Obamacare 2022 Rates for Saint Louis County

Obamacare > Rates > Missouri > Saint Louis 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 Saint Louis County, MO.

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, 108 Plans and 2022 Rates for Saint Louis County, Missouri

Below, you’ll find a summary of the 108 plans for Saint Louis County, Missouri 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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Anthem Blue Cross and Blue Shield

Local: 1-855-738-6677 | Toll Free: 1-855-738-6677

Toc - Plan #1 Anthem Blue Cross and Blue Shield
Gold

(EPO) Anthem Gold Pathway X 1250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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 		$486.67
$552.37
$621.96
$869.19
$1,320.82 		$858.97
$924.67
$994.26
$1,241.49 		$1,231.27
$1,296.97
$1,366.56
$1,613.79 		$1,603.57
$1,669.27
$1,738.86
$1,986.09 		$372.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.34
$1,104.74
$1,243.92
$1,738.38
$2,641.64 		$1,345.64
$1,477.04
$1,616.22
$2,110.68 		$1,717.94
$1,849.34
$1,988.52
$2,482.98 		$2,090.24
$2,221.64
$2,360.82
$2,855.28 		$372.30
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 2550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$2,550 $5,100 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.42
$421.56
$474.67
$663.36
$1,008.03 		$655.56
$705.70
$758.81
$947.50 		$939.70
$989.84
$1,042.95
$1,231.64 		$1,223.84
$1,273.98
$1,327.09
$1,515.78 		$284.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.84
$843.12
$949.34
$1,326.72
$2,016.06 		$1,026.98
$1,127.26
$1,233.48
$1,610.86 		$1,311.12
$1,411.40
$1,517.62
$1,895.00 		$1,595.26
$1,695.54
$1,801.76
$2,179.14 		$284.14
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 6350

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.64
$324.20
$365.05
$510.15
$775.23 		$504.15
$542.71
$583.56
$728.66 		$722.66
$761.22
$802.07
$947.17 		$941.17
$979.73
$1,020.58
$1,165.68 		$218.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.28
$648.40
$730.10
$1,020.30
$1,550.46 		$789.79
$866.91
$948.61
$1,238.81 		$1,008.30
$1,085.42
$1,167.12
$1,457.32 		$1,226.81
$1,303.93
$1,385.63
$1,675.83 		$218.51
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 0 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$278.07
$315.61
$355.37
$496.63
$754.68 		$490.79
$528.33
$568.09
$709.35 		$703.51
$741.05
$780.81
$922.07 		$916.23
$953.77
$993.53
$1,134.79 		$212.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.14
$631.22
$710.74
$993.26
$1,509.36 		$768.86
$843.94
$923.46
$1,205.98 		$981.58
$1,056.66
$1,136.18
$1,418.70 		$1,194.30
$1,269.38
$1,348.90
$1,631.42 		$212.72
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 20 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279.66
$317.41
$357.41
$499.47
$759.00 		$493.60
$531.35
$571.35
$713.41 		$707.54
$745.29
$785.29
$927.35 		$921.48
$959.23
$999.23
$1,141.29 		$213.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559.32
$634.82
$714.82
$998.94
$1,518.00 		$773.26
$848.76
$928.76
$1,212.88 		$987.20
$1,062.70
$1,142.70
$1,426.82 		$1,201.14
$1,276.64
$1,356.64
$1,640.76 		$213.94
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 3750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$3,750 $7,500 Annual Deductible
$7,100 $14,200 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 		$367.30
$416.89
$469.41
$656.00
$996.85 		$648.28
$697.87
$750.39
$936.98 		$929.26
$978.85
$1,031.37
$1,217.96 		$1,210.24
$1,259.83
$1,312.35
$1,498.94 		$280.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.60
$833.78
$938.82
$1,312.00
$1,993.70 		$1,015.58
$1,114.76
$1,219.80
$1,592.98 		$1,296.56
$1,395.74
$1,500.78
$1,873.96 		$1,577.54
$1,676.72
$1,781.76
$2,154.94 		$280.98
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 2950 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$2,950 $5,900 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 		$361.57
$410.38
$462.09
$645.76
$981.30 		$638.17
$686.98
$738.69
$922.36 		$914.77
$963.58
$1,015.29
$1,198.96 		$1,191.37
$1,240.18
$1,291.89
$1,475.56 		$276.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.14
$820.76
$924.18
$1,291.52
$1,962.60 		$999.74
$1,097.36
$1,200.78
$1,568.12 		$1,276.34
$1,373.96
$1,477.38
$1,844.72 		$1,552.94
$1,650.56
$1,753.98
$2,121.32 		$276.60
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 6150

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$279.62
$317.37
$357.35
$499.40
$758.89 		$493.53
$531.28
$571.26
$713.31 		$707.44
$745.19
$785.17
$927.22 		$921.35
$959.10
$999.08
$1,141.13 		$213.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559.24
$634.74
$714.70
$998.80
$1,517.78 		$773.15
$848.65
$928.61
$1,212.71 		$987.06
$1,062.56
$1,142.52
$1,426.62 		$1,200.97
$1,276.47
$1,356.43
$1,640.53 		$213.91
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$355.31
$403.28
$454.09
$634.58
$964.31 		$627.12
$675.09
$725.90
$906.39 		$898.93
$946.90
$997.71
$1,178.20 		$1,170.74
$1,218.71
$1,269.52
$1,450.01 		$271.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.62
$806.56
$908.18
$1,269.16
$1,928.62 		$982.43
$1,078.37
$1,179.99
$1,540.97 		$1,254.24
$1,350.18
$1,451.80
$1,812.78 		$1,526.05
$1,621.99
$1,723.61
$2,084.59 		$271.81
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$339.92
$385.81
$434.42
$607.10
$922.54 		$599.96
$645.85
$694.46
$867.14 		$860.00
$905.89
$954.50
$1,127.18 		$1,120.04
$1,165.93
$1,214.54
$1,387.22 		$260.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.84
$771.62
$868.84
$1,214.20
$1,845.08 		$939.88
$1,031.66
$1,128.88
$1,474.24 		$1,199.92
$1,291.70
$1,388.92
$1,734.28 		$1,459.96
$1,551.74
$1,648.96
$1,994.32 		$260.04
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 6800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$333.12
$378.09
$425.73
$594.95
$904.09 		$587.96
$632.93
$680.57
$849.79 		$842.80
$887.77
$935.41
$1,104.63 		$1,097.64
$1,142.61
$1,190.25
$1,359.47 		$254.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.24
$756.18
$851.46
$1,189.90
$1,808.18 		$921.08
$1,011.02
$1,106.30
$1,444.74 		$1,175.92
$1,265.86
$1,361.14
$1,699.58 		$1,430.76
$1,520.70
$1,615.98
$1,954.42 		$254.84
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Catastrophic

(EPO) Anthem Catastrophic Pathway X 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$205.49
$233.23
$262.62
$367.01
$557.70 		$362.69
$390.43
$419.82
$524.21 		$519.89
$547.63
$577.02
$681.41 		$677.09
$704.83
$734.22
$838.61 		$157.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$410.98
$466.46
$525.24
$734.02
$1,115.40 		$568.18
$623.66
$682.44
$891.22 		$725.38
$780.86
$839.64
$1,048.42 		$882.58
$938.06
$996.84
$1,205.62 		$157.20
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 4350

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$4,350 $8,700 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 		$292.25
$331.70
$373.50
$521.96
$793.17 		$515.82
$555.27
$597.07
$745.53 		$739.39
$778.84
$820.64
$969.10 		$962.96
$1,002.41
$1,044.21
$1,192.67 		$223.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.50
$663.40
$747.00
$1,043.92
$1,586.34 		$808.07
$886.97
$970.57
$1,267.49 		$1,031.64
$1,110.54
$1,194.14
$1,491.06 		$1,255.21
$1,334.11
$1,417.71
$1,714.63 		$223.57

ADVERTISEMENT

WellFirst Health

Local: 1-866-514-4194 | Toll Free: 1-866-514-4194 | TTY: 1-866-514-4194
Toc - Plan #14 WellFirst Health
Gold

(EPO) WellFirst Gold Copay Plus 1500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,100 $10,200 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 		$380.62
$432.01
$486.43
$679.79
$1,033.01 		$671.80
$723.19
$777.61
$970.97 		$962.98
$1,014.37
$1,068.79
$1,262.15 		$1,254.16
$1,305.55
$1,359.97
$1,553.33 		$291.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.24
$864.02
$972.86
$1,359.58
$2,066.02 		$1,052.42
$1,155.20
$1,264.04
$1,650.76 		$1,343.60
$1,446.38
$1,555.22
$1,941.94 		$1,634.78
$1,737.56
$1,846.40
$2,233.12 		$291.18
Toc - Plan #15 WellFirst Health
Silver

