Obamacare 2022 Rates for Buncombe County

Obamacare > Rates > North Carolina > Buncombe 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 Buncombe County, NC.

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, 128 Plans and 2022 Rates for Buncombe County, North Carolina

Below, you’ll find a summary of the 128 plans for Buncombe County, North Carolina 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

ADVERTISEMENT

ADVERTISEMENT

Blue Cross and Blue Shield of NC

Local: 1-800-324-4973 | Toll Free: 1-800-324-4973

Toc - Plan #1 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver $0 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$491.78
$558.17
$628.49
$878.32
$1,334.69 		$867.99
$934.38
$1,004.70
$1,254.53 		$1,244.20
$1,310.59
$1,380.91
$1,630.74 		$1,620.41
$1,686.80
$1,757.12
$2,006.95 		$376.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.56
$1,116.34
$1,256.98
$1,756.64
$2,669.38 		$1,359.77
$1,492.55
$1,633.19
$2,132.85 		$1,735.98
$1,868.76
$2,009.40
$2,509.06 		$2,112.19
$2,244.97
$2,385.61
$2,885.27 		$376.21
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver 5300 + 3 Free PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 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 		$455.42
$516.90
$582.03
$813.38
$1,236.01 		$803.82
$865.30
$930.43
$1,161.78 		$1,152.22
$1,213.70
$1,278.83
$1,510.18 		$1,500.62
$1,562.10
$1,627.23
$1,858.58 		$348.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.84
$1,033.80
$1,164.06
$1,626.76
$2,472.02 		$1,259.24
$1,382.20
$1,512.46
$1,975.16 		$1,607.64
$1,730.60
$1,860.86
$2,323.56 		$1,956.04
$2,079.00
$2,209.26
$2,671.96 		$348.40
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver 2800 + $15 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$475.41
$539.59
$607.57
$849.08
$1,290.26 		$839.10
$903.28
$971.26
$1,212.77 		$1,202.79
$1,266.97
$1,334.95
$1,576.46 		$1,566.48
$1,630.66
$1,698.64
$1,940.15 		$363.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$950.82
$1,079.18
$1,215.14
$1,698.16
$2,580.52 		$1,314.51
$1,442.87
$1,578.83
$2,061.85 		$1,678.20
$1,806.56
$1,942.52
$2,425.54 		$2,041.89
$2,170.25
$2,306.21
$2,789.23 		$363.69
Toc - Plan #4 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7000 + 3 Free PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$333.19
$378.17
$425.82
$595.08
$904.28 		$588.08
$633.06
$680.71
$849.97 		$842.97
$887.95
$935.60
$1,104.86 		$1,097.86
$1,142.84
$1,190.49
$1,359.75 		$254.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.38
$756.34
$851.64
$1,190.16
$1,808.56 		$921.27
$1,011.23
$1,106.53
$1,445.05 		$1,176.16
$1,266.12
$1,361.42
$1,699.94 		$1,431.05
$1,521.01
$1,616.31
$1,954.83 		$254.89
Toc - Plan #5 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold 2500 + 3 Free PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$477.03
$541.43
$609.64
$851.98
$1,294.66 		$841.96
$906.36
$974.57
$1,216.91 		$1,206.89
$1,271.29
$1,339.50
$1,581.84 		$1,571.82
$1,636.22
$1,704.43
$1,946.77 		$364.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.06
$1,082.86
$1,219.28
$1,703.96
$2,589.32 		$1,318.99
$1,447.79
$1,584.21
$2,068.89 		$1,683.92
$1,812.72
$1,949.14
$2,433.82 		$2,048.85
$2,177.65
$2,314.07
$2,798.75 		$364.93
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver 3800 + 3 Free PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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 		$492.90
$559.44
$629.93
$880.32
$1,337.73 		$869.97
$936.51
$1,007.00
$1,257.39 		$1,247.04
$1,313.58
$1,384.07
$1,634.46 		$1,624.11
$1,690.65
$1,761.14
$2,011.53 		$377.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.80
$1,118.88
$1,259.86
$1,760.64
$2,675.46 		$1,362.87
$1,495.95
$1,636.93
$2,137.71 		$1,739.94
$1,873.02
$2,014.00
$2,514.78 		$2,117.01
$2,250.09
$2,391.07
$2,891.85 		$377.07
Toc - Plan #7 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7000 HSA Eligible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.24
$391.85
$441.22
$616.60
$936.98 		$609.35
$655.96
$705.33
$880.71 		$873.46
$920.07
$969.44
$1,144.82 		$1,137.57
$1,184.18
$1,233.55
$1,408.93 		$264.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.48
$783.70
$882.44
$1,233.20
$1,873.96 		$954.59
$1,047.81
$1,146.55
$1,497.31 		$1,218.70
$1,311.92
$1,410.66
$1,761.42 		$1,482.81
$1,576.03
$1,674.77
$2,025.53 		$264.11
Toc - Plan #8 Blue Cross and Blue Shield of NC
Catastrophic

(PPO) Blue Advantage Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$234.90
$266.61
$300.20
$419.53
$637.52 		$414.60
$446.31
$479.90
$599.23 		$594.30
$626.01
$659.60
$778.93 		$774.00
$805.71
$839.30
$958.63 		$179.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$469.80
$533.22
$600.40
$839.06
$1,275.04 		$649.50
$712.92
$780.10
$1,018.76 		$829.20
$892.62
$959.80
$1,198.46 		$1,008.90
$1,072.32
$1,139.50
$1,378.16 		$179.70
Toc - Plan #9 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver 6000 + 3 Free PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$472.61
$536.41
$604.00
$844.08
$1,282.66 		$834.16
$897.96
$965.55
$1,205.63 		$1,195.71
$1,259.51
$1,327.10
$1,567.18 		$1,557.26
$1,621.06
$1,688.65
$1,928.73 		$361.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.22
$1,072.82
$1,208.00
$1,688.16
$2,565.32 		$1,306.77
$1,434.37
$1,569.55
$2,049.71 		$1,668.32
$1,795.92
$1,931.10
$2,411.26 		$2,029.87
$2,157.47
$2,292.65
$2,772.81 		$361.55
Toc - Plan #10 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7000 Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$355.05
$402.98
$453.75
$634.12
$963.61 		$626.66
$674.59
$725.36
$905.73 		$898.27
$946.20
$996.97
$1,177.34 		$1,169.88
$1,217.81
$1,268.58
$1,448.95 		$271.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.10
$805.96
$907.50
$1,268.24
$1,927.22 		$981.71
$1,077.57
$1,179.11
$1,539.85 		$1,253.32
$1,349.18
$1,450.72
$1,811.46 		$1,524.93
$1,620.79
$1,722.33
$2,083.07 		$271.61
Toc - Plan #11 Blue Cross and Blue Shield of NC
Bronze

(PPO) Blue Advantage Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$329.64
$374.14
$421.28
$588.74
$894.64 		$581.81
$626.31
$673.45
$840.91 		$833.98
$878.48
$925.62
$1,093.08 		$1,086.15
$1,130.65
$1,177.79
$1,345.25 		$252.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.28
$748.28
$842.56
$1,177.48
$1,789.28 		$911.45
$1,000.45
$1,094.73
$1,429.65 		$1,163.62
$1,252.62
$1,346.90
$1,681.82 		$1,415.79
$1,504.79
$1,599.07
$1,933.99 		$252.17

ADVERTISEMENT

AmeriHealth Caritas Next

Local: 1-984-245-3613 | Toll Free: 1-833-613-2262 | TTY: 1-844-214-2471
Toc - Plan #12 AmeriHealth Caritas Next
Silver

(HMO) AHC Silver 15

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$526.05
$597.07
$672.29
$939.53
$1,427.70 		$928.48
$999.50
$1,074.72
$1,341.96 		$1,330.91
$1,401.93
$1,477.15
$1,744.39 		$1,733.34
$1,804.36
$1,879.58
$2,146.82 		$402.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,052.10
$1,194.14
$1,344.58
$1,879.06
$2,855.40 		$1,454.53
$1,596.57
$1,747.01
$2,281.49 		$1,856.96
$1,999.00
$2,149.44
$2,683.92 		$2,259.39
$2,401.43
$2,551.87
$3,086.35 		$402.43
Toc - Plan #13 AmeriHealth Caritas Next
Silver

(HMO) AHC Silver 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$517.62
$587.50
$661.52
$924.47
$1,404.82 		$913.60
$983.48
$1,057.50
$1,320.45 		$1,309.58
$1,379.46
$1,453.48
$1,716.43 		$1,705.56
$1,775.44
$1,849.46
$2,112.41 		$395.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,035.24
$1,175.00
$1,323.04
$1,848.94
$2,809.64 		$1,431.22
$1,570.98
$1,719.02
$2,244.92 		$1,827.20
$1,966.96
$2,115.00
$2,640.90 		$2,223.18
$2,362.94
$2,510.98
$3,036.88 		$395.98
Toc - Plan #14 AmeriHealth Caritas Next
Silver

(HMO) AHC Silver 50

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$511.63
$580.70
$653.86
$913.77
$1,388.56 		$903.03
$972.10
$1,045.26
$1,305.17 		$1,294.43
$1,363.50
$1,436.66
$1,696.57 		$1,685.83
$1,754.90
$1,828.06
$2,087.97 		$391.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,023.26
$1,161.40
$1,307.72
$1,827.54
$2,777.12 		$1,414.66
$1,552.80
$1,699.12
$2,218.94 		$1,806.06
$1,944.20
$2,090.52
$2,610.34 		$2,197.46
$2,335.60
$2,481.92
$3,001.74 		$391.40
Toc - Plan #15 AmeriHealth Caritas Next
Bronze

(HMO) AHC Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$348.14
$395.14
$444.92
$621.78
$944.85 		$614.47
$661.47
$711.25
$888.11 		$880.80
$927.80
$977.58
$1,154.44 		$1,147.13
$1,194.13
$1,243.91
$1,420.77 		$266.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.28
$790.28
$889.84
$1,243.56
$1,889.70 		$962.61
$1,056.61
$1,156.17
$1,509.89 		$1,228.94
$1,322.94
$1,422.50
$1,776.22 		$1,495.27
$1,589.27
$1,688.83
$2,042.55 		$266.33
Toc - Plan #16 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AHC Bronze 8000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$376.15
$426.93
$480.72
$671.80
$1,020.86 		$663.90
$714.68
$768.47
$959.55 		$951.65
$1,002.43
$1,056.22
$1,247.30 		$1,239.40
$1,290.18
$1,343.97
$1,535.05 		$287.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.30
$853.86
$961.44
$1,343.60
$2,041.72 		$1,040.05
$1,141.61
$1,249.19
$1,631.35 		$1,327.80
$1,429.36
$1,536.94
$1,919.10 		$1,615.55
$1,717.11
$1,824.69
$2,206.85 		$287.75
Toc - Plan #17 AmeriHealth Caritas Next
Gold

