Obamacare 2022 Rates for Johnson County

Obamacare > Rates > Kansas > Johnson 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 Johnson County, KS.

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, 82 Plans and 2022 Rates for Johnson County, Kansas

Below, you’ll find a summary of the 82 plans for Johnson County, Kansas 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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Ambetter from Sunflower Health Plan

Local: 1-312-332-5401 | Toll Free: 1-800-779-7989

Toc - Plan #1 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$353.69
$401.43
$452.01
$631.68
$959.90 		$624.26
$672.00
$722.58
$902.25 		$894.83
$942.57
$993.15
$1,172.82 		$1,165.40
$1,213.14
$1,263.72
$1,443.39 		$270.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.38
$802.86
$904.02
$1,263.36
$1,919.80 		$977.95
$1,073.43
$1,174.59
$1,533.93 		$1,248.52
$1,344.00
$1,445.16
$1,804.50 		$1,519.09
$1,614.57
$1,715.73
$2,075.07 		$270.57
Toc - Plan #2 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$349.49
$396.65
$446.63
$624.16
$948.48 		$616.84
$664.00
$713.98
$891.51 		$884.19
$931.35
$981.33
$1,158.86 		$1,151.54
$1,198.70
$1,248.68
$1,426.21 		$267.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.98
$793.30
$893.26
$1,248.32
$1,896.96 		$966.33
$1,060.65
$1,160.61
$1,515.67 		$1,233.68
$1,328.00
$1,427.96
$1,783.02 		$1,501.03
$1,595.35
$1,695.31
$2,050.37 		$267.35
Toc - Plan #3 Ambetter from Sunflower Health Plan
Gold

(EPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$376.33
$427.12
$480.94
$672.11
$1,021.33 		$664.21
$715.00
$768.82
$959.99 		$952.09
$1,002.88
$1,056.70
$1,247.87 		$1,239.97
$1,290.76
$1,344.58
$1,535.75 		$287.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.66
$854.24
$961.88
$1,344.22
$2,042.66 		$1,040.54
$1,142.12
$1,249.76
$1,632.10 		$1,328.42
$1,430.00
$1,537.64
$1,919.98 		$1,616.30
$1,717.88
$1,825.52
$2,207.86 		$287.88
Toc - Plan #4 Ambetter from Sunflower Health Plan
Bronze

(EPO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$259.90
$294.97
$332.14
$464.16
$705.33 		$458.71
$493.78
$530.95
$662.97 		$657.52
$692.59
$729.76
$861.78 		$856.33
$891.40
$928.57
$1,060.59 		$198.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.80
$589.94
$664.28
$928.32
$1,410.66 		$718.61
$788.75
$863.09
$1,127.13 		$917.42
$987.56
$1,061.90
$1,325.94 		$1,116.23
$1,186.37
$1,260.71
$1,524.75 		$198.81
Toc - Plan #5 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$284.27
$322.63
$363.28
$507.68
$771.47 		$501.73
$540.09
$580.74
$725.14 		$719.19
$757.55
$798.20
$942.60 		$936.65
$975.01
$1,015.66
$1,160.06 		$217.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568.54
$645.26
$726.56
$1,015.36
$1,542.94 		$786.00
$862.72
$944.02
$1,232.82 		$1,003.46
$1,080.18
$1,161.48
$1,450.28 		$1,220.92
$1,297.64
$1,378.94
$1,667.74 		$217.46
Toc - Plan #6 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Balanced Care 24

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 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 		$360.38
$409.02
$460.55
$643.62
$978.04 		$636.06
$684.70
$736.23
$919.30 		$911.74
$960.38
$1,011.91
$1,194.98 		$1,187.42
$1,236.06
$1,287.59
$1,470.66 		$275.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.76
$818.04
$921.10
$1,287.24
$1,956.08 		$996.44
$1,093.72
$1,196.78
$1,562.92 		$1,272.12
$1,369.40
$1,472.46
$1,838.60 		$1,547.80
$1,645.08
$1,748.14
$2,114.28 		$275.68
Toc - Plan #7 Ambetter from Sunflower Health Plan
Gold

(EPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$352.99
$400.63
$451.10
$630.42
$957.98 		$623.02
$670.66
$721.13
$900.45 		$893.05
$940.69
$991.16
$1,170.48 		$1,163.08
$1,210.72
$1,261.19
$1,440.51 		$270.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.98
$801.26
$902.20
$1,260.84
$1,915.96 		$976.01
$1,071.29
$1,172.23
$1,530.87 		$1,246.04
$1,341.32
$1,442.26
$1,800.90 		$1,516.07
$1,611.35
$1,712.29
$2,070.93 		$270.03
Toc - Plan #8 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$280.55
$318.42
$358.53
$501.05
$761.39 		$495.16
$533.03
$573.14
$715.66 		$709.77
$747.64
$787.75
$930.27 		$924.38
$962.25
$1,002.36
$1,144.88 		$214.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.10
$636.84
$717.06
$1,002.10
$1,522.78 		$775.71
$851.45
$931.67
$1,216.71 		$990.32
$1,066.06
$1,146.28
$1,431.32 		$1,204.93
$1,280.67
$1,360.89
$1,645.93 		$214.61
Toc - Plan #9 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$319.85
$363.01
$408.75
$571.23
$868.04 		$564.52
$607.68
$653.42
$815.90 		$809.19
$852.35
$898.09
$1,060.57 		$1,053.86
$1,097.02
$1,142.76
$1,305.24 		$244.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.70
$726.02
$817.50
$1,142.46
$1,736.08 		$884.37
$970.69
$1,062.17
$1,387.13 		$1,129.04
$1,215.36
$1,306.84
$1,631.80 		$1,373.71
$1,460.03
$1,551.51
$1,876.47 		$244.67
Toc - Plan #10 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$332.12
$376.94
$424.44
$593.15
$901.34 		$586.18
$631.00
$678.50
$847.21 		$840.24
$885.06
$932.56
$1,101.27 		$1,094.30
$1,139.12
$1,186.62
$1,355.33 		$254.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.24
$753.88
$848.88
$1,186.30
$1,802.68 		$918.30
$1,007.94
$1,102.94
$1,440.36 		$1,172.36
$1,262.00
$1,357.00
$1,694.42 		$1,426.42
$1,516.06
$1,611.06
$1,948.48 		$254.06
Toc - Plan #11 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$332.12
$376.94
$424.44
$593.15
$901.34 		$586.18
$631.00
$678.50
$847.21 		$840.24
$885.06
$932.56
$1,101.27 		$1,094.30
$1,139.12
$1,186.62
$1,355.33 		$254.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.24
$753.88
$848.88
$1,186.30
$1,802.68 		$918.30
$1,007.94
$1,102.94
$1,440.36 		$1,172.36
$1,262.00
$1,357.00
$1,694.42 		$1,426.42
$1,516.06
$1,611.06
$1,948.48 		$254.06
Toc - Plan #12 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$339.19
$384.97
$433.48
$605.78
$920.54 		$598.67
$644.45
$692.96
$865.26 		$858.15
$903.93
$952.44
$1,124.74 		$1,117.63
$1,163.41
$1,211.92
$1,384.22 		$259.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.38
$769.94
$866.96
$1,211.56
$1,841.08 		$937.86
$1,029.42
$1,126.44
$1,471.04 		$1,197.34
$1,288.90
$1,385.92
$1,730.52 		$1,456.82
$1,548.38
$1,645.40
$1,990.00 		$259.48
Toc - Plan #13 Ambetter from Sunflower Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$304.60
$345.71
$389.27
$544.00
$826.66 		$537.61
$578.72
$622.28
$777.01 		$770.62
$811.73
$855.29
$1,010.02 		$1,003.63
$1,044.74
$1,088.30
$1,243.03 		$233.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.20
$691.42
$778.54
$1,088.00
$1,653.32 		$842.21
$924.43
$1,011.55
$1,321.01 		$1,075.22
$1,157.44
$1,244.56
$1,554.02 		$1,308.23
$1,390.45
$1,477.57
$1,787.03 		$233.01
Toc - Plan #14 Ambetter from Sunflower Health Plan
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$270.07
$306.51
$345.13
$482.32
$732.93 		$476.66
$513.10
$551.72
$688.91 		$683.25
$719.69
$758.31
$895.50 		$889.84
$926.28
$964.90
$1,102.09 		$206.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.14
$613.02
$690.26
$964.64
$1,465.86 		$746.73
$819.61
$896.85
$1,171.23 		$953.32
$1,026.20
$1,103.44
$1,377.82 		$1,159.91
$1,232.79
$1,310.03
$1,584.41 		$206.59
Toc - Plan #15 Ambetter from Sunflower Health Plan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$391.05
$443.84
$499.76
$698.41
$1,061.30 		$690.20
$742.99
$798.91
$997.56 		$989.35
$1,042.14
$1,098.06
$1,296.71 		$1,288.50
$1,341.29
$1,397.21
$1,595.86 		$299.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.10
$887.68
$999.52
$1,396.82
$2,122.60 		$1,081.25
$1,186.83
$1,298.67
$1,695.97 		$1,380.40
$1,485.98
$1,597.82
$1,995.12 		$1,679.55
$1,785.13
$1,896.97
$2,294.27 		$299.15
Toc - Plan #16 Ambetter from Sunflower Health Plan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$367.53
$417.14
$469.69
$656.40
$997.46 		$648.69
$698.30
$750.85
$937.56 		$929.85
$979.46
$1,032.01
$1,218.72 		$1,211.01
$1,260.62
$1,313.17
$1,499.88 		$281.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.06
$834.28
$939.38
$1,312.80
$1,994.92 		$1,016.22
$1,115.44
$1,220.54
$1,593.96 		$1,297.38
$1,396.60
$1,501.70
$1,875.12 		$1,578.54
$1,677.76
$1,782.86
$2,156.28 		$281.16
Toc - Plan #17 Ambetter from Sunflower Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$295.39
$335.25
$377.49
$527.55
$801.66 		$521.35
$561.21
$603.45
$753.51 		$747.31
$787.17
$829.41
$979.47 		$973.27
$1,013.13
$1,055.37
$1,205.43 		$225.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.78
$670.50
$754.98
$1,055.10
$1,603.32 		$816.74
$896.46
$980.94
$1,281.06 		$1,042.70
$1,122.42
$1,206.90
$1,507.02 		$1,268.66
$1,348.38
$1,432.86
$1,732.98 		$225.96
Toc - Plan #18 Ambetter from Sunflower Health Plan
Silver

(EPO) Ambetter Balanced Care 24 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 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 		$374.48
$425.02
$478.57
$668.80
$1,016.31 		$660.95
$711.49
$765.04
$955.27 		$947.42
$997.96
$1,051.51
$1,241.74 		$1,233.89
$1,284.43
$1,337.98
$1,528.21 		$286.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.96
$850.04
$957.14
$1,337.60
$2,032.62 		$1,035.43
$1,136.51
$1,243.61
$1,624.07 		$1,321.90
$1,422.98
$1,530.08
$1,910.54 		$1,608.37
$1,709.45
$1,816.55
$2,197.01 		$286.47
Toc - Plan #19 Ambetter from Sunflower Health Plan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$366.80
$416.30
$468.76
$655.08
$995.46 		$647.39
$696.89
$749.35
$935.67 		$927.98
$977.48
$1,029.94
$1,216.26 		$1,208.57
$1,258.07
$1,310.53
$1,496.85 		$280.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.60
$832.60
$937.52
$1,310.16
$1,990.92 		$1,014.19
$1,113.19
$1,218.11
$1,590.75 		$1,294.78
$1,393.78
$1,498.70
$1,871.34 		$1,575.37
$1,674.37
$1,779.29
$2,151.93 		$280.59
Toc - Plan #20 Ambetter from Sunflower Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$291.53
$330.87
$372.56
$520.65
$791.18 		$514.54
$553.88
$595.57
$743.66 		$737.55
$776.89
$818.58
$966.67 		$960.56
$999.90
$1,041.59
$1,189.68 		$223.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.06
$661.74
$745.12
$1,041.30
$1,582.36 		$806.07
$884.75
$968.13
$1,264.31 		$1,029.08
$1,107.76
$1,191.14
$1,487.32 		$1,252.09
$1,330.77
$1,414.15
$1,710.33 		$223.01
Toc - Plan #21 Ambetter from Sunflower Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$332.36
$377.22
$424.74
$593.58
$902.00 		$586.61
$631.47
$678.99
$847.83 		$840.86
$885.72
$933.24
$1,102.08 		$1,095.11
$1,139.97
$1,187.49
$1,356.33 		$254.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.72
$754.44
$849.48
$1,187.16
$1,804.00 		$918.97
$1,008.69
$1,103.73
$1,441.41 		$1,173.22
$1,262.94
$1,357.98
$1,695.66 		$1,427.47
$1,517.19
$1,612.23
$1,949.91 		$254.25
Toc - Plan #22 Ambetter from Sunflower Health Plan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$345.11
$391.69
$441.04
$616.36
$936.61 		$609.11
$655.69
$705.04
$880.36 		$873.11
$919.69
$969.04
$1,144.36 		$1,137.11
$1,183.69
$1,233.04
$1,408.36 		$264.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.22
$783.38
$882.08
$1,232.72
$1,873.22 		$954.22
$1,047.38
$1,146.08
$1,496.72 		$1,218.22
$1,311.38
$1,410.08
$1,760.72 		$1,482.22
$1,575.38
$1,674.08
$2,024.72 		$264.00
Toc - Plan #23 Ambetter from Sunflower Health Plan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$352.46
$400.04
$450.44
$629.48
$956.56 		$622.09
$669.67
$720.07
$899.11 		$891.72
$939.30
$989.70
$1,168.74 		$1,161.35
$1,208.93
$1,259.33
$1,438.37 		$269.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.92
$800.08
$900.88
$1,258.96
$1,913.12 		$974.55
$1,069.71
$1,170.51
$1,528.59 		$1,244.18
$1,339.34
$1,440.14
$1,798.22 		$1,513.81
$1,608.97
$1,709.77
$2,067.85 		$269.63
Toc - Plan #24 Ambetter from Sunflower Health Plan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$363.16
$412.17
$464.11
$648.59
$985.59 		$640.97
$689.98
$741.92
$926.40 		$918.78
$967.79
$1,019.73
$1,204.21 		$1,196.59
$1,245.60
$1,297.54
$1,482.02 		$277.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.32
$824.34
$928.22
$1,297.18
$1,971.18 		$1,004.13
$1,102.15
$1,206.03
$1,574.99 		$1,281.94
$1,379.96
$1,483.84
$1,852.80 		$1,559.75
$1,657.77
$1,761.65
$2,130.61 		$277.81
Toc - Plan #25 Ambetter from Sunflower Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-779-7989