(EPO) WellFirst Silver Copay Plus 4800X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$351.49
$398.94
$449.20
$627.76
$953.94 		$620.38
$667.83
$718.09
$896.65 		$889.27
$936.72
$986.98
$1,165.54 		$1,158.16
$1,205.61
$1,255.87
$1,434.43 		$268.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.98
$797.88
$898.40
$1,255.52
$1,907.88 		$971.87
$1,066.77
$1,167.29
$1,524.41 		$1,240.76
$1,335.66
$1,436.18
$1,793.30 		$1,509.65
$1,604.55
$1,705.07
$2,062.19 		$268.89
Toc - Plan #16 WellFirst Health
Expanded Bronze

(EPO) WellFirst Bronze Copay Plus 8650X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$8,650 $17,300 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 		$251.61
$285.58
$321.56
$449.38
$682.87 		$444.09
$478.06
$514.04
$641.86 		$636.57
$670.54
$706.52
$834.34 		$829.05
$863.02
$899.00
$1,026.82 		$192.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$503.22
$571.16
$643.12
$898.76
$1,365.74 		$695.70
$763.64
$835.60
$1,091.24 		$888.18
$956.12
$1,028.08
$1,283.72 		$1,080.66
$1,148.60
$1,220.56
$1,476.20 		$192.48
Toc - Plan #17 WellFirst Health
Silver

(EPO) WellFirst Silver Classic 5000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$336.09
$381.47
$429.53
$600.27
$912.16 		$593.20
$638.58
$686.64
$857.38 		$850.31
$895.69
$943.75
$1,114.49 		$1,107.42
$1,152.80
$1,200.86
$1,371.60 		$257.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.18
$762.94
$859.06
$1,200.54
$1,824.32 		$929.29
$1,020.05
$1,116.17
$1,457.65 		$1,186.40
$1,277.16
$1,373.28
$1,714.76 		$1,443.51
$1,534.27
$1,630.39
$1,971.87 		$257.11
Toc - Plan #18 WellFirst Health
Gold

(EPO) WellFirst Gold Value Copay 3700X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 Annual Deductible
$3,700 $7,400 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 		$377.35
$428.30
$482.26
$673.95
$1,024.14 		$666.02
$716.97
$770.93
$962.62 		$954.69
$1,005.64
$1,059.60
$1,251.29 		$1,243.36
$1,294.31
$1,348.27
$1,539.96 		$288.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.70
$856.60
$964.52
$1,347.90
$2,048.28 		$1,043.37
$1,145.27
$1,253.19
$1,636.57 		$1,332.04
$1,433.94
$1,541.86
$1,925.24 		$1,620.71
$1,722.61
$1,830.53
$2,213.91 		$288.67
Toc - Plan #19 WellFirst Health
Silver

(EPO) WellFirst Silver Value Copay 5000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$348.41
$395.44
$445.27
$622.26
$945.58 		$614.94
$661.97
$711.80
$888.79 		$881.47
$928.50
$978.33
$1,155.32 		$1,148.00
$1,195.03
$1,244.86
$1,421.85 		$266.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.82
$790.88
$890.54
$1,244.52
$1,891.16 		$963.35
$1,057.41
$1,157.07
$1,511.05 		$1,229.88
$1,323.94
$1,423.60
$1,777.58 		$1,496.41
$1,590.47
$1,690.13
$2,044.11 		$266.53
Toc - Plan #20 WellFirst Health
Bronze

(EPO) WellFirst Bronze Value Copay 8650X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$8,650 $17,300 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 		$249.90
$283.63
$319.37
$446.32
$678.22 		$441.07
$474.80
$510.54
$637.49 		$632.24
$665.97
$701.71
$828.66 		$823.41
$857.14
$892.88
$1,019.83 		$191.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.80
$567.26
$638.74
$892.64
$1,356.44 		$690.97
$758.43
$829.91
$1,083.81 		$882.14
$949.60
$1,021.08
$1,274.98 		$1,073.31
$1,140.77
$1,212.25
$1,466.15 		$191.17
Toc - Plan #21 WellFirst Health
Silver

(EPO) WellFirst Silver HSA-E 4500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$327.81
$372.07
$418.94
$585.47
$889.68 		$578.59
$622.85
$669.72
$836.25 		$829.37
$873.63
$920.50
$1,087.03 		$1,080.15
$1,124.41
$1,171.28
$1,337.81 		$250.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.62
$744.14
$837.88
$1,170.94
$1,779.36 		$906.40
$994.92
$1,088.66
$1,421.72 		$1,157.18
$1,245.70
$1,339.44
$1,672.50 		$1,407.96
$1,496.48
$1,590.22
$1,923.28 		$250.78
Toc - Plan #22 WellFirst Health
Expanded Bronze

(EPO) WellFirst Bronze HSA-E 6950X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$6,950 $13,900 Annual Deductible
$6,950 $13,900 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 		$263.39
$298.94
$336.61
$470.41
$714.83 		$464.88
$500.43
$538.10
$671.90 		$666.37
$701.92
$739.59
$873.39 		$867.86
$903.41
$941.08
$1,074.88 		$201.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.78
$597.88
$673.22
$940.82
$1,429.66 		$728.27
$799.37
$874.71
$1,142.31 		$929.76
$1,000.86
$1,076.20
$1,343.80 		$1,131.25
$1,202.35
$1,277.69
$1,545.29 		$201.49
Toc - Plan #23 WellFirst Health
Catastrophic

(EPO) WellFirst Catastrophic Safety Net

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$215.72
$244.84
$275.69
$385.27
$585.45 		$380.74
$409.86
$440.71
$550.29 		$545.76
$574.88
$605.73
$715.31 		$710.78
$739.90
$770.75
$880.33 		$165.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$431.44
$489.68
$551.38
$770.54
$1,170.90 		$596.46
$654.70
$716.40
$935.56 		$761.48
$819.72
$881.42
$1,100.58 		$926.50
$984.74
$1,046.44
$1,265.60 		$165.02

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915 | TTY: 1-877-336-3915
Toc - Plan #24 Aetna CVS Health
Expanded Bronze

(EPO) Aetna CVS Bronze: Low-Cost MinuteClinic Visits, Telehealth, Store Discounts, St. Louis

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$294.09
$333.79
$375.85
$525.24
$798.16 		$519.07
$558.77
$600.83
$750.22 		$744.05
$783.75
$825.81
$975.20 		$969.03
$1,008.73
$1,050.79
$1,200.18 		$224.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.18
$667.58
$751.70
$1,050.48
$1,596.32 		$813.16
$892.56
$976.68
$1,275.46 		$1,038.14
$1,117.54
$1,201.66
$1,500.44 		$1,263.12
$1,342.52
$1,426.64
$1,725.42 		$224.98
Toc - Plan #25 Aetna CVS Health
Bronze

(EPO) Aetna CVS Bronze: $0 MinuteClinic Visits, Telehealth, Store Discounts, St. Louis

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.99
$331.41
$373.16
$521.49
$792.46 		$515.36
$554.78
$596.53
$744.86 		$738.73
$778.15
$819.90
$968.23 		$962.10
$1,001.52
$1,043.27
$1,191.60 		$223.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.98
$662.82
$746.32
$1,042.98
$1,584.92 		$807.35
$886.19
$969.69
$1,266.35 		$1,030.72
$1,109.56
$1,193.06
$1,489.72 		$1,254.09
$1,332.93
$1,416.43
$1,713.09 		$223.37
Toc - Plan #26 Aetna CVS Health
Gold

(EPO) Aetna CVS Gold: $0 MinuteClinic Visits, Telehealth, Store Discounts, St. Louis

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$438.25
$497.41
$560.08
$782.71
$1,189.41 		$773.51
$832.67
$895.34
$1,117.97 		$1,108.77
$1,167.93
$1,230.60
$1,453.23 		$1,444.03
$1,503.19
$1,565.86
$1,788.49 		$335.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.50
$994.82
$1,120.16
$1,565.42
$2,378.82 		$1,211.76
$1,330.08
$1,455.42
$1,900.68 		$1,547.02
$1,665.34
$1,790.68
$2,235.94 		$1,882.28
$2,000.60
$2,125.94
$2,571.20 		$335.26
Toc - Plan #27 Aetna CVS Health
Silver