(HMO) AHC Gold 10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$681.76
$773.80
$871.29
$1,217.62
$1,850.29 		$1,203.31
$1,295.35
$1,392.84
$1,739.17 		$1,724.86
$1,816.90
$1,914.39
$2,260.72 		$2,246.41
$2,338.45
$2,435.94
$2,782.27 		$521.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,363.52
$1,547.60
$1,742.58
$2,435.24
$3,700.58 		$1,885.07
$2,069.15
$2,264.13
$2,956.79 		$2,406.62
$2,590.70
$2,785.68
$3,478.34 		$2,928.17
$3,112.25
$3,307.23
$3,999.89 		$521.55

ADVERTISEMENT

Bright HealthCare

Local: 1-855-521-9349 | Toll Free: 1-855-521-9349

Toc - Plan #18 Bright HealthCare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$648.67
$736.24
$829.00
$1,158.52
$1,760.49 		$1,144.90
$1,232.47
$1,325.23
$1,654.75 		$1,641.13
$1,728.70
$1,821.46
$2,150.98 		$2,137.36
$2,224.93
$2,317.69
$2,647.21 		$496.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,297.34
$1,472.48
$1,658.00
$2,317.04
$3,520.98 		$1,793.57
$1,968.71
$2,154.23
$2,813.27 		$2,289.80
$2,464.94
$2,650.46
$3,309.50 		$2,786.03
$2,961.17
$3,146.69
$3,805.73 		$496.23
Toc - Plan #19 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$481.62
$546.64
$615.51
$860.18
$1,307.12 		$850.06
$915.08
$983.95
$1,228.62 		$1,218.50
$1,283.52
$1,352.39
$1,597.06 		$1,586.94
$1,651.96
$1,720.83
$1,965.50 		$368.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$963.24
$1,093.28
$1,231.02
$1,720.36
$2,614.24 		$1,331.68
$1,461.72
$1,599.46
$2,088.80 		$1,700.12
$1,830.16
$1,967.90
$2,457.24 		$2,068.56
$2,198.60
$2,336.34
$2,825.68 		$368.44
Toc - Plan #20 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$486.62
$552.31
$621.90
$869.10
$1,320.69 		$858.88
$924.57
$994.16
$1,241.36 		$1,231.14
$1,296.83
$1,366.42
$1,613.62 		$1,603.40
$1,669.09
$1,738.68
$1,985.88 		$372.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.24
$1,104.62
$1,243.80
$1,738.20
$2,641.38 		$1,345.50
$1,476.88
$1,616.06
$2,110.46 		$1,717.76
$1,849.14
$1,988.32
$2,482.72 		$2,090.02
$2,221.40
$2,360.58
$2,854.98 		$372.26
Toc - Plan #21 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$510.79
$579.75
$652.79
$912.27
$1,386.28 		$901.54
$970.50
$1,043.54
$1,303.02 		$1,292.29
$1,361.25
$1,434.29
$1,693.77 		$1,683.04
$1,752.00
$1,825.04
$2,084.52 		$390.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.58
$1,159.50
$1,305.58
$1,824.54
$2,772.56 		$1,412.33
$1,550.25
$1,696.33
$2,215.29 		$1,803.08
$1,941.00
$2,087.08
$2,606.04 		$2,193.83
$2,331.75
$2,477.83
$2,996.79 		$390.75
Toc - Plan #22 Bright HealthCare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$347.03
$393.88
$443.50
$619.80
$941.84 		$612.51
$659.36
$708.98
$885.28 		$877.99
$924.84
$974.46
$1,150.76 		$1,143.47
$1,190.32
$1,239.94
$1,416.24 		$265.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.06
$787.76
$887.00
$1,239.60
$1,883.68 		$959.54
$1,053.24
$1,152.48
$1,505.08 		$1,225.02
$1,318.72
$1,417.96
$1,770.56 		$1,490.50
$1,584.20
$1,683.44
$2,036.04 		$265.48
Toc - Plan #23 Bright HealthCare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.97
$407.43
$458.77
$641.13
$974.25 		$633.58
$682.04
$733.38
$915.74 		$908.19
$956.65
$1,007.99
$1,190.35 		$1,182.80
$1,231.26
$1,282.60
$1,464.96 		$274.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.94
$814.86
$917.54
$1,282.26
$1,948.50 		$992.55
$1,089.47
$1,192.15
$1,556.87 		$1,267.16
$1,364.08
$1,466.76
$1,831.48 		$1,541.77
$1,638.69
$1,741.37
$2,106.09 		$274.61
Toc - Plan #24 Bright HealthCare
Expanded Bronze

(HMO) Bronze 5300 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.77
$427.63
$481.51
$672.90
$1,022.54 		$665.00
$715.86
$769.74
$961.13 		$953.23
$1,004.09
$1,057.97
$1,249.36 		$1,241.46
$1,292.32
$1,346.20
$1,537.59 		$288.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.54
$855.26
$963.02
$1,345.80
$2,045.08 		$1,041.77
$1,143.49
$1,251.25
$1,634.03 		$1,330.00
$1,431.72
$1,539.48
$1,922.26 		$1,618.23
$1,719.95
$1,827.71
$2,210.49 		$288.23
Toc - Plan #25 Bright HealthCare
Catastrophic

(HMO) Catastrophic 8700 ($0 Primary Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$249.86
$283.59
$319.32
$446.25
$678.12 		$441.00
$474.73
$510.46
$637.39 		$632.14
$665.87
$701.60
$828.53 		$823.28
$857.01
$892.74
$1,019.67 		$191.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.72
$567.18
$638.64
$892.50
$1,356.24 		$690.86
$758.32
$829.78
$1,083.64 		$882.00
$949.46
$1,020.92
$1,274.78 		$1,073.14
$1,140.60
$1,212.06
$1,465.92 		$191.14
Toc - Plan #26 Bright HealthCare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$400.53
$454.60
$511.88
$715.35
$1,087.04 		$706.94
$761.01
$818.29
$1,021.76 		$1,013.35
$1,067.42
$1,124.70
$1,328.17 		$1,319.76
$1,373.83
$1,431.11
$1,634.58 		$306.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.06
$909.20
$1,023.76
$1,430.70
$2,174.08 		$1,107.47
$1,215.61
$1,330.17
$1,737.11 		$1,413.88
$1,522.02
$1,636.58
$2,043.52 		$1,720.29
$1,828.43
$1,942.99
$2,349.93 		$306.41
Toc - Plan #27 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$488.35
$554.28
$624.12
$872.20
$1,325.39 		$861.94
$927.87
$997.71
$1,245.79 		$1,235.53
$1,301.46
$1,371.30
$1,619.38 		$1,609.12
$1,675.05
$1,744.89
$1,992.97 		$373.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976.70
$1,108.56
$1,248.24
$1,744.40
$2,650.78 		$1,350.29
$1,482.15
$1,621.83
$2,117.99 		$1,723.88
$1,855.74
$1,995.42
$2,491.58 		$2,097.47
$2,229.33
$2,369.01
$2,865.17 		$373.59
Toc - Plan #28 Bright HealthCare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.87
$425.48
$479.08
$669.52
$1,017.40 		$661.65
$712.26
$765.86
$956.30 		$948.43
$999.04
$1,052.64
$1,243.08 		$1,235.21
$1,285.82
$1,339.42
$1,529.86 		$286.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.74
$850.96
$958.16
$1,339.04
$2,034.80 		$1,036.52
$1,137.74
$1,244.94
$1,625.82 		$1,323.30
$1,424.52
$1,531.72
$1,912.60 		$1,610.08
$1,711.30
$1,818.50
$2,199.38 		$286.78
Toc - Plan #29 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$504.03
$572.07
$644.15
$900.20
$1,367.94 		$889.61
$957.65
$1,029.73
$1,285.78 		$1,275.19
$1,343.23
$1,415.31
$1,671.36 		$1,660.77
$1,728.81
$1,800.89
$2,056.94 		$385.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,008.06
$1,144.14
$1,288.30
$1,800.40
$2,735.88 		$1,393.64
$1,529.72
$1,673.88
$2,185.98 		$1,779.22
$1,915.30
$2,059.46
$2,571.56 		$2,164.80
$2,300.88
$2,445.04
$2,957.14 		$385.58
Toc - Plan #30 Bright HealthCare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$717.33
$814.17
$916.75
$1,281.16
$1,946.85 		$1,266.09
$1,362.93
$1,465.51
$1,829.92 		$1,814.85
$1,911.69
$2,014.27
$2,378.68 		$2,363.61
$2,460.45
$2,563.03
$2,927.44 		$548.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,434.66
$1,628.34
$1,833.50
$2,562.32
$3,893.70 		$1,983.42
$2,177.10
$2,382.26
$3,111.08 		$2,532.18
$2,725.86
$2,931.02
$3,659.84 		$3,080.94
$3,274.62
$3,479.78
$4,208.60 		$548.76
Toc - Plan #31 Bright HealthCare
Expanded Bronze

(HMO) Bronze 8700 ($25 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$335.81
$381.14
$429.16
$599.75
$911.38 		$592.70
$638.03
$686.05
$856.64 		$849.59
$894.92
$942.94
$1,113.53 		$1,106.48
$1,151.81
$1,199.83
$1,370.42 		$256.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.62
$762.28
$858.32
$1,199.50
$1,822.76 		$928.51
$1,019.17
$1,115.21
$1,456.39 		$1,185.40
$1,276.06
$1,372.10
$1,713.28 		$1,442.29
$1,532.95
$1,628.99
$1,970.17 		$256.89
Toc - Plan #32 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9349