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 		$316.52
$359.24
$404.50
$565.29
$859.01 		$558.65
$601.37
$646.63
$807.42 		$800.78
$843.50
$888.76
$1,049.55 		$1,042.91
$1,085.63
$1,130.89
$1,291.68 		$242.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.04
$718.48
$809.00
$1,130.58
$1,718.02 		$875.17
$960.61
$1,051.13
$1,372.71 		$1,117.30
$1,202.74
$1,293.26
$1,614.84 		$1,359.43
$1,444.87
$1,535.39
$1,856.97 		$242.13

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-866-735-2957
Toc - Plan #26 Medica
Gold

(EPO) Select by Medica Gold Copay ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$850 $2,550 Annual Deductible
$8,100 $16,200 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 		$508.36
$576.98
$649.67
$907.92
$1,379.67 		$897.25
$965.87
$1,038.56
$1,296.81 		$1,286.14
$1,354.76
$1,427.45
$1,685.70 		$1,675.03
$1,743.65
$1,816.34
$2,074.59 		$388.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,016.72
$1,153.96
$1,299.34
$1,815.84
$2,759.34 		$1,405.61
$1,542.85
$1,688.23
$2,204.73 		$1,794.50
$1,931.74
$2,077.12
$2,593.62 		$2,183.39
$2,320.63
$2,466.01
$2,982.51 		$388.89
Toc - Plan #27 Medica
Silver

(EPO) Select by Medica Silver Copay ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$568.78
$645.56
$726.89
$1,015.83
$1,543.65 		$1,003.89
$1,080.67
$1,162.00
$1,450.94 		$1,439.00
$1,515.78
$1,597.11
$1,886.05 		$1,874.11
$1,950.89
$2,032.22
$2,321.16 		$435.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,137.56
$1,291.12
$1,453.78
$2,031.66
$3,087.30 		$1,572.67
$1,726.23
$1,888.89
$2,466.77 		$2,007.78
$2,161.34
$2,324.00
$2,901.88 		$2,442.89
$2,596.45
$2,759.11
$3,336.99 		$435.11
Toc - Plan #28 Medica
Expanded Bronze

(EPO) Select by Medica Bronze H S A ($0 Virtual Care after deductible)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$390.27
$442.94
$498.75
$697.00
$1,059.15 		$688.82
$741.49
$797.30
$995.55 		$987.37
$1,040.04
$1,095.85
$1,294.10 		$1,285.92
$1,338.59
$1,394.40
$1,592.65 		$298.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.54
$885.88
$997.50
$1,394.00
$2,118.30 		$1,079.09
$1,184.43
$1,296.05
$1,692.55 		$1,377.64
$1,482.98
$1,594.60
$1,991.10 		$1,676.19
$1,781.53
$1,893.15
$2,289.65 		$298.55
Toc - Plan #29 Medica
Catastrophic

(EPO) Select by Medica Catastrophic ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$247.35
$280.73
$316.10
$441.75
$671.28 		$436.57
$469.95
$505.32
$630.97 		$625.79
$659.17
$694.54
$820.19 		$815.01
$848.39
$883.76
$1,009.41 		$189.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.70
$561.46
$632.20
$883.50
$1,342.56 		$683.92
$750.68
$821.42
$1,072.72 		$873.14
$939.90
$1,010.64
$1,261.94 		$1,062.36
$1,129.12
$1,199.86
$1,451.16 		$189.22
Toc - Plan #30 Medica
Gold

(EPO) Select by Medica Gold Share ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,000 $3,000 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 		$479.41
$544.11
$612.67
$856.20
$1,301.08 		$846.15
$910.85
$979.41
$1,222.94 		$1,212.89
$1,277.59
$1,346.15
$1,589.68 		$1,579.63
$1,644.33
$1,712.89
$1,956.42 		$366.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.82
$1,088.22
$1,225.34
$1,712.40
$2,602.16 		$1,325.56
$1,454.96
$1,592.08
$2,079.14 		$1,692.30
$1,821.70
$1,958.82
$2,445.88 		$2,059.04
$2,188.44
$2,325.56
$2,812.62 		$366.74
Toc - Plan #31 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Share Plus ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,300 $6,900 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 		$355.34
$403.30
$454.11
$634.62
$964.36 		$627.17
$675.13
$725.94
$906.45 		$899.00
$946.96
$997.77
$1,178.28 		$1,170.83
$1,218.79
$1,269.60
$1,450.11 		$271.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.68
$806.60
$908.22
$1,269.24
$1,928.72 		$982.51
$1,078.43
$1,180.05
$1,541.07 		$1,254.34
$1,350.26
$1,451.88
$1,812.90 		$1,526.17
$1,622.09
$1,723.71
$2,084.73 		$271.83
Toc - Plan #32 Medica
Bronze