(EPO) Aetna CVS Silver 2: $0 MinuteClinic Visits, Telehealth, Store Discounts, St. Louis

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$355.09
$403.03
$453.81
$634.20
$963.72 		$626.74
$674.68
$725.46
$905.85 		$898.39
$946.33
$997.11
$1,177.50 		$1,170.04
$1,217.98
$1,268.76
$1,449.15 		$271.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.18
$806.06
$907.62
$1,268.40
$1,927.44 		$981.83
$1,077.71
$1,179.27
$1,540.05 		$1,253.48
$1,349.36
$1,450.92
$1,811.70 		$1,525.13
$1,621.01
$1,722.57
$2,083.35 		$271.65
Toc - Plan #28 Aetna CVS Health
Silver

(EPO) Aetna CVS Silver 1: $0 MinuteClinic Visits, Telehealth, Store Discounts, St. Louis

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$396.34
$449.85
$506.53
$707.87
$1,075.68 		$699.54
$753.05
$809.73
$1,011.07 		$1,002.74
$1,056.25
$1,112.93
$1,314.27 		$1,305.94
$1,359.45
$1,416.13
$1,617.47 		$303.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.68
$899.70
$1,013.06
$1,415.74
$2,151.36 		$1,095.88
$1,202.90
$1,316.26
$1,718.94 		$1,399.08
$1,506.10
$1,619.46
$2,022.14 		$1,702.28
$1,809.30
$1,922.66
$2,325.34 		$303.20

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777
Toc - Plan #29 Medica
Gold

(EPO) Balance by Medica Gold Copay ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

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 		$364.33
$413.50
$465.60
$650.67
$988.75 		$643.03
$692.20
$744.30
$929.37 		$921.73
$970.90
$1,023.00
$1,208.07 		$1,200.43
$1,249.60
$1,301.70
$1,486.77 		$278.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.66
$827.00
$931.20
$1,301.34
$1,977.50 		$1,007.36
$1,105.70
$1,209.90
$1,580.04 		$1,286.06
$1,384.40
$1,488.60
$1,858.74 		$1,564.76
$1,663.10
$1,767.30
$2,137.44 		$278.70
Toc - Plan #30 Medica
Silver

(EPO) Balance by Medica Silver Copay ($0 Virtual Care + Online Wellness)

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 		$329.91
$374.43
$421.61
$589.20
$895.34 		$582.28
$626.80
$673.98
$841.57 		$834.65
$879.17
$926.35
$1,093.94 		$1,087.02
$1,131.54
$1,178.72
$1,346.31 		$252.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.82
$748.86
$843.22
$1,178.40
$1,790.68 		$912.19
$1,001.23
$1,095.59
$1,430.77 		$1,164.56
$1,253.60
$1,347.96
$1,683.14 		$1,416.93
$1,505.97
$1,600.33
$1,935.51 		$252.37
Toc - Plan #31 Medica
Catastrophic

(EPO) Balance by Medica Catastrophic ($0 Virtual Care + Online Wellness)

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 		$176.55
$200.38
$225.62
$315.30
$479.13 		$311.60
$335.43
$360.67
$450.35 		$446.65
$470.48
$495.72
$585.40 		$581.70
$605.53
$630.77
$720.45 		$135.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$353.10
$400.76
$451.24
$630.60
$958.26 		$488.15
$535.81
$586.29
$765.65 		$623.20
$670.86
$721.34
$900.70 		$758.25
$805.91
$856.39
$1,035.75 		$135.05
Toc - Plan #32 Medica
Gold

(EPO) Balance by Medica Gold Share ($0 Virtual Care + $5 Generic Drugs + Online Wellness)

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 		$343.21
$389.53
$438.61
$612.96
$931.45 		$605.76
$652.08
$701.16
$875.51 		$868.31
$914.63
$963.71
$1,138.06 		$1,130.86
$1,177.18
$1,226.26
$1,400.61 		$262.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.42
$779.06
$877.22
$1,225.92
$1,862.90 		$948.97
$1,041.61
$1,139.77
$1,488.47 		$1,211.52
$1,304.16
$1,402.32
$1,751.02 		$1,474.07
$1,566.71
$1,664.87
$2,013.57 		$262.55
Toc - Plan #33 Medica
Silver

(EPO) Balance by Medica Silver Share ($0 Virtual Care + Online Wellness)

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

Annual Out of Pocket Expenses:

Individual Family
$2,700 $8,100 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331.31
$376.02
$423.40
$591.69
$899.14 		$584.75
$629.46
$676.84
$845.13 		$838.19
$882.90
$930.28
$1,098.57 		$1,091.63
$1,136.34
$1,183.72
$1,352.01 		$253.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.62
$752.04
$846.80
$1,183.38
$1,798.28 		$916.06
$1,005.48
$1,100.24
$1,436.82 		$1,169.50
$1,258.92
$1,353.68
$1,690.26 		$1,422.94
$1,512.36
$1,607.12
$1,943.70 		$253.44
Toc - Plan #34 Medica
Expanded Bronze

(EPO) Balance by Medica Bronze Share Plus ($0 Virtual Care + Online Wellness)

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 		$247.01
$280.35
$315.67
$441.15
$670.37 		$435.97
$469.31
$504.63
$630.11 		$624.93
$658.27
$693.59
$819.07 		$813.89
$847.23
$882.55
$1,008.03 		$188.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.02
$560.70
$631.34
$882.30
$1,340.74 		$682.98
$749.66
$820.30
$1,071.26 		$871.94
$938.62
$1,009.26
$1,260.22 		$1,060.90
$1,127.58
$1,198.22
$1,449.18 		$188.96
Toc - Plan #35 Medica
Bronze

(EPO) Balance by Medica Bronze Value ($0 Virtual Care + Online Wellness)

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 		$234.91
$266.61
$300.20
$419.52
$637.51 		$414.60
$446.30
$479.89
$599.21 		$594.29
$625.99
$659.58
$778.90 		$773.98
$805.68
$839.27
$958.59 		$179.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$469.82
$533.22
$600.40
$839.04
$1,275.02 		$649.51
$712.91
$780.09
$1,018.73 		$829.20
$892.60
$959.78
$1,198.42 		$1,008.89
$1,072.29
$1,139.47
$1,378.11 		$179.69
Toc - Plan #36 Medica
Expanded Bronze

(EPO) Balance by Medica Bronze Copay $0 Primary Care ($0 Virtual Care + Online Wellness)

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

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 		$251.72
$285.69
$321.69
$449.56
$683.15 		$444.28
$478.25
$514.25
$642.12 		$636.84
$670.81
$706.81
$834.68 		$829.40
$863.37
$899.37
$1,027.24 		$192.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$503.44
$571.38
$643.38
$899.12
$1,366.30 		$696.00
$763.94
$835.94
$1,091.68 		$888.56
$956.50
$1,028.50
$1,284.24 		$1,081.12
$1,149.06
$1,221.06
$1,476.80 		$192.56
Toc - Plan #37 Medica
Expanded Bronze

(EPO) Balance by Medica Bronze Copay $0 Primary Care + Dental Reimbursement ($0 Virtual Care + Online Wellness)

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

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 		$269.59
$305.98
$344.53
$481.48
$731.65 		$475.82
$512.21
$550.76
$687.71 		$682.05
$718.44
$756.99
$893.94 		$888.28
$924.67
$963.22
$1,100.17 		$206.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.18
$611.96
$689.06
$962.96
$1,463.30 		$745.41
$818.19
$895.29
$1,169.19 		$951.64
$1,024.42
$1,101.52
$1,375.42 		$1,157.87
$1,230.65
$1,307.75
$1,581.65 		$206.23