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 		$472.91
$536.76
$604.38
$844.62
$1,283.49 		$834.69
$898.54
$966.16
$1,206.40 		$1,196.47
$1,260.32
$1,327.94
$1,568.18 		$1,558.25
$1,622.10
$1,689.72
$1,929.96 		$361.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.82
$1,073.52
$1,208.76
$1,689.24
$2,566.98 		$1,307.60
$1,435.30
$1,570.54
$2,051.02 		$1,669.38
$1,797.08
$1,932.32
$2,412.80 		$2,031.16
$2,158.86
$2,294.10
$2,774.58 		$361.78

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #33 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$533.54
$605.56
$681.85
$952.88
$1,448.00 		$941.69
$1,013.71
$1,090.00
$1,361.03 		$1,349.84
$1,421.86
$1,498.15
$1,769.18 		$1,757.99
$1,830.01
$1,906.30
$2,177.33 		$408.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,067.08
$1,211.12
$1,363.70
$1,905.76
$2,896.00 		$1,475.23
$1,619.27
$1,771.85
$2,313.91 		$1,883.38
$2,027.42
$2,180.00
$2,722.06 		$2,291.53
$2,435.57
$2,588.15
$3,130.21 		$408.15
Toc - Plan #34 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

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

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 		$761.95
$864.80
$973.75
$1,360.82
$2,067.89 		$1,344.83
$1,447.68
$1,556.63
$1,943.70 		$1,927.71
$2,030.56
$2,139.51
$2,526.58 		$2,510.59
$2,613.44
$2,722.39
$3,109.46 		$582.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,523.90
$1,729.60
$1,947.50
$2,721.64
$4,135.78 		$2,106.78
$2,312.48
$2,530.38
$3,304.52 		$2,689.66
$2,895.36
$3,113.26
$3,887.40 		$3,272.54
$3,478.24
$3,696.14
$4,470.28 		$582.88
Toc - Plan #35 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,350 $2,700 Annual Deductible
$5,850 $11,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$755.43
$857.40
$965.42
$1,349.17
$2,050.20 		$1,333.32
$1,435.29
$1,543.31
$1,927.06 		$1,911.21
$2,013.18
$2,121.20
$2,504.95 		$2,489.10
$2,591.07
$2,699.09
$3,082.84 		$577.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,510.86
$1,714.80
$1,930.84
$2,698.34
$4,100.40 		$2,088.75
$2,292.69
$2,508.73
$3,276.23 		$2,666.64
$2,870.58
$3,086.62
$3,854.12 		$3,244.53
$3,448.47
$3,664.51
$4,432.01 		$577.89

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5357 | Toll Free: 1-800-980-5357 | TTY: 1-800-980-5357
Toc - Plan #36 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$500.31
$567.85
$639.40
$893.55
$1,357.84 		$883.05
$950.59
$1,022.14
$1,276.29 		$1,265.79
$1,333.33
$1,404.88
$1,659.03 		$1,648.53
$1,716.07
$1,787.62
$2,041.77 		$382.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,000.62
$1,135.70
$1,278.80
$1,787.10
$2,715.68 		$1,383.36
$1,518.44
$1,661.54
$2,169.84 		$1,766.10
$1,901.18
$2,044.28
$2,552.58 		$2,148.84
$2,283.92
$2,427.02
$2,935.32 		$382.74
Toc - Plan #37 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$524.31
$595.09
$670.06
$936.41
$1,422.96 		$925.40
$996.18
$1,071.15
$1,337.50 		$1,326.49
$1,397.27
$1,472.24
$1,738.59 		$1,727.58
$1,798.36
$1,873.33
$2,139.68 		$401.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,048.62
$1,190.18
$1,340.12
$1,872.82
$2,845.92 		$1,449.71
$1,591.27
$1,741.21
$2,273.91 		$1,850.80
$1,992.36
$2,142.30
$2,675.00 		$2,251.89
$2,393.45
$2,543.39
$3,076.09 		$401.09
Toc - Plan #38 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$7,950 $15,900 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 		$525.74
$596.71
$671.89
$938.97
$1,426.85 		$927.93
$998.90
$1,074.08
$1,341.16 		$1,330.12
$1,401.09
$1,476.27
$1,743.35 		$1,732.31
$1,803.28
$1,878.46
$2,145.54 		$402.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.48
$1,193.42
$1,343.78
$1,877.94
$2,853.70 		$1,453.67
$1,595.61
$1,745.97
$2,280.13 		$1,855.86
$1,997.80
$2,148.16
$2,682.32 		$2,258.05
$2,399.99
$2,550.35
$3,084.51 		$402.19
Toc - Plan #39 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ ($3 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 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 		$372.10
$422.33
$475.54
$664.57
$1,009.88 		$656.76
$706.99
$760.20
$949.23 		$941.42
$991.65
$1,044.86
$1,233.89 		$1,226.08
$1,276.31
$1,329.52
$1,518.55 		$284.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.20
$844.66
$951.08
$1,329.14
$2,019.76 		$1,028.86
$1,129.32
$1,235.74
$1,613.80 		$1,313.52
$1,413.98
$1,520.40
$1,898.46 		$1,598.18
$1,698.64
$1,805.06
$2,183.12 		$284.66
Toc - Plan #40 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$499.24
$566.63
$638.02
$891.64
$1,354.93 		$881.16
$948.55
$1,019.94
$1,273.56 		$1,263.08
$1,330.47
$1,401.86
$1,655.48 		$1,645.00
$1,712.39
$1,783.78
$2,037.40 		$381.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.48
$1,133.26
$1,276.04
$1,783.28
$2,709.86 		$1,380.40
$1,515.18
$1,657.96
$2,165.20 		$1,762.32
$1,897.10
$2,039.88
$2,547.12 		$2,144.24
$2,279.02
$2,421.80
$2,929.04 		$381.92
Toc - Plan #41 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 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 		$507.12
$575.58
$648.09
$905.71
$1,376.31 		$895.06
$963.52
$1,036.03
$1,293.65 		$1,283.00
$1,351.46
$1,423.97
$1,681.59 		$1,670.94
$1,739.40
$1,811.91
$2,069.53 		$387.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,014.24
$1,151.16
$1,296.18
$1,811.42
$2,752.62 		$1,402.18
$1,539.10
$1,684.12
$2,199.36 		$1,790.12
$1,927.04
$2,072.06
$2,587.30 		$2,178.06
$2,314.98
$2,460.00
$2,975.24 		$387.94
Toc - Plan #42 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$522.16
$592.65
$667.32
$932.57
$1,417.13 		$921.61
$992.10
$1,066.77
$1,332.02 		$1,321.06
$1,391.55
$1,466.22
$1,731.47 		$1,720.51
$1,791.00
$1,865.67
$2,130.92 		$399.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.32
$1,185.30
$1,334.64
$1,865.14
$2,834.26 		$1,443.77
$1,584.75
$1,734.09
$2,264.59 		$1,843.22
$1,984.20
$2,133.54
$2,664.04 		$2,242.67
$2,383.65
$2,532.99
$3,063.49 		$399.45
Toc - Plan #43 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value+ (HSA)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$377.83
$428.84
$482.87
$674.80
$1,025.43 		$666.87
$717.88
$771.91
$963.84 		$955.91
$1,006.92
$1,060.95
$1,252.88 		$1,244.95
$1,295.96
$1,349.99
$1,541.92 		$289.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.66
$857.68
$965.74
$1,349.60
$2,050.86 		$1,044.70
$1,146.72
$1,254.78
$1,638.64 		$1,333.74
$1,435.76
$1,543.82
$1,927.68 		$1,622.78
$1,724.80
$1,832.86
$2,216.72 		$289.04
Toc - Plan #44 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$358.13
$406.48
$457.69
$639.62
$971.97 		$632.10
$680.45
$731.66
$913.59 		$906.07
$954.42
$1,005.63
$1,187.56 		$1,180.04
$1,228.39
$1,279.60
$1,461.53 		$273.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.26
$812.96
$915.38
$1,279.24
$1,943.94 		$990.23
$1,086.93
$1,189.35
$1,553.21 		$1,264.20
$1,360.90
$1,463.32
$1,827.18 		$1,538.17
$1,634.87
$1,737.29
$2,101.15 		$273.97
Toc - Plan #45 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$520.72
$591.02
$665.49
$930.01
$1,413.25 		$919.07
$989.37
$1,063.84
$1,328.36 		$1,317.42
$1,387.72
$1,462.19
$1,726.71 		$1,715.77
$1,786.07
$1,860.54
$2,125.06 		$398.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,041.44
$1,182.04
$1,330.98
$1,860.02
$2,826.50 		$1,439.79
$1,580.39
$1,729.33
$2,258.37 		$1,838.14
$1,978.74
$2,127.68
$2,656.72 		$2,236.49
$2,377.09
$2,526.03
$3,055.07 		$398.35
Toc - Plan #46 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 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 		$372.82
$423.15
$476.46
$665.85
$1,011.82 		$658.02
$708.35
$761.66
$951.05 		$943.22
$993.55
$1,046.86
$1,236.25 		$1,228.42
$1,278.75
$1,332.06
$1,521.45 		$285.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.64
$846.30
$952.92
$1,331.70
$2,023.64 		$1,030.84
$1,131.50
$1,238.12
$1,616.90 		$1,316.04
$1,416.70
$1,523.32
$1,902.10 		$1,601.24
$1,701.90
$1,808.52
$2,187.30 		$285.20

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #47 Aetna CVS Health
Expanded Bronze

(HMO) Aetna CVS Bronze: Low-Cost MinuteClinic Visits, Telehealth, Store Discounts

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 		$368.33
$418.05
$470.72
$657.83
$999.64 		$650.10
$699.82
$752.49
$939.60 		$931.87
$981.59
$1,034.26
$1,221.37 		$1,213.64
$1,263.36
$1,316.03
$1,503.14 		$281.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.66
$836.10
$941.44
$1,315.66
$1,999.28 		$1,018.43
$1,117.87
$1,223.21
$1,597.43 		$1,300.20
$1,399.64
$1,504.98
$1,879.20 		$1,581.97
$1,681.41
$1,786.75
$2,160.97 		$281.77
Toc - Plan #48 Aetna CVS Health
Bronze