(EPO) Select by Medica Bronze Value ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$337.62
$383.18
$431.46
$602.96
$916.26 		$595.89
$641.45
$689.73
$861.23 		$854.16
$899.72
$948.00
$1,119.50 		$1,112.43
$1,157.99
$1,206.27
$1,377.77 		$258.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.24
$766.36
$862.92
$1,205.92
$1,832.52 		$933.51
$1,024.63
$1,121.19
$1,464.19 		$1,191.78
$1,282.90
$1,379.46
$1,722.46 		$1,450.05
$1,541.17
$1,637.73
$1,980.73 		$258.27
Toc - Plan #33 Medica
Bronze

(EPO) Select by Medica Bronze Value + Dental Reimbursement ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$359.22
$407.71
$459.07
$641.55
$974.90 		$634.02
$682.51
$733.87
$916.35 		$908.82
$957.31
$1,008.67
$1,191.15 		$1,183.62
$1,232.11
$1,283.47
$1,465.95 		$274.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.44
$815.42
$918.14
$1,283.10
$1,949.80 		$993.24
$1,090.22
$1,192.94
$1,557.90 		$1,268.04
$1,365.02
$1,467.74
$1,832.70 		$1,542.84
$1,639.82
$1,742.54
$2,107.50 		$274.80
Toc - Plan #34 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Copay $0 Preferred Primary Care ($0 Virtual Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$352.73
$400.34
$450.78
$629.96
$957.29 		$622.56
$670.17
$720.61
$899.79 		$892.39
$940.00
$990.44
$1,169.62 		$1,162.22
$1,209.83
$1,260.27
$1,439.45 		$269.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.46
$800.68
$901.56
$1,259.92
$1,914.58 		$975.29
$1,070.51
$1,171.39
$1,529.75 		$1,245.12
$1,340.34
$1,441.22
$1,799.58 		$1,514.95
$1,610.17
$1,711.05
$2,069.41 		$269.83

ADVERTISEMENT

Oscar Insurance Company

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

Toc - Plan #35 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $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 		$300.84
$341.44
$384.46
$537.29
$816.46 		$530.98
$571.58
$614.60
$767.43 		$761.12
$801.72
$844.74
$997.57 		$991.26
$1,031.86
$1,074.88
$1,227.71 		$230.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.68
$682.88
$768.92
$1,074.58
$1,632.92 		$831.82
$913.02
$999.06
$1,304.72 		$1,061.96
$1,143.16
$1,229.20
$1,534.86 		$1,292.10
$1,373.30
$1,459.34
$1,765.00 		$230.14
Toc - Plan #36 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$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 		$294.50
$334.25
$376.36
$525.96
$799.25 		$519.79
$559.54
$601.65
$751.25 		$745.08
$784.83
$826.94
$976.54 		$970.37
$1,010.12
$1,052.23
$1,201.83 		$225.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.00
$668.50
$752.72
$1,051.92
$1,598.50 		$814.29
$893.79
$978.01
$1,277.21 		$1,039.58
$1,119.08
$1,203.30
$1,502.50 		$1,264.87
$1,344.37
$1,428.59
$1,727.79 		$225.29
Toc - Plan #37 Oscar Insurance Company
Expanded Bronze

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

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

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 		$346.02
$392.72
$442.20
$617.98
$939.08 		$610.72
$657.42
$706.90
$882.68 		$875.42
$922.12
$971.60
$1,147.38 		$1,140.12
$1,186.82
$1,236.30
$1,412.08 		$264.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.04
$785.44
$884.40
$1,235.96
$1,878.16 		$956.74
$1,050.14
$1,149.10
$1,500.66 		$1,221.44
$1,314.84
$1,413.80
$1,765.36 		$1,486.14
$1,579.54
$1,678.50
$2,030.06 		$264.70
Toc - Plan #38 Oscar Insurance Company
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 Annual Deductible
$8,700 $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 		$371.28
$421.40
$474.49
$663.10
$1,007.64 		$655.30
$705.42
$758.51
$947.12 		$939.32
$989.44
$1,042.53
$1,231.14 		$1,223.34
$1,273.46
$1,326.55
$1,515.16 		$284.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.56
$842.80
$948.98
$1,326.20
$2,015.28 		$1,026.58
$1,126.82
$1,233.00
$1,610.22 		$1,310.60
$1,410.84
$1,517.02
$1,894.24 		$1,594.62
$1,694.86
$1,801.04
$2,178.26 		$284.02
Toc - Plan #39 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

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

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 		$364.86
$414.11
$466.28
$651.63
$990.21 		$643.97
$693.22
$745.39
$930.74 		$923.08
$972.33
$1,024.50
$1,209.85 		$1,202.19
$1,251.44
$1,303.61
$1,488.96 		$279.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.72
$828.22
$932.56
$1,303.26
$1,980.42 		$1,008.83
$1,107.33
$1,211.67
$1,582.37 		$1,287.94
$1,386.44
$1,490.78
$1,861.48 		$1,567.05
$1,665.55
$1,769.89
$2,140.59 		$279.11
Toc - Plan #40 Oscar Insurance Company
Catastrophic

(EPO) Secure

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

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 		$248.84
$282.42
$318.01
$444.41
$675.33 		$439.20
$472.78
$508.37
$634.77 		$629.56
$663.14
$698.73
$825.13 		$819.92
$853.50
$889.09
$1,015.49 		$190.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$497.68
$564.84
$636.02
$888.82
$1,350.66 		$688.04
$755.20
$826.38
$1,079.18 		$878.40
$945.56
$1,016.74
$1,269.54 		$1,068.76
$1,135.92
$1,207.10
$1,459.90 		$190.36
Toc - Plan #41 Oscar Insurance Company
Expanded Bronze

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

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

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 		$346.14
$392.86
$442.36
$618.19
$939.41 		$610.93
$657.65
$707.15
$882.98 		$875.72
$922.44
$971.94
$1,147.77 		$1,140.51
$1,187.23
$1,236.73
$1,412.56 		$264.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.28
$785.72
$884.72
$1,236.38
$1,878.82 		$957.07
$1,050.51
$1,149.51
$1,501.17 		$1,221.86
$1,315.30
$1,414.30
$1,765.96 		$1,486.65
$1,580.09
$1,679.09
$2,030.75 		$264.79
Toc - Plan #42 Oscar Insurance Company
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$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 		$412.00
$467.61
$526.53
$735.82
$1,118.15 		$727.17
$782.78
$841.70
$1,050.99 		$1,042.34
$1,097.95
$1,156.87
$1,366.16 		$1,357.51
$1,413.12
$1,472.04
$1,681.33 		$315.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.00
$935.22
$1,053.06
$1,471.64
$2,236.30 		$1,139.17
$1,250.39
$1,368.23
$1,786.81 		$1,454.34
$1,565.56
$1,683.40
$2,101.98 		$1,769.51
$1,880.73
$1,998.57
$2,417.15 		$315.17
Toc - Plan #43 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