ADVERTISEMENT

Oscar Insurance Company

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

Toc - Plan #38 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 		$292.11
$331.53
$373.30
$521.68
$792.75 		$515.56
$554.98
$596.75
$745.13 		$739.01
$778.43
$820.20
$968.58 		$962.46
$1,001.88
$1,043.65
$1,192.03 		$223.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.22
$663.06
$746.60
$1,043.36
$1,585.50 		$807.67
$886.51
$970.05
$1,266.81 		$1,031.12
$1,109.96
$1,193.50
$1,490.26 		$1,254.57
$1,333.41
$1,416.95
$1,713.71 		$223.45
Toc - Plan #39 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 		$286.38
$325.03
$365.98
$511.45
$777.20 		$505.45
$544.10
$585.05
$730.52 		$724.52
$763.17
$804.12
$949.59 		$943.59
$982.24
$1,023.19
$1,168.66 		$219.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.76
$650.06
$731.96
$1,022.90
$1,554.40 		$791.83
$869.13
$951.03
$1,241.97 		$1,010.90
$1,088.20
$1,170.10
$1,461.04 		$1,229.97
$1,307.27
$1,389.17
$1,680.11 		$219.07
Toc - Plan #40 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 		$332.75
$377.66
$425.25
$594.28
$903.07 		$587.30
$632.21
$679.80
$848.83 		$841.85
$886.76
$934.35
$1,103.38 		$1,096.40
$1,141.31
$1,188.90
$1,357.93 		$254.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.50
$755.32
$850.50
$1,188.56
$1,806.14 		$920.05
$1,009.87
$1,105.05
$1,443.11 		$1,174.60
$1,264.42
$1,359.60
$1,697.66 		$1,429.15
$1,518.97
$1,614.15
$1,952.21 		$254.55
Toc - Plan #41 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 		$355.46
$403.44
$454.27
$634.84
$964.70 		$627.38
$675.36
$726.19
$906.76 		$899.30
$947.28
$998.11
$1,178.68 		$1,171.22
$1,219.20
$1,270.03
$1,450.60 		$271.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.92
$806.88
$908.54
$1,269.68
$1,929.40 		$982.84
$1,078.80
$1,180.46
$1,541.60 		$1,254.76
$1,350.72
$1,452.38
$1,813.52 		$1,526.68
$1,622.64
$1,724.30
$2,085.44 		$271.92
Toc - Plan #42 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 		$349.31
$396.45
$446.40
$623.84
$947.99 		$616.52
$663.66
$713.61
$891.05 		$883.73
$930.87
$980.82
$1,158.26 		$1,150.94
$1,198.08
$1,248.03
$1,425.47 		$267.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.62
$792.90
$892.80
$1,247.68
$1,895.98 		$965.83
$1,060.11
$1,160.01
$1,514.89 		$1,233.04
$1,327.32
$1,427.22
$1,782.10 		$1,500.25
$1,594.53
$1,694.43
$2,049.31 		$267.21
Toc - Plan #43 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 		$243.55
$276.41
$311.24
$434.96
$660.96 		$429.86
$462.72
$497.55
$621.27 		$616.17
$649.03
$683.86
$807.58 		$802.48
$835.34
$870.17
$993.89 		$186.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$487.10
$552.82
$622.48
$869.92
$1,321.92 		$673.41
$739.13
$808.79
$1,056.23 		$859.72
$925.44
$995.10
$1,242.54 		$1,046.03
$1,111.75
$1,181.41
$1,428.85 		$186.31
Toc - Plan #44 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 		$332.87
$377.79
$425.39
$594.48
$903.37 		$587.50
$632.42
$680.02
$849.11 		$842.13
$887.05
$934.65
$1,103.74 		$1,096.76
$1,141.68
$1,189.28
$1,358.37 		$254.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.74
$755.58
$850.78
$1,188.96
$1,806.74 		$920.37
$1,010.21
$1,105.41
$1,443.59 		$1,175.00
$1,264.84
$1,360.04
$1,698.22 		$1,429.63
$1,519.47
$1,614.67
$1,952.85 		$254.63
Toc - Plan #45 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 		$432.39
$490.75
$552.58
$772.23
$1,173.47 		$763.16
$821.52
$883.35
$1,103.00 		$1,093.93
$1,152.29
$1,214.12
$1,433.77 		$1,424.70
$1,483.06
$1,544.89
$1,764.54 		$330.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.78
$981.50
$1,105.16
$1,544.46
$2,346.94 		$1,195.55
$1,312.27
$1,435.93
$1,875.23 		$1,526.32
$1,643.04
$1,766.70
$2,206.00 		$1,857.09
$1,973.81
$2,097.47
$2,536.77 		$330.77
Toc - Plan #46 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 		$307.68
$349.21
$393.21
$549.51
$835.03 		$543.05
$584.58
$628.58
$784.88 		$778.42
$819.95
$863.95
$1,020.25 		$1,013.79
$1,055.32
$1,099.32
$1,255.62 		$235.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.36
$698.42
$786.42
$1,099.02
$1,670.06 		$850.73
$933.79
$1,021.79
$1,334.39 		$1,086.10
$1,169.16
$1,257.16
$1,569.76 		$1,321.47
$1,404.53
$1,492.53
$1,805.13 		$235.37
Toc - Plan #47 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 		$348.81
$395.89
$445.76
$622.95
$946.64 		$615.64
$662.72
$712.59
$889.78 		$882.47
$929.55
$979.42
$1,156.61 		$1,149.30
$1,196.38
$1,246.25
$1,423.44 		$266.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.62
$791.78
$891.52
$1,245.90
$1,893.28 		$964.45
$1,058.61
$1,158.35
$1,512.73 		$1,231.28
$1,325.44
$1,425.18
$1,779.56 		$1,498.11
$1,592.27
$1,692.01
$2,046.39 		$266.83
Toc - Plan #48 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 		$433.42
$491.92
$553.90
$774.08
$1,176.28 		$764.98
$823.48
$885.46
$1,105.64 		$1,096.54
$1,155.04
$1,217.02
$1,437.20 		$1,428.10
$1,486.60
$1,548.58
$1,768.76 		$331.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.84
$983.84
$1,107.80
$1,548.16
$2,352.56 		$1,198.40
$1,315.40
$1,439.36
$1,879.72 		$1,529.96
$1,646.96
$1,770.92
$2,211.28 		$1,861.52
$1,978.52
$2,102.48
$2,542.84 		$331.56
Toc - Plan #49 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 		$301.13
$341.77
$384.83
$537.80
$817.24 		$531.49
$572.13
$615.19
$768.16 		$761.85
$802.49
$845.55
$998.52 		$992.21
$1,032.85
$1,075.91
$1,228.88 		$230.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.26
$683.54
$769.66
$1,075.60
$1,634.48 		$832.62
$913.90
$1,000.02
$1,305.96 		$1,062.98
$1,144.26
$1,230.38
$1,536.32 		$1,293.34
$1,374.62
$1,460.74
$1,766.68 		$230.36
Toc - Plan #50 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 		$319.32
$362.41
$408.07
$570.28
$866.60 		$563.59
$606.68
$652.34
$814.55 		$807.86
$850.95
$896.61
$1,058.82 		$1,052.13
$1,095.22
$1,140.88
$1,303.09 		$244.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.64
$724.82
$816.14
$1,140.56
$1,733.20 		$882.91
$969.09
$1,060.41
$1,384.83 		$1,127.18
$1,213.36
$1,304.68
$1,629.10 		$1,371.45
$1,457.63
$1,548.95
$1,873.37 		$244.27
Toc - Plan #51 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 		$304.61
$345.72
$389.28
$544.02
$826.69 		$537.63
$578.74
$622.30
$777.04 		$770.65
$811.76
$855.32
$1,010.06 		$1,003.67
$1,044.78
$1,088.34
$1,243.08 		$233.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.22
$691.44
$778.56
$1,088.04
$1,653.38 		$842.24
$924.46
$1,011.58
$1,321.06 		$1,075.26
$1,157.48
$1,244.60
$1,554.08 		$1,308.28
$1,390.50
$1,477.62
$1,787.10 		$233.02
Toc - Plan #52 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 		$344.00
$390.43
$439.62
$614.37
$933.60 		$607.16
$653.59
$702.78
$877.53 		$870.32
$916.75
$965.94
$1,140.69 		$1,133.48
$1,179.91
$1,229.10