(HMO) Aetna CVS Bronze: $0 MinuteClinic Visits, Telehealth, Store Discounts

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 		$318.98
$362.05
$407.66
$569.70
$865.72 		$563.00
$606.07
$651.68
$813.72 		$807.02
$850.09
$895.70
$1,057.74 		$1,051.04
$1,094.11
$1,139.72
$1,301.76 		$244.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.96
$724.10
$815.32
$1,139.40
$1,731.44 		$881.98
$968.12
$1,059.34
$1,383.42 		$1,126.00
$1,212.14
$1,303.36
$1,627.44 		$1,370.02
$1,456.16
$1,547.38
$1,871.46 		$244.02
Toc - Plan #49 Aetna CVS Health
Gold

(HMO) Aetna CVS Gold: $0 MinuteClinic Visits, Telehealth, Store Discounts

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 		$532.05
$603.88
$679.96
$950.24
$1,443.99 		$939.07
$1,010.90
$1,086.98
$1,357.26 		$1,346.09
$1,417.92
$1,494.00
$1,764.28 		$1,753.11
$1,824.94
$1,901.02
$2,171.30 		$407.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,064.10
$1,207.76
$1,359.92
$1,900.48
$2,887.98 		$1,471.12
$1,614.78
$1,766.94
$2,307.50 		$1,878.14
$2,021.80
$2,173.96
$2,714.52 		$2,285.16
$2,428.82
$2,580.98
$3,121.54 		$407.02
Toc - Plan #50 Aetna CVS Health
Silver

(HMO) Aetna CVS Silver 1: $0 MinuteClinic Visits, Telehealth, Store Discounts

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 		$509.49
$578.27
$651.12
$909.94
$1,382.74 		$899.25
$968.03
$1,040.88
$1,299.70 		$1,289.01
$1,357.79
$1,430.64
$1,689.46 		$1,678.77
$1,747.55
$1,820.40
$2,079.22 		$389.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,018.98
$1,156.54
$1,302.24
$1,819.88
$2,765.48 		$1,408.74
$1,546.30
$1,692.00
$2,209.64 		$1,798.50
$1,936.06
$2,081.76
$2,599.40 		$2,188.26
$2,325.82
$2,471.52
$2,989.16 		$389.76
Toc - Plan #51 Aetna CVS Health
Silver

(HMO) Aetna CVS Silver 2: $0 MinuteClinic Visits, Telehealth, Store Discounts

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 		$443.61
$503.49
$566.93
$792.28
$1,203.95 		$782.97
$842.85
$906.29
$1,131.64 		$1,122.33
$1,182.21
$1,245.65
$1,471.00 		$1,461.69
$1,521.57
$1,585.01
$1,810.36 		$339.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.22
$1,006.98
$1,133.86
$1,584.56
$2,407.90 		$1,226.58
$1,346.34
$1,473.22
$1,923.92 		$1,565.94
$1,685.70
$1,812.58
$2,263.28 		$1,905.30
$2,025.06
$2,151.94
$2,602.64 		$339.36

ADVERTISEMENT

Oscar Health Plan of North Carolina, Inc

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755 | TTY: 1-855-672-2755
Toc - Plan #52 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze 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 		$367.92
$417.58
$470.19
$657.08
$998.50 		$649.37
$699.03
$751.64
$938.53 		$930.82
$980.48
$1,033.09
$1,219.98 		$1,212.27
$1,261.93
$1,314.54
$1,501.43 		$281.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.84
$835.16
$940.38
$1,314.16
$1,997.00 		$1,017.29
$1,116.61
$1,221.83
$1,595.61 		$1,298.74
$1,398.06
$1,503.28
$1,877.06 		$1,580.19
$1,679.51
$1,784.73
$2,158.51 		$281.45
Toc - Plan #53 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$376.23
$427.01
$480.81
$671.92
$1,021.06 		$664.04
$714.82
$768.62
$959.73 		$951.85
$1,002.63
$1,056.43
$1,247.54 		$1,239.66
$1,290.44
$1,344.24
$1,535.35 		$287.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.46
$854.02
$961.62
$1,343.84
$2,042.12 		$1,040.27
$1,141.83
$1,249.43
$1,631.65 		$1,328.08
$1,429.64
$1,537.24
$1,919.46 		$1,615.89
$1,717.45
$1,825.05
$2,207.27 		$287.81
Toc - Plan #54 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$368.96
$418.76
$471.52
$658.95
$1,001.33 		$651.21
$701.01
$753.77
$941.20 		$933.46
$983.26
$1,036.02
$1,223.45 		$1,215.71
$1,265.51
$1,318.27
$1,505.70 		$282.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.92
$837.52
$943.04
$1,317.90
$2,002.66 		$1,020.17
$1,119.77
$1,225.29
$1,600.15 		$1,302.42
$1,402.02
$1,507.54
$1,882.40 		$1,584.67
$1,684.27
$1,789.79
$2,164.65 		$282.25
Toc - Plan #55 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$438.57
$497.76
$560.48
$783.26
$1,190.24 		$774.07
$833.26
$895.98
$1,118.76 		$1,109.57
$1,168.76
$1,231.48
$1,454.26 		$1,445.07
$1,504.26
$1,566.98
$1,789.76 		$335.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.14
$995.52
$1,120.96
$1,566.52
$2,380.48 		$1,212.64
$1,331.02
$1,456.46
$1,902.02 		$1,548.14
$1,666.52
$1,791.96
$2,237.52 		$1,883.64
$2,002.02
$2,127.46
$2,573.02 		$335.50
Toc - Plan #56 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$492.00
$558.40
$628.76
$878.69
$1,335.25 		$868.37
$934.77
$1,005.13
$1,255.06 		$1,244.74
$1,311.14
$1,381.50
$1,631.43 		$1,621.11
$1,687.51
$1,757.87
$2,007.80 		$376.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$984.00
$1,116.80
$1,257.52
$1,757.38
$2,670.50 		$1,360.37
$1,493.17
$1,633.89
$2,133.75 		$1,736.74
$1,869.54
$2,010.26
$2,510.12 		$2,113.11
$2,245.91
$2,386.63
$2,886.49 		$376.37
Toc - Plan #57 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$481.05
$545.98
$614.76
$859.13
$1,305.53 		$849.04
$913.97
$982.75
$1,227.12 		$1,217.03
$1,281.96
$1,350.74
$1,595.11 		$1,585.02
$1,649.95
$1,718.73
$1,963.10 		$367.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$962.10
$1,091.96
$1,229.52
$1,718.26
$2,611.06 		$1,330.09
$1,459.95
$1,597.51
$2,086.25 		$1,698.08
$1,827.94
$1,965.50
$2,454.24 		$2,066.07
$2,195.93
$2,333.49
$2,822.23 		$367.99
Toc - Plan #58 Oscar Health Plan of North Carolina, Inc
Catastrophic