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

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 		$317.93
$360.84
$406.30
$567.81
$862.84 		$561.14
$604.05
$649.51
$811.02 		$804.35
$847.26
$892.72
$1,054.23 		$1,047.56
$1,090.47
$1,135.93
$1,297.44 		$243.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.86
$721.68
$812.60
$1,135.62
$1,725.68 		$879.07
$964.89
$1,055.81
$1,378.83 		$1,122.28
$1,208.10
$1,299.02
$1,622.04 		$1,365.49
$1,451.31
$1,542.23
$1,865.25 		$243.21
Toc - Plan #44 Oscar Insurance Company
Silver

(EPO) Silver Simple

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

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 		$364.41
$413.60
$465.71
$650.82
$988.99 		$643.18
$692.37
$744.48
$929.59 		$921.95
$971.14
$1,023.25
$1,208.36 		$1,200.72
$1,249.91
$1,302.02
$1,487.13 		$278.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.82
$827.20
$931.42
$1,301.64
$1,977.98 		$1,007.59
$1,105.97
$1,210.19
$1,580.41 		$1,286.36
$1,384.74
$1,488.96
$1,859.18 		$1,565.13
$1,663.51
$1,767.73
$2,137.95 		$278.77
Toc - Plan #45 Oscar Insurance Company
Gold

(EPO) Gold Classic- Low Ded

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

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 		$413.61
$469.43
$528.58
$738.69
$1,122.51 		$730.01
$785.83
$844.98
$1,055.09 		$1,046.41
$1,102.23
$1,161.38
$1,371.49 		$1,362.81
$1,418.63
$1,477.78
$1,687.89 		$316.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.22
$938.86
$1,057.16
$1,477.38
$2,245.02 		$1,143.62
$1,255.26
$1,373.56
$1,793.78 		$1,460.02
$1,571.66
$1,689.96
$2,110.18 		$1,776.42
$1,888.06
$2,006.36
$2,426.58 		$316.40
Toc - Plan #46 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

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

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 		$311.00
$352.98
$397.45
$555.43
$844.03 		$548.91
$590.89
$635.36
$793.34 		$786.82
$828.80
$873.27
$1,031.25 		$1,024.73
$1,066.71
$1,111.18
$1,269.16 		$237.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.00
$705.96
$794.90
$1,110.86
$1,688.06 		$859.91
$943.87
$1,032.81
$1,348.77 		$1,097.82
$1,181.78
$1,270.72
$1,586.68 		$1,335.73
$1,419.69
$1,508.63
$1,824.59 		$237.91
Toc - Plan #47 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$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 		$331.34
$376.06
$423.44
$591.76
$899.24 		$584.81
$629.53
$676.91
$845.23 		$838.28
$883.00
$930.38
$1,098.70 		$1,091.75
$1,136.47
$1,183.85
$1,352.17 		$253.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.68
$752.12
$846.88
$1,183.52
$1,798.48 		$916.15
$1,005.59
$1,100.35
$1,436.99 		$1,169.62
$1,259.06
$1,353.82
$1,690.46 		$1,423.09
$1,512.53
$1,607.29
$1,943.93 		$253.47
Toc - Plan #48 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$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 		$314.51
$356.95
$401.93
$561.69
$853.54 		$555.10
$597.54
$642.52
$802.28 		$795.69
$838.13
$883.11
$1,042.87 		$1,036.28
$1,078.72
$1,123.70
$1,283.46 		$240.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.02
$713.90
$803.86
$1,123.38
$1,707.08 		$869.61
$954.49
$1,044.45
$1,363.97 		$1,110.20
$1,195.08
$1,285.04
$1,604.56 		$1,350.79
$1,435.67
$1,525.63
$1,845.15 		$240.59
Toc - Plan #49 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $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 		$359.29
$407.78
$459.15
$641.67
$975.07 		$634.14
$682.63
$734.00
$916.52 		$908.99
$957.48
$1,008.85
$1,191.37 		$1,183.84
$1,232.33
$1,283.70
$1,466.22 		$274.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.58
$815.56
$918.30
$1,283.34
$1,950.14 		$993.43
$1,090.41
$1,193.15
$1,558.19 		$1,268.28
$1,365.26
$1,468.00
$1,833.04 		$1,543.13
$1,640.11
$1,742.85
$2,107.89 		$274.85
Toc - Plan #50 Oscar Insurance Company
Silver

(EPO) Silver Elite- Specialist Saver

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

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 		$382.53
$434.16
$488.86
$683.18
$1,038.15 		$675.16
$726.79
$781.49
$975.81 		$967.79
$1,019.42
$1,074.12
$1,268.44 		$1,260.42
$1,312.05
$1,366.75
$1,561.07 		$292.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.06
$868.32
$977.72
$1,366.36
$2,076.30 		$1,057.69
$1,160.95
$1,270.35
$1,658.99 		$1,350.32
$1,453.58
$1,562.98
$1,951.62 		$1,642.95
$1,746.21
$1,855.61
$2,244.25 		$292.63
Toc - Plan #51 Oscar Insurance Company
Silver

(EPO) Silver Classic- Low Ded

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,000 $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 		$372.47
$422.74
$476.00
$665.21
$1,010.84 		$657.40
$707.67
$760.93
$950.14 		$942.33
$992.60
$1,045.86
$1,235.07 		$1,227.26
$1,277.53
$1,330.79
$1,520.00 		$284.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.94
$845.48
$952.00
$1,330.42
$2,021.68 		$1,029.87
$1,130.41
$1,236.93
$1,615.35 		$1,314.80
$1,415.34
$1,521.86
$1,900.28 		$1,599.73
$1,700.27
$1,806.79
$2,185.21 		$284.93
Toc - Plan #52 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,500 $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 		$381.40
$432.88
$487.42
$681.17
$1,035.10 		$673.17
$724.65
$779.19
$972.94 		$964.94
$1,016.42
$1,070.96
$1,264.71 		$1,256.71
$1,308.19
$1,362.73
$1,556.48 		$291.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.80
$865.76
$974.84
$1,362.34
$2,070.20 		$1,054.57
$1,157.53
$1,266.61
$1,654.11 		$1,346.34
$1,449.30
$1,558.38
$1,945.88 		$1,638.11
$1,741.07
$1,850.15
$2,237.65 		$291.77
Toc - Plan #53 Oscar Insurance Company
Silver