$1,403.85 		$263.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.00
$780.86
$879.24
$1,228.74
$1,867.20 		$951.16
$1,044.02
$1,142.40
$1,491.90 		$1,214.32
$1,307.18
$1,405.56
$1,755.06 		$1,477.48
$1,570.34
$1,668.72
$2,018.22 		$263.16
Toc - Plan #53 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 		$365.96
$415.35
$467.68
$653.59
$993.19 		$645.91
$695.30
$747.63
$933.54 		$925.86
$975.25
$1,027.58
$1,213.49 		$1,205.81
$1,255.20
$1,307.53
$1,493.44 		$279.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.92
$830.70
$935.36
$1,307.18
$1,986.38 		$1,011.87
$1,110.65
$1,215.31
$1,587.13 		$1,291.82
$1,390.60
$1,495.26
$1,867.08 		$1,571.77
$1,670.55
$1,775.21
$2,147.03 		$279.95
Toc - Plan #54 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 		$356.77
$404.92
$455.93
$637.17
$968.24 		$629.69
$677.84
$728.85
$910.09 		$902.61
$950.76
$1,001.77
$1,183.01 		$1,175.53
$1,223.68
$1,274.69
$1,455.93 		$272.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.54
$809.84
$911.86
$1,274.34
$1,936.48 		$986.46
$1,082.76
$1,184.78
$1,547.26 		$1,259.38
$1,355.68
$1,457.70
$1,820.18 		$1,532.30
$1,628.60
$1,730.62
$2,093.10 		$272.92
Toc - Plan #55 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 		$364.63
$413.85
$465.99
$651.22
$989.59 		$643.57
$692.79
$744.93
$930.16 		$922.51
$971.73
$1,023.87
$1,209.10 		$1,201.45
$1,250.67
$1,302.81
$1,488.04 		$278.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.26
$827.70
$931.98
$1,302.44
$1,979.18 		$1,008.20
$1,106.64
$1,210.92
$1,581.38 		$1,287.14
$1,385.58
$1,489.86
$1,860.32 		$1,566.08
$1,664.52
$1,768.80
$2,139.26 		$278.94
Toc - Plan #56 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 		$363.54
$412.60
$464.59
$649.26
$986.61 		$641.64
$690.70
$742.69
$927.36 		$919.74
$968.80
$1,020.79
$1,205.46 		$1,197.84
$1,246.90
$1,298.89
$1,483.56 		$278.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.08
$825.20
$929.18
$1,298.52
$1,973.22 		$1,005.18
$1,103.30
$1,207.28
$1,576.62 		$1,283.28
$1,381.40
$1,485.38
$1,854.72 		$1,561.38
$1,659.50
$1,763.48
$2,132.82 		$278.10
Toc - Plan #57 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 		$360.43
$409.08
$460.62
$643.71
$978.18 		$636.15
$684.80
$736.34
$919.43 		$911.87
$960.52
$1,012.06
$1,195.15 		$1,187.59
$1,236.24
$1,287.78
$1,470.87 		$275.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.86
$818.16
$921.24
$1,287.42
$1,956.36 		$996.58
$1,093.88
$1,196.96
$1,563.14 		$1,272.30
$1,369.60
$1,472.68
$1,838.86 		$1,548.02
$1,645.32
$1,748.40
$2,114.58 		$275.72
Toc - Plan #58 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 		$417.63
$474.00
$533.72
$745.87
$1,133.43 		$737.11
$793.48
$853.20
$1,065.35 		$1,056.59
$1,112.96
$1,172.68
$1,384.83 		$1,376.07
$1,432.44
$1,492.16
$1,704.31 		$319.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.26
$948.00
$1,067.44
$1,491.74
$2,266.86 		$1,154.74
$1,267.48
$1,386.92
$1,811.22 		$1,474.22
$1,586.96
$1,706.40
$2,130.70 		$1,793.70
$1,906.44
$2,025.88
$2,450.18 		$319.48
Toc - Plan #59 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 		$463.10
$525.61
$591.83
$827.08
$1,256.83 		$817.36
$879.87
$946.09
$1,181.34 		$1,171.62
$1,234.13
$1,300.35
$1,535.60 		$1,525.88
$1,588.39
$1,654.61
$1,889.86 		$354.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.20
$1,051.22
$1,183.66
$1,654.16
$2,513.66 		$1,280.46
$1,405.48
$1,537.92
$2,008.42 		$1,634.72
$1,759.74
$1,892.18
$2,362.68 		$1,988.98
$2,114.00
$2,246.44
$2,716.94 		$354.26
Toc - Plan #60 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 		$443.64
$503.52
$566.96
$792.33
$1,204.02 		$783.02
$842.90
$906.34
$1,131.71 		$1,122.40
$1,182.28
$1,245.72
$1,471.09 		$1,461.78
$1,521.66
$1,585.10
$1,810.47 		$339.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.28
$1,007.04
$1,133.92
$1,584.66
$2,408.04 		$1,226.66
$1,346.42
$1,473.30
$1,924.04 		$1,566.04
$1,685.80
$1,812.68
$2,263.42 		$1,905.42
$2,025.18
$2,152.06
$2,602.80 		$339.38
Toc - Plan #61 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 		$418.65
$475.16
$535.02
$747.69
$1,136.19 		$738.91
$795.42
$855.28
$1,067.95 		$1,059.17
$1,115.68
$1,175.54
$1,388.21 		$1,379.43
$1,435.94
$1,495.80
$1,708.47 		$320.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.30
$950.32
$1,070.04
$1,495.38
$2,272.38 		$1,157.56
$1,270.58
$1,390.30
$1,815.64 		$1,477.82
$1,590.84
$1,710.56
$2,135.90 		$1,798.08
$1,911.10
$2,030.82
$2,456.16 		$320.26
Toc - Plan #62 Oscar Insurance Company
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 		$285.53
$324.06
$364.89
$509.93
$774.90 		$503.95
$542.48
$583.31
$728.35 		$722.37
$760.90
$801.73
$946.77 		$940.79
$979.32
$1,020.15
$1,165.19 		$218.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.06
$648.12
$729.78
$1,019.86
$1,549.80 		$789.48
$866.54
$948.20
$1,238.28 		$1,007.90
$1,084.96
$1,166.62
$1,456.70 		$1,226.32
$1,303.38
$1,385.04
$1,675.12 		$218.42
Toc - Plan #63 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 		$322.08
$365.55
$411.61
$575.22
$874.10 		$568.46
$611.93
$657.99
$821.60 		$814.84
$858.31
$904.37
$1,067.98 		$1,061.22
$1,104.69
$1,150.75
$1,314.36 		$246.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.16
$731.10
$823.22
$1,150.44
$1,748.20 		$890.54
$977.48
$1,069.60
$1,396.82 		$1,136.92
$1,223.86
$1,315.98
$1,643.20 		$1,383.30
$1,470.24
$1,562.36
$1,889.58 		$246.38
Toc - Plan #64 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 		$329.15
$373.57
$420.64
$587.84
$893.27 		$580.94
$625.36
$672.43
$839.63 		$832.73
$877.15
$924.22
$1,091.42 		$1,084.52
$1,128.94
$1,176.01
$1,343.21 		$251.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.30
$747.14
$841.28
$1,175.68
$1,786.54 		$910.09
$998.93
$1,093.07
$1,427.47 		$1,161.88
$1,250.72
$1,344.86
$1,679.26 		$1,413.67
$1,502.51
$1,596.65
$1,931.05 		$251.79
Toc - Plan #65 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 		$330.11
$374.66
$421.87
$589.55
$895.89 		$582.63
$627.18
$674.39
$842.07 		$835.15
$879.70
$926.91
$1,094.59 		$1,087.67
$1,132.22
$1,179.43
$1,347.11 		$252.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.22
$749.32
$843.74
$1,179.10
$1,791.78 		$912.74
$1,001.84
$1,096.26
$1,431.62 		$1,165.26
$1,254.36
$1,348.78
$1,684.14 		$1,417.78
$1,506.88
$1,601.30
$1,936.66 		$252.52
Toc - Plan #66 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 		$351.48
$398.92
$449.18
$627.72
$953.89 		$620.35
$667.79
$718.05
$896.59 		$889.22
$936.66
$986.92
$1,165.46 		$1,158.09
$1,205.53
$1,255.79
$1,434.33 		$268.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.96
$797.84
$898.36
$1,255.44
$1,907.78 		$971.83
$1,066.71
$1,167.23
$1,524.31 		$1,240.70
$1,335.58
$1,436.10
$1,793.18 		$1,509.57
$1,604.45
$1,704.97
$2,062.05 		$268.87