(HMO) 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 		$317.25
$360.06
$405.43
$566.58
$860.98 		$559.94
$602.75
$648.12
$809.27 		$802.63
$845.44
$890.81
$1,051.96 		$1,045.32
$1,088.13
$1,133.50
$1,294.65 		$242.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.50
$720.12
$810.86
$1,133.16
$1,721.96 		$877.19
$962.81
$1,053.55
$1,375.85 		$1,119.88
$1,205.50
$1,296.24
$1,618.54 		$1,362.57
$1,448.19
$1,538.93
$1,861.23 		$242.69
Toc - Plan #59 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$438.42
$497.60
$560.29
$783.00
$1,189.85 		$773.80
$832.98
$895.67
$1,118.38 		$1,109.18
$1,168.36
$1,231.05
$1,453.76 		$1,444.56
$1,503.74
$1,566.43
$1,789.14 		$335.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.84
$995.20
$1,120.58
$1,566.00
$2,379.70 		$1,212.22
$1,330.58
$1,455.96
$1,901.38 		$1,547.60
$1,665.96
$1,791.34
$2,236.76 		$1,882.98
$2,001.34
$2,126.72
$2,572.14 		$335.38
Toc - Plan #60 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) 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 		$523.82
$594.53
$669.43
$935.53
$1,421.63 		$924.54
$995.25
$1,070.15
$1,336.25 		$1,325.26
$1,395.97
$1,470.87
$1,736.97 		$1,725.98
$1,796.69
$1,871.59
$2,137.69 		$400.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.64
$1,189.06
$1,338.86
$1,871.06
$2,843.26 		$1,448.36
$1,589.78
$1,739.58
$2,271.78 		$1,849.08
$1,990.50
$2,140.30
$2,672.50 		$2,249.80
$2,391.22
$2,541.02
$3,073.22 		$400.72
Toc - Plan #61 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$403.88
$458.39
$516.15
$721.31
$1,096.11 		$712.84
$767.35
$825.11
$1,030.27 		$1,021.80
$1,076.31
$1,134.07
$1,339.23 		$1,330.76
$1,385.27
$1,443.03
$1,648.19 		$308.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.76
$916.78
$1,032.30
$1,442.62
$2,192.22 		$1,116.72
$1,225.74
$1,341.26
$1,751.58 		$1,425.68
$1,534.70
$1,650.22
$2,060.54 		$1,734.64
$1,843.66
$1,959.18
$2,369.50 		$308.96
Toc - Plan #62 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$480.92
$545.83
$614.60
$858.90
$1,305.19 		$848.82
$913.73
$982.50
$1,226.80 		$1,216.72
$1,281.63
$1,350.40
$1,594.70 		$1,584.62
$1,649.53
$1,718.30
$1,962.60 		$367.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$961.84
$1,091.66
$1,229.20
$1,717.80
$2,610.38 		$1,329.74
$1,459.56
$1,597.10
$2,085.70 		$1,697.64
$1,827.46
$1,965.00
$2,453.60 		$2,065.54
$2,195.36
$2,332.90
$2,821.50 		$367.90
Toc - Plan #63 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Classic- $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 		$516.65
$586.39
$660.27
$922.72
$1,402.17 		$911.88
$981.62
$1,055.50
$1,317.95 		$1,307.11
$1,376.85
$1,450.73
$1,713.18 		$1,702.34
$1,772.08
$1,845.96
$2,108.41 		$395.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,033.30
$1,172.78
$1,320.54
$1,845.44
$2,804.34 		$1,428.53
$1,568.01
$1,715.77
$2,240.67 		$1,823.76
$1,963.24
$2,111.00
$2,635.90 		$2,218.99
$2,358.47
$2,506.23
$3,031.13 		$395.23
Toc - Plan #64 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) 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 		$530.32
$601.90
$677.74
$947.13
$1,439.26 		$936.01
$1,007.59
$1,083.43
$1,352.82 		$1,341.70
$1,413.28
$1,489.12
$1,758.51 		$1,747.39
$1,818.97
$1,894.81
$2,164.20 		$405.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,060.64
$1,203.80
$1,355.48
$1,894.26
$2,878.52 		$1,466.33
$1,609.49
$1,761.17
$2,299.95 		$1,872.02
$2,015.18
$2,166.86
$2,705.64 		$2,277.71
$2,420.87
$2,572.55
$3,111.33 		$405.69
Toc - Plan #65 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$391.48
$444.32
$500.30
$699.17
$1,062.45 		$690.96
$743.80
$799.78
$998.65 		$990.44
$1,043.28
$1,099.26
$1,298.13 		$1,289.92
$1,342.76
$1,398.74
$1,597.61 		$299.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.96
$888.64
$1,000.60
$1,398.34
$2,124.90 		$1,082.44
$1,188.12
$1,300.08
$1,697.82 		$1,381.92
$1,487.60
$1,599.56
$1,997.30 		$1,681.40
$1,787.08
$1,899.04
$2,296.78 		$299.48
Toc - Plan #66 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$419.70
$476.35
$536.36
$749.56
$1,139.04 		$740.76
$797.41
$857.42
$1,070.62 		$1,061.82
$1,118.47
$1,178.48
$1,391.68 		$1,382.88
$1,439.53
$1,499.54
$1,712.74 		$321.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.40
$952.70
$1,072.72
$1,499.12
$2,278.08 		$1,160.46
$1,273.76
$1,393.78
$1,820.18 		$1,481.52
$1,594.82
$1,714.84
$2,141.24 		$1,802.58
$1,915.88
$2,035.90
$2,462.30 		$321.06
Toc - Plan #67 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Classic- $3000 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$420.32
$477.05
$537.15
$750.67
$1,140.71 		$741.85
$798.58
$858.68
$1,072.20 		$1,063.38
$1,120.11
$1,180.21
$1,393.73 		$1,384.91
$1,441.64
$1,501.74
$1,715.26 		$321.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.64
$954.10
$1,074.30
$1,501.34
$2,281.42 		$1,162.17
$1,275.63
$1,395.83
$1,822.87 		$1,483.70
$1,597.16
$1,717.36
$2,144.40 		$1,805.23
$1,918.69
$2,038.89
$2,465.93 		$321.53
Toc - Plan #68 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$390.88
$443.64
$499.53
$698.10
$1,060.82 		$689.90
$742.66
$798.55
$997.12 		$988.92
$1,041.68
$1,097.57
$1,296.14 		$1,287.94
$1,340.70
$1,396.59
$1,595.16 		$299.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.76
$887.28
$999.06
$1,396.20
$2,121.64 		$1,080.78
$1,186.30
$1,298.08
$1,695.22 		$1,379.80
$1,485.32
$1,597.10
$1,994.24 		$1,678.82
$1,784.34
$1,896.12
$2,293.26 		$299.02
Toc - Plan #69 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$475.53
$539.72
$607.72
$849.28
$1,290.56 		$839.30
$903.49
$971.49
$1,213.05 		$1,203.07
$1,267.26
$1,335.26
$1,576.82 		$1,566.84
$1,631.03
$1,699.03
$1,940.59 		$363.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$951.06
$1,079.44
$1,215.44
$1,698.56
$2,581.12 		$1,314.83
$1,443.21
$1,579.21
$2,062.33 		$1,678.60
$1,806.98
$1,942.98
$2,426.10 		$2,042.37
$2,170.75
$2,306.75
$2,789.87 		$363.77
Toc - Plan #70 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$510.60
$579.51
$652.53
$911.91
$1,385.73 		$901.20
$970.11
$1,043.13
$1,302.51 		$1,291.80
$1,360.71
$1,433.73
$1,693.11 		$1,682.40
$1,751.31
$1,824.33
$2,083.71 		$390.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.20
$1,159.02
$1,305.06
$1,823.82
$2,771.46 		$1,411.80
$1,549.62
$1,695.66
$2,214.42 		$1,802.40
$1,940.22
$2,086.26
$2,605.02 		$2,193.00
$2,330.82
$2,476.86
$2,995.62 		$390.60
Toc - Plan #71 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$491.98
$558.39
$628.74
$878.67
$1,335.22 		$868.34
$934.75
$1,005.10
$1,255.03 		$1,244.70
$1,311.11
$1,381.46
$1,631.39 		$1,621.06
$1,687.47
$1,757.82
$2,007.75 		$376.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.96
$1,116.78
$1,257.48
$1,757.34
$2,670.44 		$1,360.32
$1,493.14
$1,633.84
$2,133.70 		$1,736.68
$1,869.50
$2,010.20
$2,510.06 		$2,113.04
$2,245.86
$2,386.56
$2,886.42 		$376.36
Toc - Plan #72 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$510.03
$578.87
$651.80
$910.89
$1,384.19 		$900.19
$969.03
$1,041.96
$1,301.05 		$1,290.35
$1,359.19
$1,432.12
$1,691.21 		$1,680.51
$1,749.35
$1,822.28
$2,081.37 		$390.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,020.06
$1,157.74
$1,303.60
$1,821.78
$2,768.38 		$1,410.22
$1,547.90
$1,693.76
$2,211.94 		$1,800.38
$1,938.06
$2,083.92
$2,602.10 		$2,190.54
$2,328.22
$2,474.08
$2,992.26 		$390.16
Toc - Plan #73 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$505.95
$574.24
$646.59
$903.61
$1,373.12 		$892.99
$961.28
$1,033.63
$1,290.65 		$1,280.03
$1,348.32
$1,420.67
$1,677.69 		$1,667.07
$1,735.36
$1,807.71
$2,064.73 		$387.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.90
$1,148.48
$1,293.18
$1,807.22
$2,746.24 		$1,398.94
$1,535.52
$1,680.22
$2,194.26 		$1,785.98
$1,922.56
$2,067.26
$2,581.30 		$2,173.02
$2,309.60
$2,454.30
$2,968.34 		$387.04
Toc - Plan #74 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$501.98
$569.74
$641.52
$896.52
$1,362.34 		$885.99
$953.75
$1,025.53
$1,280.53 		$1,270.00
$1,337.76
$1,409.54
$1,664.54 		$1,654.01
$1,721.77
$1,793.55
$2,048.55 		$384.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.96
$1,139.48
$1,283.04
$1,793.04
$2,724.68 		$1,387.97
$1,523.49
$1,667.05
$2,177.05 		$1,771.98
$1,907.50
$2,051.06
$2,561.06 		$2,155.99
$2,291.51
$2,435.07
$2,945.07 		$384.01
Toc - Plan #75 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) 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 		$502.79
$570.66
$642.56
$897.97
$1,364.56 		$887.42
$955.29
$1,027.19
$1,282.60 		$1,272.05
$1,339.92
$1,411.82
$1,667.23 		$1,656.68
$1,724.55
$1,796.45
$2,051.86 		$384.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,005.58
$1,141.32
$1,285.12
$1,795.94
$2,729.12 		$1,390.21
$1,525.95
$1,669.75
$2,180.57 		$1,774.84
$1,910.58
$2,054.38
$2,565.20 		$2,159.47
$2,295.21
$2,439.01
$2,949.83 		$384.63
Toc - Plan #76 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) 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 		$576.96
$654.84
$737.34
$1,030.44
$1,565.85 		$1,018.33
$1,096.21
$1,178.71
$1,471.81 		$1,459.70
$1,537.58
$1,620.08
$1,913.18 		$1,901.07
$1,978.95
$2,061.45
$2,354.55 		$441.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,153.92
$1,309.68
$1,474.68
$2,060.88
$3,131.70 		$1,595.29
$1,751.05
$1,916.05
$2,502.25 		$2,036.66
$2,192.42
$2,357.42
$2,943.62 		$2,478.03
$2,633.79
$2,798.79
$3,384.99 		$441.37
Toc - Plan #77 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) 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 		$546.75
$620.55
$698.73
$976.47
$1,483.84 		$965.00
$1,038.80
$1,116.98
$1,394.72 		$1,383.25
$1,457.05
$1,535.23
$1,812.97 		$1,801.50
$1,875.30
$1,953.48
$2,231.22 		$418.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,093.50
$1,241.10
$1,397.46
$1,952.94
$2,967.68 		$1,511.75
$1,659.35
$1,815.71
$2,371.19 		$1,930.00
$2,077.60
$2,233.96
$2,789.44 		$2,348.25
$2,495.85
$2,652.21
$3,207.69 		$418.25
Toc - Plan #78 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) 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 		$512.45
$581.62
$654.90
$915.22
$1,390.76 		$904.47
$973.64
$1,046.92
$1,307.24 		$1,296.49
$1,365.66
$1,438.94
$1,699.26 		$1,688.51
$1,757.68
$1,830.96
$2,091.28 		$392.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.90
$1,163.24
$1,309.80
$1,830.44
$2,781.52 		$1,416.92
$1,555.26
$1,701.82
$2,222.46 		$1,808.94
$1,947.28
$2,093.84
$2,614.48 		$2,200.96
$2,339.30
$2,485.86
$3,006.50 		$392.02
Toc - Plan #79 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$367.96
$417.62
$470.24
$657.16
$998.62 		$649.44
$699.10
$751.72
$938.64 		$930.92
$980.58
$1,033.20
$1,220.12 		$1,212.40
$1,262.06
$1,314.68
$1,501.60 		$281.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.92
$835.24
$940.48
$1,314.32
$1,997.24 		$1,017.40
$1,116.72
$1,221.96
$1,595.80 		$1,298.88
$1,398.20
$1,503.44
$1,877.28 		$1,580.36
$1,679.68
$1,784.92
$2,158.76 		$281.48
Toc - Plan #80 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Classic- $5000 Ded

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.27
$474.72
$534.53
$747.01
$1,135.15 		$738.24
$794.69
$854.50
$1,066.98 		$1,058.21
$1,114.66
$1,174.47
$1,386.95 		$1,378.18
$1,434.63
$1,494.44
$1,706.92 		$319.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.54
$949.44
$1,069.06
$1,494.02
$2,270.30 		$1,156.51
$1,269.41
$1,389.03
$1,813.99 		$1,476.48
$1,589.38
$1,709.00
$2,133.96 		$1,796.45
$1,909.35
$2,028.97
$2,453.93 		$319.97
Toc - Plan #81 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Elite