(EPO) Silver Simple- HSA

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

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 		$379.28
$430.47
$484.71
$677.38
$1,029.34 		$669.42
$720.61
$774.85
$967.52 		$959.56
$1,010.75
$1,064.99
$1,257.66 		$1,249.70
$1,300.89
$1,355.13
$1,547.80 		$290.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.56
$860.94
$969.42
$1,354.76
$2,058.68 		$1,048.70
$1,151.08
$1,259.56
$1,644.90 		$1,338.84
$1,441.22
$1,549.70
$1,935.04 		$1,628.98
$1,731.36
$1,839.84
$2,225.18 		$290.14
Toc - Plan #54 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

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

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 		$376.46
$427.28
$481.11
$672.35
$1,021.70 		$664.45
$715.27
$769.10
$960.34 		$952.44
$1,003.26
$1,057.09
$1,248.33 		$1,240.43
$1,291.25
$1,345.08
$1,536.32 		$287.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.92
$854.56
$962.22
$1,344.70
$2,043.40 		$1,040.91
$1,142.55
$1,250.21
$1,632.69 		$1,328.90
$1,430.54
$1,538.20
$1,920.68 		$1,616.89
$1,718.53
$1,826.19
$2,208.67 		$287.99
Toc - Plan #55 Oscar Insurance Company
Gold

(EPO) Gold Simple

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

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 		$397.07
$450.66
$507.44
$709.15
$1,077.62 		$700.82
$754.41
$811.19
$1,012.90 		$1,004.57
$1,058.16
$1,114.94
$1,316.65 		$1,308.32
$1,361.91
$1,418.69
$1,620.40 		$303.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.14
$901.32
$1,014.88
$1,418.30
$2,155.24 		$1,097.89
$1,205.07
$1,318.63
$1,722.05 		$1,401.64
$1,508.82
$1,622.38
$2,025.80 		$1,705.39
$1,812.57
$1,926.13
$2,329.55 		$303.75
Toc - Plan #56 Oscar Insurance Company
Gold

(EPO) Gold Elite- $0 Ded

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

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 		$444.36
$504.34
$567.88
$793.61
$1,205.97 		$784.29
$844.27
$907.81
$1,133.54 		$1,124.22
$1,184.20
$1,247.74
$1,473.47 		$1,464.15
$1,524.13
$1,587.67
$1,813.40 		$339.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.72
$1,008.68
$1,135.76
$1,587.22
$2,411.94 		$1,228.65
$1,348.61
$1,475.69
$1,927.15 		$1,568.58
$1,688.54
$1,815.62
$2,267.08 		$1,908.51
$2,028.47
$2,155.55
$2,607.01 		$339.93
Toc - Plan #57 Oscar Insurance Company
Gold

(EPO) Gold Elite

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

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 		$424.26
$481.53
$542.20
$757.72
$1,151.43 		$748.81
$806.08
$866.75
$1,082.27 		$1,073.36
$1,130.63
$1,191.30
$1,406.82 		$1,397.91
$1,455.18
$1,515.85
$1,731.37 		$324.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.52
$963.06
$1,084.40
$1,515.44
$2,302.86 		$1,173.07
$1,287.61
$1,408.95
$1,839.99 		$1,497.62
$1,612.16
$1,733.50
$2,164.54 		$1,822.17
$1,936.71
$2,058.05
$2,489.09 		$324.55
Toc - Plan #58 Oscar Insurance Company
Gold

(EPO) Gold Classic- HSA

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

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 		$397.69
$451.37
$508.24
$710.26
$1,079.31 		$701.92
$755.60
$812.47
$1,014.49 		$1,006.15
$1,059.83
$1,116.70
$1,318.72 		$1,310.38
$1,364.06
$1,420.93
$1,622.95 		$304.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.38
$902.74
$1,016.48
$1,420.52
$2,158.62 		$1,099.61
$1,206.97
$1,320.71
$1,724.75 		$1,403.84
$1,511.20
$1,624.94
$2,028.98 		$1,708.07
$1,815.43
$1,929.17
$2,333.21 		$304.23
Toc - Plan #59 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Super Simple

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

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 		$293.58
$333.20
$375.18
$524.31
$796.74 		$518.16
$557.78
$599.76
$748.89 		$742.74
$782.36
$824.34
$973.47 		$967.32
$1,006.94
$1,048.92
$1,198.05 		$224.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.16
$666.40
$750.36
$1,048.62
$1,593.48 		$811.74
$890.98
$974.94
$1,273.20 		$1,036.32
$1,115.56
$1,199.52
$1,497.78 		$1,260.90
$1,340.14
$1,424.10
$1,722.36 		$224.58
Toc - Plan #60 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4000 Ded

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

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 		$333.79
$378.84
$426.57
$596.13
$905.88 		$589.13
$634.18
$681.91
$851.47 		$844.47
$889.52
$937.25
$1,106.81 		$1,099.81
$1,144.86
$1,192.59
$1,362.15 		$255.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.58
$757.68
$853.14
$1,192.26
$1,811.76 		$922.92
$1,013.02
$1,108.48
$1,447.60 		$1,178.26
$1,268.36
$1,363.82
$1,702.94 		$1,433.60
$1,523.70
$1,619.16
$1,958.28 		$255.34
Toc - Plan #61 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $1000 Ded

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

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 		$341.83
$387.96
$436.84
$610.49
$927.70 		$603.32
$649.45
$698.33
$871.98 		$864.81
$910.94
$959.82
$1,133.47 		$1,126.30
$1,172.43
$1,221.31
$1,394.96 		$261.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.66
$775.92
$873.68
$1,220.98
$1,855.40 		$945.15
$1,037.41
$1,135.17
$1,482.47 		$1,206.64
$1,298.90
$1,396.66
$1,743.96 		$1,468.13
$1,560.39
$1,658.15
$2,005.45 		$261.49
Toc - Plan #62 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded

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

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 		$342.95
$389.24
$438.28
$612.49
$930.74 		$605.30
$651.59
$700.63
$874.84 		$867.65
$913.94
$962.98
$1,137.19 		$1,130.00
$1,176.29
$1,225.33
$1,399.54 		$262.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.90
$778.48
$876.56
$1,224.98
$1,861.48 		$948.25
$1,040.83
$1,138.91
$1,487.33 		$1,210.60
$1,303.18
$1,401.26
$1,749.68 		$1,472.95
$1,565.53
$1,663.61
$2,012.03 		$262.35
Toc - Plan #63 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