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #67 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5900 (BJC HealthCare, $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 		$295.01
$334.83
$377.02
$526.88
$800.64 		$520.69
$560.51
$602.70
$752.56 		$746.37
$786.19
$828.38
$978.24 		$972.05
$1,011.87
$1,054.06
$1,203.92 		$225.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.02
$669.66
$754.04
$1,053.76
$1,601.28 		$815.70
$895.34
$979.72
$1,279.44 		$1,041.38
$1,121.02
$1,205.40
$1,505.12 		$1,267.06
$1,346.70
$1,431.08
$1,730.80 		$225.68
Toc - Plan #68 Cigna Healthcare
Silver

(EPO) Cigna Connect 5500 (BJC HealthCare, $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
$5,500 $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 		$353.97
$401.76
$452.38
$632.20
$960.69 		$624.76
$672.55
$723.17
$902.99 		$895.55
$943.34
$993.96
$1,173.78 		$1,166.34
$1,214.13
$1,264.75
$1,444.57 		$270.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.94
$803.52
$904.76
$1,264.40
$1,921.38 		$978.73
$1,074.31
$1,175.55
$1,535.19 		$1,249.52
$1,345.10
$1,446.34
$1,805.98 		$1,520.31
$1,615.89
$1,717.13
$2,076.77 		$270.79
Toc - Plan #69 Cigna Healthcare
Silver

(EPO) Cigna Connect 2900 (BJC HealthCare, $0 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
$2,900 $5,800 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 		$365.03
$414.30
$466.50
$651.94
$990.68 		$644.28
$693.55
$745.75
$931.19 		$923.53
$972.80
$1,025.00
$1,210.44 		$1,202.78
$1,252.05
$1,304.25
$1,489.69 		$279.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.06
$828.60
$933.00
$1,303.88
$1,981.36 		$1,009.31
$1,107.85
$1,212.25
$1,583.13 		$1,288.56
$1,387.10
$1,491.50
$1,862.38 		$1,567.81
$1,666.35
$1,770.75
$2,141.63 		$279.25
Toc - Plan #70 Cigna Healthcare
Gold

(EPO) Cigna Connect 850 (BJC HealthCare, $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
$850 $1,700 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 		$464.17
$526.84
$593.21
$829.01
$1,259.76 		$819.26
$881.93
$948.30
$1,184.10 		$1,174.35
$1,237.02
$1,303.39
$1,539.19 		$1,529.44
$1,592.11
$1,658.48
$1,894.28 		$355.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$928.34
$1,053.68
$1,186.42
$1,658.02
$2,519.52 		$1,283.43
$1,408.77
$1,541.51
$2,013.11 		$1,638.52
$1,763.86
$1,896.60
$2,368.20 		$1,993.61
$2,118.95
$2,251.69
$2,723.29 		$355.09
Toc - Plan #71 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7000 (BJC HealthCare, $0 Telehealth)

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

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 		$287.42
$326.23
$367.33
$513.34
$780.07 		$507.30
$546.11
$587.21
$733.22 		$727.18
$765.99
$807.09
$953.10 		$947.06
$985.87
$1,026.97
$1,172.98 		$219.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.84
$652.46
$734.66
$1,026.68
$1,560.14 		$794.72
$872.34
$954.54
$1,246.56 		$1,014.60
$1,092.22
$1,174.42
$1,466.44 		$1,234.48
$1,312.10
$1,394.30
$1,686.32 		$219.88
Toc - Plan #72 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8700 (BJC HealthCare, $0 Telehealth)

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

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 		$279.21
$316.90
$356.83
$498.66
$757.76 		$492.80
$530.49
$570.42
$712.25 		$706.39
$744.08
$784.01
$925.84 		$919.98
$957.67
$997.60
$1,139.43 		$213.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558.42
$633.80
$713.66
$997.32
$1,515.52 		$772.01
$847.39
$927.25
$1,210.91 		$985.60
$1,060.98
$1,140.84
$1,424.50 		$1,199.19
$1,274.57
$1,354.43
$1,638.09 		$213.59
Toc - Plan #73 Cigna Healthcare
Silver

(EPO) Cigna Connect 7300 (BJC HealthCare, $0 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
$7,300 $14,600 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 		$355.13
$403.07
$453.86
$634.27
$963.83 		$626.81
$674.75
$725.54
$905.95 		$898.49
$946.43
$997.22
$1,177.63 		$1,170.17
$1,218.11
$1,268.90
$1,449.31 		$271.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.26
$806.14
$907.72
$1,268.54
$1,927.66 		$981.94
$1,077.82
$1,179.40
$1,540.22 		$1,253.62
$1,349.50
$1,451.08
$1,811.90 		$1,525.30
$1,621.18
$1,722.76
$2,083.58 		$271.68
Toc - Plan #74 Cigna Healthcare
Silver

(EPO) Cigna Connect 4500 (BJC HealthCare, $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
$4,500 $9,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.98
$398.36
$448.56
$626.85
$952.57 		$619.48
$666.86
$717.06
$895.35 		$887.98
$935.36
$985.56
$1,163.85 		$1,156.48
$1,203.86
$1,254.06
$1,432.35 		$268.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.96
$796.72
$897.12
$1,253.70
$1,905.14 		$970.46
$1,065.22
$1,165.62
$1,522.20 		$1,238.96
$1,333.72
$1,434.12
$1,790.70 		$1,507.46
$1,602.22
$1,702.62
$2,059.20 		$268.50
Toc - Plan #75 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 Enhanced Diabetes Care (BJC HealthCare, $0 Select 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 		$361.63
$410.46
$462.17
$645.88
$981.48 		$638.28
$687.11
$738.82
$922.53 		$914.93
$963.76
$1,015.47
$1,199.18 		$1,191.58
$1,240.41
$1,292.12
$1,475.83 		$276.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.26
$820.92
$924.34
$1,291.76
$1,962.96 		$999.91
$1,097.57
$1,200.99
$1,568.41 		$1,276.56
$1,374.22
$1,477.64
$1,845.06 		$1,553.21
$1,650.87
$1,754.29
$2,121.71 		$276.65
Toc - Plan #76 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care (BJC HealthCare, $0 Select 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 		$295.60
$335.51
$377.78
$527.95
$802.27 		$521.74
$561.65
$603.92
$754.09 		$747.88
$787.79
$830.06
$980.23 		$974.02
$1,013.93
$1,056.20
$1,206.37 		$226.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.20
$671.02
$755.56
$1,055.90
$1,604.54 		$817.34
$897.16
$981.70
$1,282.04 		$1,043.48
$1,123.30
$1,207.84
$1,508.18 		$1,269.62
$1,349.44
$1,433.98
$1,734.32 		$226.14
Toc - Plan #77 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care (BJC HealthCare, $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 		$357.72
$406.02
$457.17
$638.90
$970.87 		$631.38
$679.68
$730.83
$912.56 		$905.04
$953.34
$1,004.49
$1,186.22 		$1,178.70
$1,227.00
$1,278.15
$1,459.88 		$273.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.44
$812.04
$914.34
$1,277.80
$1,941.74 		$989.10
$1,085.70
$1,188.00
$1,551.46 		$1,262.76
$1,359.36
$1,461.66
$1,825.12 		$1,536.42
$1,633.02
$1,735.32
$2,098.78 		$273.66
Toc - Plan #78 Cigna Healthcare
Silver

(EPO) Cigna Connect 0 (BJC HealthCare, $0 Medical Deductible, $0 Telehealth)

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

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 		$364.99
$414.26
$466.45
$651.87
$990.57 		$644.20
$693.47
$745.66
$931.08 		$923.41
$972.68
$1,024.87
$1,210.29 		$1,202.62
$1,251.89
$1,304.08
$1,489.50 		$279.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.98
$828.52
$932.90
$1,303.74
$1,981.14 		$1,009.19
$1,107.73
$1,212.11
$1,582.95 		$1,288.40
$1,386.94
$1,491.32
$1,862.16 		$1,567.61
$1,666.15
$1,770.53
$2,141.37 		$279.21
Toc - Plan #79 Cigna Healthcare
Gold

(EPO) Cigna Connect 1500 (BJC HealthCare, $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
$1,500 $3,000 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 		$445.10
$505.19
$568.84
$794.95
$1,208.01 		$785.60
$845.69
$909.34
$1,135.45 		$1,126.10
$1,186.19
$1,249.84
$1,475.95 		$1,466.60
$1,526.69
$1,590.34
$1,816.45 		$340.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.20
$1,010.38
$1,137.68
$1,589.90
$2,416.02 		$1,230.70
$1,350.88
$1,478.18
$1,930.40 		$1,571.20
$1,691.38
$1,818.68
$2,270.90 		$1,911.70
$2,031.88
$2,159.18
$2,611.40 		$340.50