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$430.47
$488.57
$550.13
$768.80
$1,168.27 		$759.77
$817.87
$879.43
$1,098.10 		$1,089.07
$1,147.17
$1,208.73
$1,427.40 		$1,418.37
$1,476.47
$1,538.03
$1,756.70 		$329.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.94
$977.14
$1,100.26
$1,537.60
$2,336.54 		$1,190.24
$1,306.44
$1,429.56
$1,866.90 		$1,519.54
$1,635.74
$1,758.86
$2,196.20 		$1,848.84
$1,965.04
$2,088.16
$2,525.50 		$329.30
Toc - Plan #82 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$431.26
$489.47
$551.14
$770.22
$1,170.42 		$761.17
$819.38
$881.05
$1,100.13 		$1,091.08
$1,149.29
$1,210.96
$1,430.04 		$1,420.99
$1,479.20
$1,540.87
$1,759.95 		$329.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.52
$978.94
$1,102.28
$1,540.44
$2,340.84 		$1,192.43
$1,308.85
$1,432.19
$1,870.35 		$1,522.34
$1,638.76
$1,762.10
$2,200.26 		$1,852.25
$1,968.67
$2,092.01
$2,530.17 		$329.91
Toc - Plan #83 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$433.42
$491.93
$553.90
$774.08
$1,176.29 		$764.98
$823.49
$885.46
$1,105.64 		$1,096.54
$1,155.05
$1,217.02
$1,437.20 		$1,428.10
$1,486.61
$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
$983.86
$1,107.80
$1,548.16
$2,352.58 		$1,198.40
$1,315.42
$1,439.36
$1,879.72 		$1,529.96
$1,646.98
$1,770.92
$2,211.28 		$1,861.52
$1,978.54
$2,102.48
$2,542.84 		$331.56
Toc - Plan #84 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Simple- High Ded

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

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$480.94
$545.86
$614.63
$858.95
$1,305.25 		$848.85
$913.77
$982.54
$1,226.86 		$1,216.76
$1,281.68
$1,350.45
$1,594.77 		$1,584.67
$1,649.59
$1,718.36
$1,962.68 		$367.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$961.88
$1,091.72
$1,229.26
$1,717.90
$2,610.50 		$1,329.79
$1,459.63
$1,597.17
$2,085.81 		$1,697.70
$1,827.54
$1,965.08
$2,453.72 		$2,065.61
$2,195.45
$2,332.99
$2,821.63 		$367.91
Toc - Plan #85 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$485.81
$551.38
$620.85
$867.63
$1,318.45 		$857.44
$923.01
$992.48
$1,239.26 		$1,229.07
$1,294.64
$1,364.11
$1,610.89 		$1,600.70
$1,666.27
$1,735.74
$1,982.52 		$371.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$971.62
$1,102.76
$1,241.70
$1,735.26
$2,636.90 		$1,343.25
$1,474.39
$1,613.33
$2,106.89 		$1,714.88
$1,846.02
$1,984.96
$2,478.52 		$2,086.51
$2,217.65
$2,356.59
$2,850.15 		$371.63

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #86 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8700 ($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 		$463.69
$526.28
$592.59
$828.14
$1,258.45 		$818.41
$881.00
$947.31
$1,182.86 		$1,173.13
$1,235.72
$1,302.03
$1,537.58 		$1,527.85
$1,590.44
$1,656.75
$1,892.30 		$354.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.38
$1,052.56
$1,185.18
$1,656.28
$2,516.90 		$1,282.10
$1,407.28
$1,539.90
$2,011.00 		$1,636.82
$1,762.00
$1,894.62
$2,365.72 		$1,991.54
$2,116.72
$2,249.34
$2,720.44 		$354.72
Toc - Plan #87 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7300 ($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 		$484.76
$550.21
$619.53
$865.79
$1,315.65 		$855.60
$921.05
$990.37
$1,236.63 		$1,226.44
$1,291.89
$1,361.21
$1,607.47 		$1,597.28
$1,662.73
$1,732.05
$1,978.31 		$370.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.52
$1,100.42
$1,239.06
$1,731.58
$2,631.30 		$1,340.36
$1,471.26
$1,609.90
$2,102.42 		$1,711.20
$1,842.10
$1,980.74
$2,473.26 		$2,082.04
$2,212.94
$2,351.58
$2,844.10 		$370.84
Toc - Plan #88 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5900 ($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 		$491.75
$558.14
$628.46
$878.27
$1,334.61 		$867.94
$934.33
$1,004.65
$1,254.46 		$1,244.13
$1,310.52
$1,380.84
$1,630.65 		$1,620.32
$1,686.71
$1,757.03
$2,006.84 		$376.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.50
$1,116.28
$1,256.92
$1,756.54
$2,669.22 		$1,359.69
$1,492.47
$1,633.11
$2,132.73 		$1,735.88
$1,868.66
$2,009.30
$2,508.92 		$2,112.07
$2,244.85
$2,385.49
$2,885.11 		$376.19
Toc - Plan #89 Cigna Healthcare
Silver

(HMO) Cigna Connect 5500 ($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 		$523.51
$594.18
$669.05
$934.99
$1,420.81 		$924.00
$994.67
$1,069.54
$1,335.48 		$1,324.49
$1,395.16
$1,470.03
$1,735.97 		$1,724.98
$1,795.65
$1,870.52
$2,136.46 		$400.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.02
$1,188.36
$1,338.10
$1,869.98
$2,841.62 		$1,447.51
$1,588.85
$1,738.59
$2,270.47 		$1,848.00
$1,989.34
$2,139.08
$2,670.96 		$2,248.49
$2,389.83
$2,539.57
$3,071.45 		$400.49
Toc - Plan #90 Cigna Healthcare
Silver

(HMO) Cigna Connect 4500 ($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 		$524.90
$595.76
$670.82
$937.46
$1,424.57 		$926.45
$997.31
$1,072.37
$1,339.01 		$1,328.00
$1,398.86
$1,473.92
$1,740.56 		$1,729.55
$1,800.41
$1,875.47
$2,142.11 		$401.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,049.80
$1,191.52
$1,341.64
$1,874.92
$2,849.14 		$1,451.35
$1,593.07
$1,743.19
$2,276.47 		$1,852.90
$1,994.62
$2,144.74
$2,678.02 		$2,254.45
$2,396.17
$2,546.29
$3,079.57 		$401.55
Toc - Plan #91 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$526.17
$597.20
$672.44
$939.73
$1,428.02 		$928.69
$999.72
$1,074.96
$1,342.25 		$1,331.21
$1,402.24
$1,477.48
$1,744.77 		$1,733.73
$1,804.76
$1,880.00
$2,147.29 		$402.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,052.34
$1,194.40
$1,344.88
$1,879.46
$2,856.04 		$1,454.86
$1,596.92
$1,747.40
$2,281.98 		$1,857.38
$1,999.44
$2,149.92
$2,684.50 		$2,259.90
$2,401.96
$2,552.44
$3,087.02 		$402.52
Toc - Plan #92 Cigna Healthcare
Gold

(HMO) Cigna Connect 2000B ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$762.23
$865.13
$974.12
$1,361.33
$2,068.68 		$1,345.33
$1,448.23
$1,557.22
$1,944.43 		$1,928.43
$2,031.33
$2,140.32
$2,527.53 		$2,511.53
$2,614.43
$2,723.42
$3,110.63 		$583.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,524.46
$1,730.26
$1,948.24
$2,722.66
$4,137.36 		$2,107.56
$2,313.36
$2,531.34
$3,305.76 		$2,690.66
$2,896.46
$3,114.44
$3,888.86 		$3,273.76
$3,479.56
$3,697.54
$4,471.96 		$583.10
Toc - Plan #93 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500 Enhanced Diabetes Care ($0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$524.66
$595.49
$670.52
$937.05
$1,423.94 		$926.03
$996.86
$1,071.89
$1,338.42 		$1,327.40
$1,398.23
$1,473.26
$1,739.79 		$1,728.77
$1,799.60
$1,874.63
$2,141.16 		$401.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,049.32
$1,190.98
$1,341.04
$1,874.10
$2,847.88 		$1,450.69
$1,592.35
$1,742.41
$2,275.47 		$1,852.06
$1,993.72
$2,143.78
$2,676.84 		$2,253.43
$2,395.09
$2,545.15
$3,078.21 		$401.37
Toc - Plan #94 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care ($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 		$523.68
$594.38
$669.27
$935.30
$1,421.28 		$924.30
$995.00
$1,069.89
$1,335.92 		$1,324.92
$1,395.62
$1,470.51
$1,736.54 		$1,725.54
$1,796.24
$1,871.13
$2,137.16 		$400.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.36
$1,188.76
$1,338.54
$1,870.60
$2,842.56 		$1,447.98
$1,589.38
$1,739.16
$2,271.22 		$1,848.60
$1,990.00
$2,139.78
$2,671.84 		$2,249.22
$2,390.62
$2,540.40
$3,072.46 		$400.62