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

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 		$367.21
$416.77
$469.28
$655.81
$996.57 		$648.11
$697.67
$750.18
$936.71 		$929.01
$978.57
$1,031.08
$1,217.61 		$1,209.91
$1,259.47
$1,311.98
$1,498.51 		$280.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.42
$833.54
$938.56
$1,311.62
$1,993.14 		$1,015.32
$1,114.44
$1,219.46
$1,592.52 		$1,296.22
$1,395.34
$1,500.36
$1,873.42 		$1,577.12
$1,676.24
$1,781.26
$2,154.32 		$280.90

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #64 Cigna Healthcare
Bronze

(EPO) Cigna Connect 6500 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$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 		$334.43
$379.58
$427.41
$597.30
$907.65 		$590.27
$635.42
$683.25
$853.14 		$846.11
$891.26
$939.09
$1,108.98 		$1,101.95
$1,147.10
$1,194.93
$1,364.82 		$255.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.86
$759.16
$854.82
$1,194.60
$1,815.30 		$924.70
$1,015.00
$1,110.66
$1,450.44 		$1,180.54
$1,270.84
$1,366.50
$1,706.28 		$1,436.38
$1,526.68
$1,622.34
$1,962.12 		$255.84
Toc - Plan #65 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5900 ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$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 		$350.72
$398.06
$448.22
$626.38
$951.85 		$619.02
$666.36
$716.52
$894.68 		$887.32
$934.66
$984.82
$1,162.98 		$1,155.62
$1,202.96
$1,253.12
$1,431.28 		$268.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.44
$796.12
$896.44
$1,252.76
$1,903.70 		$969.74
$1,064.42
$1,164.74
$1,521.06 		$1,238.04
$1,332.72
$1,433.04
$1,789.36 		$1,506.34
$1,601.02
$1,701.34
$2,057.66 		$268.30
Toc - Plan #66 Cigna Healthcare
Silver

(EPO) Cigna Connect 6000 ($0 PCP, $3 Tier 1 Rx, $0 Telehealth)

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

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 		$416.98
$473.27
$532.90
$744.73
$1,131.69 		$735.97
$792.26
$851.89
$1,063.72 		$1,054.96
$1,111.25
$1,170.88
$1,382.71 		$1,373.95
$1,430.24
$1,489.87
$1,701.70 		$318.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.96
$946.54
$1,065.80
$1,489.46
$2,263.38 		$1,152.95
$1,265.53
$1,384.79
$1,808.45 		$1,471.94
$1,584.52
$1,703.78
$2,127.44 		$1,790.93
$1,903.51
$2,022.77
$2,446.43 		$318.99
Toc - Plan #67 Cigna Healthcare
Silver

(EPO) Cigna Connect 5000 ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$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 		$416.14
$472.31
$531.82
$743.22
$1,129.39 		$734.48
$790.65
$850.16
$1,061.56 		$1,052.82
$1,108.99
$1,168.50
$1,379.90 		$1,371.16
$1,427.33
$1,486.84
$1,698.24 		$318.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.28
$944.62
$1,063.64
$1,486.44
$2,258.78 		$1,150.62
$1,262.96
$1,381.98
$1,804.78 		$1,468.96
$1,581.30
$1,700.32
$2,123.12 		$1,787.30
$1,899.64
$2,018.66
$2,441.46 		$318.34
Toc - Plan #68 Cigna Healthcare
Gold

(EPO) Cigna Connect 1250 ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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 		$490.31
$556.50
$626.61
$875.69
$1,330.69 		$865.40
$931.59
$1,001.70
$1,250.78 		$1,240.49
$1,306.68
$1,376.79
$1,625.87 		$1,615.58
$1,681.77
$1,751.88
$2,000.96 		$375.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$980.62
$1,113.00
$1,253.22
$1,751.38
$2,661.38 		$1,355.71
$1,488.09
$1,628.31
$2,126.47 		$1,730.80
$1,863.18
$2,003.40
$2,501.56 		$2,105.89
$2,238.27
$2,378.49
$2,876.65 		$375.09
Toc - Plan #69 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 ($3 Tier 1 Rx, $0 Telehealth)

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

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 		$418.21
$474.66
$534.47
$746.92
$1,135.01 		$738.14
$794.59
$854.40
$1,066.85 		$1,058.07
$1,114.52
$1,174.33
$1,386.78 		$1,378.00
$1,434.45
$1,494.26
$1,706.71 		$319.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.42
$949.32
$1,068.94
$1,493.84
$2,270.02 		$1,156.35
$1,269.25
$1,388.87
$1,813.77 		$1,476.28
$1,589.18
$1,708.80
$2,133.70 		$1,796.21
$1,909.11
$2,028.73
$2,453.63 		$319.93
Toc - Plan #70 Cigna Healthcare
Silver

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

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

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 		$418.54
$475.04
$534.89
$747.50
$1,135.91 		$738.72
$795.22
$855.07
$1,067.68 		$1,058.90
$1,115.40
$1,175.25
$1,387.86 		$1,379.08
$1,435.58
$1,495.43
$1,708.04 		$320.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.08
$950.08
$1,069.78
$1,495.00
$2,271.82 		$1,157.26
$1,270.26
$1,389.96
$1,815.18 		$1,477.44
$1,590.44
$1,710.14
$2,135.36 		$1,797.62
$1,910.62
$2,030.32
$2,455.54 		$320.18
Toc - Plan #71 Cigna Healthcare
Expanded Bronze

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

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

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 		$350.62
$397.96
$448.10
$626.21
$951.59 		$618.85
$666.19
$716.33
$894.44 		$887.08
$934.42
$984.56
$1,162.67 		$1,155.31
$1,202.65
$1,252.79
$1,430.90 		$268.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.24
$795.92
$896.20
$1,252.42
$1,903.18 		$969.47
$1,064.15
$1,164.43
$1,520.65 		$1,237.70
$1,332.38
$1,432.66
$1,788.88 		$1,505.93
$1,600.61
$1,700.89
$2,057.11 		$268.23
Toc - Plan #72 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care ($3 Tier 1 Rx, $0 Telehealth)

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

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 		$417.22
$473.54
$533.20
$745.15
$1,132.33 		$736.39
$792.71
$852.37
$1,064.32 		$1,055.56
$1,111.88
$1,171.54
$1,383.49 		$1,374.73
$1,431.05
$1,490.71
$1,702.66 		$319.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.44
$947.08
$1,066.40
$1,490.30
$2,264.66 		$1,153.61
$1,266.25
$1,385.57
$1,809.47 		$1,472.78
$1,585.42
$1,704.74
$2,128.64 		$1,791.95
$1,904.59
$2,023.91
$2,447.81 		$319.17
Toc - Plan #73 Cigna Healthcare
Gold

