,020.40
$1,098.42
$1,181.10
$1,474.78 		$1,241.53
$1,319.55
$1,402.23
$1,695.91 		$221.13
Toc - Plan #64 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40376

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$291.48
$330.81
$372.49
$520.56
$791.04 		$514.45
$553.78
$595.46
$743.53 		$737.42
$776.75
$818.43
$966.50 		$960.39
$999.72
$1,041.40
$1,189.47 		$222.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.96
$661.62
$744.98
$1,041.12
$1,582.08 		$805.93
$884.59
$967.95
$1,264.09 		$1,028.90
$1,107.56
$1,190.92
$1,487.06 		$1,251.87
$1,330.53
$1,413.89
$1,710.03 		$222.97
Toc - Plan #65 Alliant Health Plans
Gold

(HMO) SoloCare Gold No Referral HMO (3 Free PCP Visits) 110003

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$275.65
$312.85
$352.27
$492.29
$748.08 		$486.51
$523.71
$563.13
$703.15 		$697.37
$734.57
$773.99
$914.01 		$908.23
$945.43
$984.85
$1,124.87 		$210.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.30
$625.70
$704.54
$984.58
$1,496.16 		$762.16
$836.56
$915.40
$1,195.44 		$973.02
$1,047.42
$1,126.26
$1,406.30 		$1,183.88
$1,258.28
$1,337.12
$1,617.16 		$210.86
Toc - Plan #66 Alliant Health Plans
Gold

(HMO) SoloCare Gold No Referral HMO (3 Free PCP Visits) 110004

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$6,800 $13,600 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 		$285.62
$324.17
$365.02
$510.11
$775.16 		$504.12
$542.67
$583.52
$728.61 		$722.62
$761.17
$802.02
$947.11 		$941.12
$979.67
$1,020.52
$1,165.61 		$218.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.24
$648.34
$730.04
$1,020.22
$1,550.32 		$789.74
$866.84
$948.54
$1,238.72 		$1,008.24
$1,085.34
$1,167.04
$1,457.22 		$1,226.74
$1,303.84
$1,385.54
$1,675.72 		$218.50
Toc - Plan #67 Alliant Health Plans
Silver

(HMO) SoloCare Silver No Referral HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110008

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$260.16
$295.27
$332.47
$464.63
$706.05 		$459.18
$494.29
$531.49
$663.65 		$658.20
$693.31
$730.51
$862.67 		$857.22
$892.33
$929.53
$1,061.69 		$199.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520.32
$590.54
$664.94
$929.26
$1,412.10 		$719.34
$789.56
$863.96
$1,128.28 		$918.36
$988.58
$1,062.98
$1,327.30 		$1,117.38
$1,187.60
$1,262.00
$1,526.32 		$199.02
Toc - Plan #68 Alliant Health Plans
Silver

(HMO) SoloCare Silver No Referral HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110009

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$260.85
$296.05
$333.36
$465.86
$707.92 		$460.39
$495.59
$532.90
$665.40 		$659.93
$695.13
$732.44
$864.94 		$859.47
$894.67
$931.98
$1,064.48 		$199.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.70
$592.10
$666.72
$931.72
$1,415.84 		$721.24
$791.64
$866.26
$1,131.26 		$920.78
$991.18
$1,065.80
$1,330.80 		$1,120.32
$1,190.72
$1,265.34
$1,530.34 		$199.54
Toc - Plan #69 Alliant Health Plans
Silver

(HMO) SoloCare Silver HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110010

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$275.30
$312.45
$351.82
$491.67
$747.14 		$485.90
$523.05
$562.42
$702.27 		$696.50
$733.65
$773.02
$912.87 		$907.10
$944.25
$983.62
$1,123.47 		$210.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.60
$624.90
$703.64
$983.34
$1,494.28 		$761.20
$835.50
$914.24
$1,193.94 		$971.80
$1,046.10
$1,124.84
$1,404.54 		$1,182.40
$1,256.70
$1,335.44
$1,615.14 		$210.60
Toc - Plan #70 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO ($250 Specialty Drug Copay) 110011

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$205.79
$233.56
$262.99
$367.53
$558.50 		$363.21
$390.98
$420.41
$524.95 		$520.63
$548.40
$577.83
$682.37 		$678.05
$705.82
$735.25
$839.79 		$157.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$411.58
$467.12
$525.98
$735.06
$1,117.00 		$569.00
$624.54
$683.40
$892.48 		$726.42
$781.96
$840.82
$1,049.90 		$883.84
$939.38
$998.24
$1,207.32 		$157.42
Toc - Plan #71 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO ($250 Specialty Drug Copay + Dental) 110013

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$213.36
$242.15
$272.66
$381.05
$579.04 		$376.57
$405.36
$435.87
$544.26 		$539.78
$568.57
$599.08
$707.47 		$702.99
$731.78
$762.29
$870.68 		$163.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$426.72
$484.30
$545.32
$762.10
$1,158.08 		$589.93
$647.51
$708.53
$925.31 		$753.14
$810.72
$871.74
$1,088.52 		$916.35
$973.93
$1,034.95
$1,251.73 		$163.21
Toc - Plan #72 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO 110015

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 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 		$206.13
$233.95
$263.43
$368.14
$559.42 		$363.81
$391.63
$421.11
$525.82 		$521.49
$549.31
$578.79
$683.50 		$679.17
$706.99
$736.47
$841.18 		$157.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$412.26
$467.90
$526.86
$736.28
$1,118.84 		$569.94
$625.58
$684.54
$893.96 		$727.62
$783.26
$842.22
$1,051.64 		$885.30
$940.94
$999.90
$1,209.32 		$157.68
Toc - Plan #73 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO (+ Dental) 110017

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 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 		$214.05
$242.94
$273.54
$382.28
$580.91 		$377.79
$406.68
$437.28
$546.02 		$541.53
$570.42
$601.02
$709.76 		$705.27
$734.16
$764.76
$873.50 		$163.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$428.10
$485.88
$547.08
$764.56
$1,161.82 		$591.84
$649.62
$710.82
$928.30 		$755.58
$813.36
$874.56
$1,092.04 		$919.32
$977.10
$1,038.30
$1,255.78 		$163.74
Toc - Plan #74 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO HDHP 110019

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$210.96
$239.42
$269.59
$376.75
$572.51 		$372.33
$400.79
$430.96
$538.12 		$533.70
$562.16
$592.33
$699.49 		$695.07
$723.53
$753.70
$860.86 		$161.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$421.92
$478.84
$539.18
$753.50
$1,145.02 		$583.29
$640.21
$700.55
$914.87 		$744.66
$801.58
$861.92
$1,076.24 		$906.03
$962.95
$1,023.29
$1,237.61 		$161.37
Toc - Plan #75 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO HDHP (+ Dental) 110021

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$219.21
$248.80
$280.14
$391.50
$594.92 		$386.90
$416.49
$447.83
$559.19 		$554.59
$584.18
$615.52
$726.88 		$722.28
$751.87
$783.21
$894.57 		$167.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$438.42
$497.60
$560.28
$783.00
$1,189.84 		$606.11
$665.29
$727.97
$950.69 		$773.80
$832.98
$895.66
$1,118.38 		$941.49
$1,000.67
$1,063.35
$1,286.07 		$167.69
Toc - Plan #76 Alliant Health Plans
Catastrophic

(HMO) SoloCare Catastropic No Referral HMO 110023

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$154.17
$174.97
$197.02
$275.33
$418.39 		$272.10
$292.90
$314.95
$393.26 		$390.03
$410.83
$432.88
$511.19 		$507.96
$528.76
$550.81
$629.12 		$117.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$308.34
$349.94
$394.04
$550.66
$836.78 		$426.27
$467.87
$511.97
$668.59 		$544.20
$585.80
$629.90
$786.52 		$662.13
$703.73
$747.83
$904.45 		$117.93

‡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 Seminole County here.

Seminole County is in “Rating Area 15” of Georgia.

Currently, there are 76 plans offered in Rating Area 15.

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2022 Obamacare Plans for Seminole County, GA

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