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310

Toc - Plan #95 Ambetter of North Carolina
Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$375.73
$426.44
$480.17
$671.04
$1,019.71 		$663.16
$713.87
$767.60
$958.47 		$950.59
$1,001.30
$1,055.03
$1,245.90 		$1,238.02
$1,288.73
$1,342.46
$1,533.33 		$287.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.46
$852.88
$960.34
$1,342.08
$2,039.42 		$1,038.89
$1,140.31
$1,247.77
$1,629.51 		$1,326.32
$1,427.74
$1,535.20
$1,916.94 		$1,613.75
$1,715.17
$1,822.63
$2,204.37 		$287.43
Toc - Plan #96 Ambetter of North Carolina
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$412.15
$467.78
$526.71
$736.08
$1,118.55 		$727.44
$783.07
$842.00
$1,051.37 		$1,042.73
$1,098.36
$1,157.29
$1,366.66 		$1,358.02
$1,413.65
$1,472.58
$1,681.95 		$315.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.30
$935.56
$1,053.42
$1,472.16
$2,237.10 		$1,139.59
$1,250.85
$1,368.71
$1,787.45 		$1,454.88
$1,566.14
$1,684.00
$2,102.74 		$1,770.17
$1,881.43
$1,999.29
$2,418.03 		$315.29
Toc - Plan #97 Ambetter of North Carolina
Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$527.04
$598.18
$673.55
$941.28
$1,430.37 		$930.22
$1,001.36
$1,076.73
$1,344.46 		$1,333.40
$1,404.54
$1,479.91
$1,747.64 		$1,736.58
$1,807.72
$1,883.09
$2,150.82 		$403.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,054.08
$1,196.36
$1,347.10
$1,882.56
$2,860.74 		$1,457.26
$1,599.54
$1,750.28
$2,285.74 		$1,860.44
$2,002.72
$2,153.46
$2,688.92 		$2,263.62
$2,405.90
$2,556.64
$3,092.10 		$403.18
Toc - Plan #98 Ambetter of North Carolina
Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$570.10
$647.05
$728.58
$1,018.18
$1,547.23 		$1,006.22
$1,083.17
$1,164.70
$1,454.30 		$1,442.34
$1,519.29
$1,600.82
$1,890.42 		$1,878.46
$1,955.41
$2,036.94
$2,326.54 		$436.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,140.20
$1,294.10
$1,457.16
$2,036.36
$3,094.46 		$1,576.32
$1,730.22
$1,893.28
$2,472.48 		$2,012.44
$2,166.34
$2,329.40
$2,908.60 		$2,448.56
$2,602.46
$2,765.52
$3,344.72 		$436.12
Toc - Plan #99 Ambetter of North Carolina
Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$520.88
$591.18
$665.67
$930.27
$1,413.63 		$919.34
$989.64
$1,064.13
$1,328.73 		$1,317.80
$1,388.10
$1,462.59
$1,727.19 		$1,716.26
$1,786.56
$1,861.05
$2,125.65 		$398.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,041.76
$1,182.36
$1,331.34
$1,860.54
$2,827.26 		$1,440.22
$1,580.82
$1,729.80
$2,259.00 		$1,838.68
$1,979.28
$2,128.26
$2,657.46 		$2,237.14
$2,377.74
$2,526.72
$3,055.92 		$398.46
Toc - Plan #100 Ambetter of North Carolina
Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$404.61
$459.22
$517.08
$722.62
$1,098.09 		$714.13
$768.74
$826.60
$1,032.14 		$1,023.65
$1,078.26
$1,136.12
$1,341.66 		$1,333.17
$1,387.78
$1,445.64
$1,651.18 		$309.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.22
$918.44
$1,034.16
$1,445.24
$2,196.18 		$1,118.74
$1,227.96
$1,343.68
$1,754.76 		$1,428.26
$1,537.48
$1,653.20
$2,064.28 		$1,737.78
$1,847.00
$1,962.72
$2,373.80 		$309.52
Toc - Plan #101 Ambetter of North Carolina
Expanded Bronze

(HMO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$429.65
$487.64
$549.08
$767.33
$1,166.04 		$758.32
$816.31
$877.75
$1,096.00 		$1,086.99
$1,144.98
$1,206.42
$1,424.67 		$1,415.66
$1,473.65
$1,535.09
$1,753.34 		$328.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.30
$975.28
$1,098.16
$1,534.66
$2,332.08 		$1,187.97
$1,303.95
$1,426.83
$1,863.33 		$1,516.64
$1,632.62
$1,755.50
$2,192.00 		$1,845.31
$1,961.29
$2,084.17
$2,520.67 		$328.67
Toc - Plan #102 Ambetter of North Carolina
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439.40
$498.70
$561.54
$784.75
$1,192.50 		$775.53
$834.83
$897.67
$1,120.88 		$1,111.66
$1,170.96
$1,233.80
$1,457.01 		$1,447.79
$1,507.09
$1,569.93
$1,793.14 		$336.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$878.80
$997.40
$1,123.08
$1,569.50
$2,385.00 		$1,214.93
$1,333.53
$1,459.21
$1,905.63 		$1,551.06
$1,669.66
$1,795.34
$2,241.76 		$1,887.19
$2,005.79
$2,131.47
$2,577.89 		$336.13
Toc - Plan #103 Ambetter of North Carolina
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$461.48
$523.77
$589.76
$824.19
$1,252.43 		$814.50
$876.79
$942.78
$1,177.21 		$1,167.52
$1,229.81
$1,295.80
$1,530.23 		$1,520.54
$1,582.83
$1,648.82
$1,883.25 		$353.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.96
$1,047.54
$1,179.52
$1,648.38
$2,504.86 		$1,275.98
$1,400.56
$1,532.54
$2,001.40 		$1,629.00
$1,753.58
$1,885.56
$2,354.42 		$1,982.02
$2,106.60
$2,238.58
$2,707.44 		$353.02
Toc - Plan #104 Ambetter of North Carolina
Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$499.16
$566.54
$637.92
$891.49
$1,354.70 		$881.01
$948.39
$1,019.77
$1,273.34 		$1,262.86
$1,330.24
$1,401.62
$1,655.19 		$1,644.71
$1,712.09
$1,783.47
$2,037.04 		$381.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.32
$1,133.08
$1,275.84
$1,782.98
$2,709.40 		$1,380.17
$1,514.93
$1,657.69
$2,164.83 		$1,762.02
$1,896.78
$2,039.54
$2,546.68 		$2,143.87
$2,278.63
$2,421.39
$2,928.53 		$381.85
Toc - Plan #105 Ambetter of North Carolina
Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$499.22
$566.60
$637.99
$891.58
$1,354.84 		$881.11
$948.49
$1,019.88
$1,273.47 		$1,263.00
$1,330.38
$1,401.77
$1,655.36 		$1,644.89
$1,712.27
$1,783.66
$2,037.25 		$381.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.44
$1,133.20
$1,275.98
$1,783.16
$2,709.68 		$1,380.33
$1,515.09
$1,657.87
$2,165.05 		$1,762.22
$1,896.98
$2,039.76
$2,546.94 		$2,144.11
$2,278.87
$2,421.65
$2,928.83 		$381.89
Toc - Plan #106 Ambetter of North Carolina
Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$505.70
$573.96
$646.27
$903.16
$1,372.44 		$892.55
$960.81
$1,033.12
$1,290.01 		$1,279.40
$1,347.66
$1,419.97
$1,676.86 		$1,666.25
$1,734.51
$1,806.82
$2,063.71 		$386.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.40
$1,147.92
$1,292.54
$1,806.32
$2,744.88 		$1,398.25
$1,534.77
$1,679.39
$2,193.17 		$1,785.10
$1,921.62
$2,066.24
$2,580.02 		$2,171.95
$2,308.47
$2,453.09
$2,966.87 		$386.85
Toc - Plan #107 Ambetter of North Carolina
Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$534.69
$606.86
$683.31
$954.93
$1,451.11 		$943.72
$1,015.89
$1,092.34
$1,363.96 		$1,352.75
$1,424.92
$1,501.37
$1,772.99 		$1,761.78
$1,833.95
$1,910.40
$2,182.02 		$409.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,069.38
$1,213.72
$1,366.62
$1,909.86
$2,902.22 		$1,478.41
$1,622.75
$1,775.65
$2,318.89 		$1,887.44
$2,031.78
$2,184.68
$2,727.92 		$2,296.47
$2,440.81
$2,593.71
$3,136.95 		$409.03
Toc - Plan #108 Ambetter of North Carolina
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$392.44
$445.40
$501.52
$700.87
$1,065.04 		$692.65
$745.61
$801.73
$1,001.08 		$992.86
$1,045.82
$1,101.94
$1,301.29 		$1,293.07
$1,346.03
$1,402.15
$1,601.50 		$300.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.88
$890.80
$1,003.04
$1,401.74
$2,130.08 		$1,085.09
$1,191.01
$1,303.25
$1,701.95 		$1,385.30
$1,491.22
$1,603.46
$2,002.16 		$1,685.51
$1,791.43
$1,903.67
$2,302.37 		$300.21
Toc - Plan #109 Ambetter of North Carolina
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$430.47
$488.57
$550.13
$768.81
$1,168.27 		$759.77
$817.87
$879.43
$1,098.11 		$1,089.07
$1,147.17
$1,208.73
$1,427.41 		$1,418.37
$1,476.47
$1,538.03
$1,756.71 		$329.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.94
$977.14
$1,100.26
$1,537.62
$2,336.54 		$1,190.24
$1,306.44
$1,429.56
$1,866.92 		$1,519.54
$1,635.74
$1,758.86
$2,196.22 		$1,848.84
$1,965.04
$2,088.16
$2,525.52 		$329.30
Toc - Plan #110 Ambetter of North Carolina
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$550.47
$624.78
$703.49
$983.13
$1,493.96 		$971.57
$1,045.88
$1,124.59
$1,404.23 		$1,392.67
$1,466.98
$1,545.69
$1,825.33 		$1,813.77
$1,888.08
$1,966.79
$2,246.43 		$421.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,100.94
$1,249.56
$1,406.98
$1,966.26
$2,987.92 		$1,522.04
$1,670.66
$1,828.08
$2,387.36 		$1,943.14
$2,091.76
$2,249.18
$2,808.46 		$2,364.24
$2,512.86
$2,670.28
$3,229.56 		$421.10
Toc - Plan #111 Ambetter of North Carolina
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$595.45
$675.82
$760.97
$1,063.45
$1,616.01 		$1,050.96
$1,131.33
$1,216.48
$1,518.96 		$1,506.47
$1,586.84
$1,671.99
$1,974.47 		$1,961.98
$2,042.35
$2,127.50
$2,429.98 		$455.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,190.90
$1,351.64
$1,521.94
$2,126.90
$3,232.02 		$1,646.41
$1,807.15
$1,977.45
$2,582.41 		$2,101.92
$2,262.66
$2,432.96
$3,037.92 		$2,557.43
$2,718.17
$2,888.47
$3,493.43 		$455.51
Toc - Plan #112 Ambetter of North Carolina
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$544.03
$617.47
$695.26
$971.62
$1,476.48 		$960.21
$1,033.65
$1,111.44
$1,387.80 		$1,376.39
$1,449.83
$1,527.62
$1,803.98 		$1,792.57
$1,866.01
$1,943.80
$2,220.16 		$416.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,088.06
$1,234.94
$1,390.52
$1,943.24
$2,952.96 		$1,504.24
$1,651.12
$1,806.70
$2,359.42 		$1,920.42
$2,067.30
$2,222.88
$2,775.60 		$2,336.60
$2,483.48
$2,639.06
$3,191.78 		$416.18
Toc - Plan #113 Ambetter of North Carolina
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$422.60
$479.64
$540.07
$754.75
$1,146.91 		$745.88
$802.92
$863.35
$1,078.03 		$1,069.16
$1,126.20
$1,186.63
$1,401.31 		$1,392.44
$1,449.48
$1,509.91
$1,724.59 		$323.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.20
$959.28
$1,080.14
$1,509.50
$2,293.82 		$1,168.48
$1,282.56
$1,403.42
$1,832.78 		$1,491.76
$1,605.84
$1,726.70
$2,156.06 		$1,815.04
$1,929.12
$2,049.98
$2,479.34 		$323.28
Toc - Plan #114 Ambetter of North Carolina
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$448.75
$509.32
$573.49
$801.44
$1,217.87 		$792.03
$852.60
$916.77
$1,144.72 		$1,135.31
$1,195.88
$1,260.05
$1,488.00 		$1,478.59
$1,539.16
$1,603.33
$1,831.28 		$343.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.50
$1,018.64
$1,146.98
$1,602.88
$2,435.74 		$1,240.78
$1,361.92
$1,490.26
$1,946.16 		$1,584.06
$1,705.20
$1,833.54
$2,289.44 		$1,927.34
$2,048.48
$2,176.82
$2,632.72 		$343.28
Toc - Plan #115 Ambetter of North Carolina
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$458.93
$520.88
$586.50
$819.63
$1,245.51 		$810.00
$871.95
$937.57
$1,170.70 		$1,161.07
$1,223.02
$1,288.64
$1,521.77 		$1,512.14
$1,574.09
$1,639.71
$1,872.84 		$351.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.86
$1,041.76
$1,173.00
$1,639.26
$2,491.02 		$1,268.93
$1,392.83
$1,524.07
$1,990.33 		$1,620.00
$1,743.90
$1,875.14
$2,341.40 		$1,971.07
$2,094.97
$2,226.21
$2,692.47 		$351.07
Toc - Plan #116 Ambetter of North Carolina
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$482.00
$547.05
$615.98
$860.83
$1,308.11 		$850.72
$915.77
$984.70
$1,229.55 		$1,219.44
$1,284.49
$1,353.42
$1,598.27 		$1,588.16
$1,653.21
$1,722.14
$1,966.99 		$368.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.00
$1,094.10
$1,231.96
$1,721.66
$2,616.22 		$1,332.72
$1,462.82
$1,600.68
$2,090.38 		$1,701.44
$1,831.54
$1,969.40
$2,459.10 		$2,070.16
$2,200.26
$2,338.12
$2,827.82 		$368.72
Toc - Plan #117 Ambetter of North Carolina
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$521.41
$591.79
$666.35
$931.22
$1,415.08 		$920.28
$990.66
$1,065.22
$1,330.09 		$1,319.15
$1,389.53
$1,464.09
$1,728.96 		$1,718.02
$1,788.40
$1,862.96
$2,127.83 		$398.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.82
$1,183.58
$1,332.70
$1,862.44
$2,830.16 		$1,441.69
$1,582.45
$1,731.57
$2,261.31 		$1,840.56
$1,981.32
$2,130.44
$2,660.18 		$2,239.43
$2,380.19
$2,529.31
$3,059.05 		$398.87
Toc - Plan #118 Ambetter of North Carolina
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$528.18
$599.47
$675.00
$943.31
$1,433.45 		$932.23
$1,003.52
$1,079.05
$1,347.36 		$1,336.28
$1,407.57
$1,483.10
$1,751.41 		$1,740.33
$1,811.62
$1,887.15
$2,155.46 		$404.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,056.36
$1,198.94
$1,350.00
$1,886.62
$2,866.90 		$1,460.41
$1,602.99
$1,754.05
$2,290.67 		$1,864.46
$2,007.04
$2,158.10
$2,694.72 		$2,268.51
$2,411.09
$2,562.15
$3,098.77 		$404.05
Toc - Plan #119 Ambetter of North Carolina
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$558.45
$633.83
$713.69
$997.38
$1,515.62 		$985.66
$1,061.04
$1,140.90
$1,424.59 		$1,412.87
$1,488.25
$1,568.11
$1,851.80 		$1,840.08
$1,915.46
$1,995.32
$2,279.01 		$427.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,116.90
$1,267.66
$1,427.38
$1,994.76
$3,031.24 		$1,544.11
$1,694.87
$1,854.59
$2,421.97 		$1,971.32
$2,122.08
$2,281.80
$2,849.18 		$2,398.53
$2,549.29
$2,709.01
$3,276.39 		$427.21