ADVERTISEMENT

Ambetter from Home State Health

Local: 1-855-650-3789 | Toll Free: 1-855-650-3789

Toc - Plan #80 Ambetter from Home State Health
Bronze

(EPO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$272.79
$309.60
$348.61
$487.18
$740.31 		$481.46
$518.27
$557.28
$695.85 		$690.13
$726.94
$765.95
$904.52 		$898.80
$935.61
$974.62
$1,113.19 		$208.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$545.58
$619.20
$697.22
$974.36
$1,480.62 		$754.25
$827.87
$905.89
$1,183.03 		$962.92
$1,036.54
$1,114.56
$1,391.70 		$1,171.59
$1,245.21
$1,323.23
$1,600.37 		$208.67
Toc - Plan #81 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$334.54
$379.69
$427.53
$597.47
$907.91 		$590.46
$635.61
$683.45
$853.39 		$846.38
$891.53
$939.37
$1,109.31 		$1,102.30
$1,147.45
$1,195.29
$1,365.23 		$255.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.08
$759.38
$855.06
$1,194.94
$1,815.82 		$925.00
$1,015.30
$1,110.98
$1,450.86 		$1,180.92
$1,271.22
$1,366.90
$1,706.78 		$1,436.84
$1,527.14
$1,622.82
$1,962.70 		$255.92
Toc - Plan #82 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$324.34
$368.11
$414.49
$579.25
$880.22 		$572.45
$616.22
$662.60
$827.36 		$820.56
$864.33
$910.71
$1,075.47 		$1,068.67
$1,112.44
$1,158.82
$1,323.58 		$248.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.68
$736.22
$828.98
$1,158.50
$1,760.44 		$896.79
$984.33
$1,077.09
$1,406.61 		$1,144.90
$1,232.44
$1,325.20
$1,654.72 		$1,393.01
$1,480.55
$1,573.31
$1,902.83 		$248.11
Toc - Plan #83 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.09
$471.12
$530.48
$741.34
$1,126.54 		$732.63
$788.66
$848.02
$1,058.88 		$1,050.17
$1,106.20
$1,165.56
$1,376.42 		$1,367.71
$1,423.74
$1,483.10
$1,693.96 		$317.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.18
$942.24
$1,060.96
$1,482.68
$2,253.08 		$1,147.72
$1,259.78
$1,378.50
$1,800.22 		$1,465.26
$1,577.32
$1,696.04
$2,117.76 		$1,782.80
$1,894.86
$2,013.58
$2,435.30 		$317.54
Toc - Plan #84 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$297.54
$337.70
$380.24
$531.39
$807.50 		$525.15
$565.31
$607.85
$759.00 		$752.76
$792.92
$835.46
$986.61 		$980.37
$1,020.53
$1,063.07
$1,214.22 		$227.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$595.08
$675.40
$760.48
$1,062.78
$1,615.00 		$822.69
$903.01
$988.09
$1,290.39 		$1,050.30
$1,130.62
$1,215.70
$1,518.00 		$1,277.91
$1,358.23
$1,443.31
$1,745.61 		$227.61
Toc - Plan #85 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$298.44
$338.72
$381.40
$533.00
$809.95 		$526.74
$567.02
$609.70
$761.30 		$755.04
$795.32
$838.00
$989.60 		$983.34
$1,023.62
$1,066.30
$1,217.90 		$228.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.88
$677.44
$762.80
$1,066.00
$1,619.90 		$825.18
$905.74
$991.10
$1,294.30 		$1,053.48
$1,134.04
$1,219.40
$1,522.60 		$1,281.78
$1,362.34
$1,447.70
$1,750.90 		$228.30
Toc - Plan #86 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 124

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$329.86
$374.38
$421.54
$589.11
$895.20 		$582.19
$626.71
$673.87
$841.44 		$834.52
$879.04
$926.20
$1,093.77 		$1,086.85
$1,131.37
$1,178.53
$1,346.10 		$252.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.72
$748.76
$843.08
$1,178.22
$1,790.40 		$912.05
$1,001.09
$1,095.41
$1,430.55 		$1,164.38
$1,253.42
$1,347.74
$1,682.88 		$1,416.71
$1,505.75
$1,600.07
$1,935.21 		$252.33
Toc - Plan #87 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 127

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.34
$389.68
$438.77
$613.18
$931.79 		$605.99
$652.33
$701.42
$875.83 		$868.64
$914.98
$964.07
$1,138.48 		$1,131.29
$1,177.63
$1,226.72
$1,401.13 		$262.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.68
$779.36
$877.54
$1,226.36
$1,863.58 		$949.33
$1,042.01
$1,140.19
$1,489.01 		$1,211.98
$1,304.66
$1,402.84
$1,751.66 		$1,474.63
$1,567.31
$1,665.49
$2,014.31 		$262.65
Toc - Plan #88 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 129

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$316.74
$359.49
$404.78
$565.68
$859.61 		$559.04
$601.79
$647.08
$807.98 		$801.34
$844.09
$889.38
$1,050.28 		$1,043.64
$1,086.39
$1,131.68
$1,292.58 		$242.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.48
$718.98
$809.56
$1,131.36
$1,719.22 		$875.78
$961.28
$1,051.86
$1,373.66 		$1,118.08
$1,203.58
$1,294.16
$1,615.96 		$1,360.38
$1,445.88
$1,536.46
$1,858.26 		$242.30
Toc - Plan #89 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$315.54
$358.12
$403.25
$563.53
$856.34 		$556.92
$599.50
$644.63
$804.91 		$798.30
$840.88
$886.01
$1,046.29 		$1,039.68
$1,082.26
$1,127.39
$1,287.67 		$241.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.08
$716.24
$806.50
$1,127.06
$1,712.68 		$872.46
$957.62
$1,047.88
$1,368.44 		$1,113.84
$1,199.00
$1,289.26
$1,609.82 		$1,355.22
$1,440.38
$1,530.64
$1,851.20 		$241.38
Toc - Plan #90 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336.68
$382.12
$430.26
$601.29
$913.72 		$594.23
$639.67
$687.81
$858.84 		$851.78
$897.22
$945.36
$1,116.39 		$1,109.33
$1,154.77
$1,202.91
$1,373.94 		$257.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$673.36
$764.24
$860.52
$1,202.58
$1,827.44 		$930.91
$1,021.79
$1,118.07
$1,460.13 		$1,188.46
$1,279.34
$1,375.62
$1,717.68 		$1,446.01
$1,536.89
$1,633.17
$1,975.23 		$257.55
Toc - Plan #91 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$301.32
$341.99
$385.08
$538.14
$817.76 		$531.82
$572.49
$615.58
$768.64 		$762.32
$802.99
$846.08
$999.14 		$992.82
$1,033.49
$1,076.58
$1,229.64 		$230.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.64
$683.98
$770.16
$1,076.28
$1,635.52 		$833.14
$914.48
$1,000.66
$1,306.78 		$1,063.64
$1,144.98
$1,231.16
$1,537.28 		$1,294.14
$1,375.48
$1,461.66
$1,767.78 		$230.50
Toc - Plan #92 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$301.69
$342.41
$385.55
$538.80
$818.76 		$532.47
$573.19
$616.33
$769.58 		$763.25
$803.97
$847.11
$1,000.36 		$994.03
$1,034.75
$1,077.89
$1,231.14 		$230.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.38
$684.82
$771.10
$1,077.60
$1,637.52 		$834.16
$915.60
$1,001.88
$1,308.38 		$1,064.94
$1,146.38
$1,232.66
$1,539.16 		$1,295.72
$1,377.16
$1,463.44
$1,769.94 		$230.78
Toc - Plan #93 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$311.12
$353.11
$397.60
$555.65
$844.36 		$549.12
$591.11
$635.60
$793.65 		$787.12
$829.11
$873.60
$1,031.65 		$1,025.12
$1,067.11
$1,111.60
$1,269.65 		$238.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.24
$706.22
$795.20
$1,111.30
$1,688.72 		$860.24
$944.22
$1,033.20
$1,349.30 		$1,098.24
$1,182.22
$1,271.20
$1,587.30 		$1,336.24
$1,420.22
$1,509.20
$1,825.30 		$238.00
Toc - Plan #94 Ambetter from Home State Health
Gold

(EPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$389.97
$442.61
$498.37
$696.47
$1,058.35 		$688.29
$740.93
$796.69
$994.79 		$986.61
$1,039.25
$1,095.01
$1,293.11 		$1,284.93
$1,337.57
$1,393.33
$1,591.43 		$298.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.94
$885.22
$996.74
$1,392.94
$2,116.70 		$1,078.26
$1,183.54
$1,295.06
$1,691.26 		$1,376.58
$1,481.86
$1,593.38
$1,989.58 		$1,674.90
$1,780.18
$1,891.70
$2,287.90 		$298.32
Toc - Plan #95 Ambetter from Home State Health
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$281.95
$320.01
$360.32
$503.55
$765.19 		$497.64
$535.70
$576.01
$719.24 		$713.33
$751.39
$791.70
$934.93 		$929.02
$967.08
$1,007.39
$1,150.62 		$215.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.90
$640.02
$720.64
$1,007.10
$1,530.38 		$779.59
$855.71
$936.33
$1,222.79 		$995.28
$1,071.40
$1,152.02
$1,438.48 		$1,210.97
$1,287.09
$1,367.71
$1,654.17 		$215.69
Toc - Plan #96 Ambetter from Home State Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$307.54
$349.05
$393.02
$549.25
$834.64 		$542.80
$584.31
$628.28
$784.51 		$778.06
$819.57
$863.54
$1,019.77 		$1,013.32
$1,054.83
$1,098.80
$1,255.03 		$235.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.08
$698.10
$786.04
$1,098.50
$1,669.28 		$850.34
$933.36
$1,021.30
$1,333.76 		$1,085.60
$1,168.62
$1,256.56
$1,569.02 		$1,320.86
$1,403.88
$1,491.82
$1,804.28 		$235.26
Toc - Plan #97 Ambetter from Home State Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.04
$486.95
$548.31
$766.26
$1,164.40 		$757.25
$815.16
$876.52
$1,094.47 		$1,085.46
$1,143.37
$1,204.73
$1,422.68 		$1,413.67
$1,471.58
$1,532.94
$1,750.89 		$328.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.08
$973.90
$1,096.62
$1,532.52
$2,328.80 		$1,186.29
$1,302.11
$1,424.83
$1,860.73 		$1,514.50
$1,630.32
$1,753.04
$2,188.94 		$1,842.71
$1,958.53
$2,081.25
$2,517.15 		$328.21
Toc - Plan #98 Ambetter from Home State Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$335.24
$380.48
$428.42
$598.72
$909.81 		$591.69
$636.93
$684.87
$855.17 		$848.14
$893.38
$941.32
$1,111.62 		$1,104.59
$1,149.83
$1,197.77
$1,368.07 		$256.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.48
$760.96
$856.84
$1,197.44
$1,819.62 		$926.93
$1,017.41
$1,113.29
$1,453.89 		$1,183.38
$1,273.86
$1,369.74
$1,710.34 		$1,439.83
$1,530.31
$1,626.19
$1,966.79 		$256.45
Toc - Plan #99 Ambetter from Home State Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$345.78
$392.45
$441.90
$617.55
$938.43 		$610.30
$656.97
$706.42
$882.07 		$874.82
$921.49
$970.94
$1,146.59 		$1,139.34
$1,186.01
$1,235.46
$1,411.11 		$264.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.56
$784.90
$883.80
$1,235.10
$1,876.86 		$956.08
$1,049.42
$1,148.32
$1,499.62 		$1,220.60
$1,313.94
$1,412.84
$1,764.14 		$1,485.12
$1,578.46
$1,677.36
$2,028.66 		$264.52
Toc - Plan #100 Ambetter from Home State Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$308.47
$350.11
$394.22
$550.92
$837.17 		$544.44
$586.08
$630.19
$786.89 		$780.41
$822.05
$866.16
$1,022.86 		$1,016.38
$1,058.02
$1,102.13
$1,258.83 		$235.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.94
$700.22
$788.44
$1,101.84
$1,674.34 		$852.91
$936.19
$1,024.41
$1,337.81 		$1,088.88
$1,172.16
$1,260.38
$1,573.78 		$1,324.85
$1,408.13
$1,496.35
$1,809.75 		$235.97
Toc - Plan #101 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 124 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$340.94
$386.96
$435.71
$608.90
$925.29 		$601.75
$647.77
$696.52
$869.71 		$862.56
$908.58
$957.33
$1,130.52 		$1,123.37
$1,169.39
$1,218.14
$1,391.33 		$260.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.88
$773.92
$871.42
$1,217.80
$1,850.58 		$942.69
$1,034.73
$1,132.23
$1,478.61 		$1,203.50
$1,295.54
$1,393.04
$1,739.42 		$1,464.31
$1,556.35
$1,653.85
$2,000.23 		$260.81
Toc - Plan #102 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 127 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.88
$402.77
$453.52
$633.79
$963.11 		$626.35
$674.24
$724.99
$905.26 		$897.82
$945.71
$996.46
$1,176.73 		$1,169.29
$1,217.18
$1,267.93
$1,448.20 		$271.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.76
$805.54
$907.04
$1,267.58
$1,926.22 		$981.23
$1,077.01
$1,178.51
$1,539.05 		$1,252.70
$1,348.48
$1,449.98
$1,810.52 		$1,524.17
$1,619.95
$1,721.45
$2,081.99 		$271.47
Toc - Plan #103 Ambetter from Home State Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$326.14
$370.16
$416.80
$582.47
$885.12 		$575.63
$619.65
$666.29
$831.96 		$825.12
$869.14
$915.78
$1,081.45 		$1,074.61
$1,118.63
$1,165.27
$1,330.94 		$249.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.28
$740.32
$833.60
$1,164.94
$1,770.24 		$901.77
$989.81
$1,083.09
$1,414.43 		$1,151.26
$1,239.30
$1,332.58
$1,663.92 		$1,400.75
$1,488.79
$1,582.07
$1,913.41 		$249.49
Toc - Plan #104 Ambetter from Home State Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$348.00
$394.96
$444.73
$621.50
$944.43 		$614.21
$661.17
$710.94
$887.71 		$880.42
$927.38
$977.15
$1,153.92 		$1,146.63
$1,193.59
$1,243.36
$1,420.13 		$266.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.00
$789.92
$889.46
$1,243.00
$1,888.86 		$962.21
$1,056.13
$1,155.67
$1,509.21 		$1,228.42
$1,322.34
$1,421.88
$1,775.42 		$1,494.63
$1,588.55
$1,688.09
$2,041.63 		$266.21
Toc - Plan #105 Ambetter from Home State Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$311.83
$353.91
$398.50
$556.91
$846.27 		$550.37
$592.45
$637.04
$795.45 		$788.91
$830.99
$875.58
$1,033.99 		$1,027.45
$1,069.53
$1,114.12
$1,272.53 		$238.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.66
$707.82
$797.00
$1,113.82
$1,692.54 		$862.20
$946.36
$1,035.54
$1,352.36 		$1,100.74
$1,184.90
$1,274.08
$1,590.90 		$1,339.28
$1,423.44
$1,512.62
$1,829.44 		$238.54
Toc - Plan #106 Ambetter from Home State Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$321.58
$364.98
$410.96
$574.32
$872.74 		$567.58
$610.98
$656.96
$820.32 		$813.58
$856.98
$902.96
$1,066.32 		$1,059.58
$1,102.98
$1,148.96
$1,312.32 		$246.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.16
$729.96
$821.92
$1,148.64
$1,745.48 		$889.16
$975.96
$1,067.92
$1,394.64 		$1,135.16
$1,221.96
$1,313.92
$1,640.64 		$1,381.16
$1,467.96
$1,559.92
$1,886.64 		$246.00
Toc - Plan #107 Ambetter from Home State Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$403.08
$457.48
$515.12
$719.88
$1,093.92 		$711.43
$765.83
$823.47
$1,028.23 		$1,019.78
$1,074.18
$1,131.82
$1,336.58 		$1,328.13
$1,382.53
$1,440.17
$1,644.93 		$308.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.16
$914.96
$1,030.24
$1,439.76
$2,187.84 		$1,114.51
$1,223.31
$1,338.59
$1,748.11 		$1,422.86
$1,531.66
$1,646.94
$2,056.46 		$1,731.21
$1,840.01
$1,955.29
$2,364.81 		$308.35
Toc - Plan #108 Ambetter from Home State Health
Silver

(EPO) Ambetter Balanced Care 129 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$327.39
$371.57
$418.39
$584.70
$888.50 		$577.83
$622.01
$668.83
$835.14 		$828.27
$872.45
$919.27
$1,085.58 		$1,078.71
$1,122.89
$1,169.71
$1,336.02 		$250.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.78
$743.14
$836.78
$1,169.40
$1,777.00 		$905.22
$993.58
$1,087.22
$1,419.84 		$1,155.66
$1,244.02
$1,337.66
$1,670.28 		$1,406.10
$1,494.46
$1,588.10
$1,920.72 		$250.44

‡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 Saint Louis County here.

Saint Louis County is in “Rating Area 6” of Missouri.

Currently, there are 108 plans offered in Rating Area 6.

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2022 Obamacare Plans for Saint Louis County, MO

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