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

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

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 		$508.52
$577.17
$649.89
$908.22
$1,380.13 		$897.54
$966.19
$1,038.91
$1,297.24 		$1,286.56
$1,355.21
$1,427.93
$1,686.26 		$1,675.58
$1,744.23
$1,816.95
$2,075.28 		$389.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,017.04
$1,154.34
$1,299.78
$1,816.44
$2,760.26 		$1,406.06
$1,543.36
$1,688.80
$2,205.46 		$1,795.08
$1,932.38
$2,077.82
$2,594.48 		$2,184.10
$2,321.40
$2,466.84
$2,983.50 		$389.02

ADVERTISEMENT

Blue Cross and Blue Shield of Kansas City

Local: 1-816-395-3558 | Toll Free: 1-888-800-4478

Toc - Plan #74 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$385.85
$437.94
$493.12
$689.13
$1,047.20 		$681.03
$733.12
$788.30
$984.31 		$976.21
$1,028.30
$1,083.48
$1,279.49 		$1,271.39
$1,323.48
$1,378.66
$1,574.67 		$295.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.70
$875.88
$986.24
$1,378.26
$2,094.40 		$1,066.88
$1,171.06
$1,281.42
$1,673.44 		$1,362.06
$1,466.24
$1,576.60
$1,968.62 		$1,657.24
$1,761.42
$1,871.78
$2,263.80 		$295.18
Toc - Plan #75 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$487.46
$553.26
$622.97
$870.60
$1,322.96 		$860.36
$926.16
$995.87
$1,243.50 		$1,233.26
$1,299.06
$1,368.77
$1,616.40 		$1,606.16
$1,671.96
$1,741.67
$1,989.30 		$372.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$974.92
$1,106.52
$1,245.94
$1,741.20
$2,645.92 		$1,347.82
$1,479.42
$1,618.84
$2,114.10 		$1,720.72
$1,852.32
$1,991.74
$2,487.00 		$2,093.62
$2,225.22
$2,364.64
$2,859.90 		$372.90
Toc - Plan #76 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$423.49
$480.66
$541.22
$756.35
$1,149.35 		$747.46
$804.63
$865.19
$1,080.32 		$1,071.43
$1,128.60
$1,189.16
$1,404.29 		$1,395.40
$1,452.57
$1,513.13
$1,728.26 		$323.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.98
$961.32
$1,082.44
$1,512.70
$2,298.70 		$1,170.95
$1,285.29
$1,406.41
$1,836.67 		$1,494.92
$1,609.26
$1,730.38
$2,160.64 		$1,818.89
$1,933.23
$2,054.35
$2,484.61 		$323.97
Toc - Plan #77 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 Blue Select EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$335.33
$380.60
$428.56
$598.91
$910.10 		$591.86
$637.13
$685.09
$855.44 		$848.39
$893.66
$941.62
$1,111.97 		$1,104.92
$1,150.19
$1,198.15
$1,368.50 		$256.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.66
$761.20
$857.12
$1,197.82
$1,820.20 		$927.19
$1,017.73
$1,113.65
$1,454.35 		$1,183.72
$1,274.26
$1,370.18
$1,710.88 		$1,440.25
$1,530.79
$1,626.71
$1,967.41 		$256.53
Toc - Plan #78 Blue Cross and Blue Shield of Kansas City
Gold

(EPO) Blue KC Community Gold 1500 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$574.45
$652.01
$734.15
$1,025.98
$1,559.07 		$1,013.91
$1,091.47
$1,173.61
$1,465.44 		$1,453.37
$1,530.93
$1,613.07
$1,904.90 		$1,892.83
$1,970.39
$2,052.53
$2,344.36 		$439.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,148.90
$1,304.02
$1,468.30
$2,051.96
$3,118.14 		$1,588.36
$1,743.48
$1,907.76
$2,491.42 		$2,027.82
$2,182.94
$2,347.22
$2,930.88 		$2,467.28
$2,622.40
$2,786.68
$3,370.34 		$439.46
Toc - Plan #79 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 8700 Blue Select EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$308.75
$350.43
$394.58
$551.42
$837.94 		$544.94
$586.62
$630.77
$787.61 		$781.13
$822.81
$866.96
$1,023.80 		$1,017.32
$1,059.00
$1,103.15
$1,259.99 		$236.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.50
$700.86
$789.16
$1,102.84
$1,675.88 		$853.69
$937.05
$1,025.35
$1,339.03 		$1,089.88
$1,173.24
$1,261.54
$1,575.22 		$1,326.07
$1,409.43
$1,497.73
$1,811.41 		$236.19
Toc - Plan #80 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$386.37
$438.53
$493.79
$690.06
$1,048.62 		$681.95
$734.11
$789.37
$985.64 		$977.53
$1,029.69
$1,084.95
$1,281.22 		$1,273.11
$1,325.27
$1,380.53
$1,576.80 		$295.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.74
$877.06
$987.58
$1,380.12
$2,097.24 		$1,068.32
$1,172.64
$1,283.16
$1,675.70 		$1,363.90
$1,468.22
$1,578.74
$1,971.28 		$1,659.48
$1,763.80
$1,874.32
$2,266.86 		$295.58
Toc - Plan #81 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$315.30
$357.86
$402.95
$563.12
$855.72 		$556.50
$599.06
$644.15
$804.32 		$797.70
$840.26
$885.35
$1,045.52 		$1,038.90
$1,081.46
$1,126.55
$1,286.72 		$241.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.60
$715.72
$805.90
$1,126.24
$1,711.44 		$871.80
$956.92
$1,047.10
$1,367.44 		$1,113.00
$1,198.12
$1,288.30
$1,608.64 		$1,354.20
$1,439.32
$1,529.50
$1,849.84 		$241.20
Toc - Plan #82 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$404.00
$458.54
$516.31
$721.54
$1,096.45 		$713.06
$767.60
$825.37
$1,030.60 		$1,022.12
$1,076.66
$1,134.43
$1,339.66 		$1,331.18
$1,385.72
$1,443.49
$1,648.72 		$309.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.00
$917.08
$1,032.62
$1,443.08
$2,192.90 		$1,117.06
$1,226.14
$1,341.68
$1,752.14 		$1,426.12
$1,535.20
$1,650.74
$2,061.20 		$1,735.18
$1,844.26
$1,959.80
$2,370.26 		$309.06

‡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 Johnson County here.

Johnson County is in “Rating Area 1” of Kansas.

Currently, there are 82 plans offered in Rating Area 1.

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2022 Obamacare Plans for Johnson County, KS

Plan Browser: 82 Plans
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