ADVERTISEMENT

Friday Health Plans

Local: 1-844-465-5500 | Toll Free: 1-844-465-5500 | TTY: 1-800-659-2656
Toc - Plan #120 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$231.32
$262.55
$295.63
$413.14
$627.81 		$408.28
$439.51
$472.59
$590.10 		$585.24
$616.47
$649.55
$767.06 		$762.20
$793.43
$826.51
$944.02 		$176.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$462.64
$525.10
$591.26
$826.28
$1,255.62 		$639.60
$702.06
$768.22
$1,003.24 		$816.56
$879.02
$945.18
$1,180.20 		$993.52
$1,055.98
$1,122.14
$1,357.16 		$176.96
Toc - Plan #121 Friday Health Plans
Bronze

(HMO) Friday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$300.50
$341.07
$384.04
$536.70
$815.57 		$530.39
$570.96
$613.93
$766.59 		$760.28
$800.85
$843.82
$996.48 		$990.17
$1,030.74
$1,073.71
$1,226.37 		$229.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.00
$682.14
$768.08
$1,073.40
$1,631.14 		$830.89
$912.03
$997.97
$1,303.29 		$1,060.78
$1,141.92
$1,227.86
$1,533.18 		$1,290.67
$1,371.81
$1,457.75
$1,763.07 		$229.89
Toc - Plan #122 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$308.85
$350.54
$394.71
$551.60
$838.22 		$545.12
$586.81
$630.98
$787.87 		$781.39
$823.08
$867.25
$1,024.14 		$1,017.66
$1,059.35
$1,103.52
$1,260.41 		$236.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.70
$701.08
$789.42
$1,103.20
$1,676.44 		$853.97
$937.35
$1,025.69
$1,339.47 		$1,090.24
$1,173.62
$1,261.96
$1,575.74 		$1,326.51
$1,409.89
$1,498.23
$1,812.01 		$236.27
Toc - Plan #123 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318.04
$360.97
$406.45
$568.01
$863.15 		$561.34
$604.27
$649.75
$811.31 		$804.64
$847.57
$893.05
$1,054.61 		$1,047.94
$1,090.87
$1,136.35
$1,297.91 		$243.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.08
$721.94
$812.90
$1,136.02
$1,726.30 		$879.38
$965.24
$1,056.20
$1,379.32 		$1,122.68
$1,208.54
$1,299.50
$1,622.62 		$1,365.98
$1,451.84
$1,542.80
$1,865.92 		$243.30
Toc - Plan #124 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$445.71
$505.88
$569.62
$796.04
$1,209.66 		$786.68
$846.85
$910.59
$1,137.01 		$1,127.65
$1,187.82
$1,251.56
$1,477.98 		$1,468.62
$1,528.79
$1,592.53
$1,818.95 		$340.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891.42
$1,011.76
$1,139.24
$1,592.08
$2,419.32 		$1,232.39
$1,352.73
$1,480.21
$1,933.05 		$1,573.36
$1,693.70
$1,821.18
$2,274.02 		$1,914.33
$2,034.67
$2,162.15
$2,614.99 		$340.97
Toc - Plan #125 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387.48
$439.79
$495.20
$692.03
$1,051.61 		$683.90
$736.21
$791.62
$988.45 		$980.32
$1,032.63
$1,088.04
$1,284.87 		$1,276.74
$1,329.05
$1,384.46
$1,581.29 		$296.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.96
$879.58
$990.40
$1,384.06
$2,103.22 		$1,071.38
$1,176.00
$1,286.82
$1,680.48 		$1,367.80
$1,472.42
$1,583.24
$1,976.90 		$1,664.22
$1,768.84
$1,879.66
$2,273.32 		$296.42
Toc - Plan #126 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$312.30
$354.46
$399.12
$557.77
$847.58 		$551.21
$593.37
$638.03
$796.68 		$790.12
$832.28
$876.94
$1,035.59 		$1,029.03
$1,071.19
$1,115.85
$1,274.50 		$238.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.60
$708.92
$798.24
$1,115.54
$1,695.16 		$863.51
$947.83
$1,037.15
$1,354.45 		$1,102.42
$1,186.74
$1,276.06
$1,593.36 		$1,341.33
$1,425.65
$1,514.97
$1,832.27 		$238.91
Toc - Plan #127 Friday Health Plans
Silver

(HMO) Friday Silver Plus Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$450.79
$511.65
$576.11
$805.12
$1,223.45 		$795.65
$856.51
$920.97
$1,149.98 		$1,140.51
$1,201.37
$1,265.83
$1,494.84 		$1,485.37
$1,546.23
$1,610.69
$1,839.70 		$344.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.58
$1,023.30
$1,152.22
$1,610.24
$2,446.90 		$1,246.44
$1,368.16
$1,497.08
$1,955.10 		$1,591.30
$1,713.02
$1,841.94
$2,299.96 		$1,936.16
$2,057.88
$2,186.80
$2,644.82 		$344.86
Toc - Plan #128 Friday Health Plans
Gold

(HMO) Friday Gold Plus Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.78
$462.83
$521.14
$728.29
$1,106.71 		$719.73
$774.78
$833.09
$1,040.24 		$1,031.68
$1,086.73
$1,145.04
$1,352.19 		$1,343.63
$1,398.68
$1,456.99
$1,664.14 		$311.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.56
$925.66
$1,042.28
$1,456.58
$2,213.42 		$1,127.51
$1,237.61
$1,354.23
$1,768.53 		$1,439.46
$1,549.56
$1,666.18
$2,080.48 		$1,751.41
$1,861.51
$1,978.13
$2,392.43 		$311.95

‡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 Buncombe County here.

Buncombe County is in “Rating Area 1” of North Carolina.

Currently, there are 128 plans offered in Rating Area 1.

Top

2022 Obamacare Plans for Buncombe County, NC

Plan Browser: 128 Plans
scroll down for more
Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork