Obamacare 2022 Rates for Orange County

Obamacare > Rates > North Carolina > Orange 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 Orange 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, 80 Plans and 2022 Rates for Orange County, North Carolina

Below, you’ll find a summary of the 80 plans for Orange 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

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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
Gold

(POS) Blue Home Gold 2500 + 3 Free PCP with UNC Health Alliance

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 		$378.25
$429.31
$483.40
$675.55
$1,026.57 		$667.61
$718.67
$772.76
$964.91 		$956.97
$1,008.03
$1,062.12
$1,254.27 		$1,246.33
$1,297.39
$1,351.48
$1,543.63 		$289.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.50
$858.62
$966.80
$1,351.10
$2,053.14 		$1,045.86
$1,147.98
$1,256.16
$1,640.46 		$1,335.22
$1,437.34
$1,545.52
$1,929.82 		$1,624.58
$1,726.70
$1,834.88
$2,219.18 		$289.36
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Home Silver 3800 + 3 Free PCP with UNC Health Alliance

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 		$387.63
$439.96
$495.39
$692.31
$1,052.03 		$684.17
$736.50
$791.93
$988.85 		$980.71
$1,033.04
$1,088.47
$1,285.39 		$1,277.25
$1,329.58
$1,385.01
$1,581.93 		$296.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.26
$879.92
$990.78
$1,384.62
$2,104.06 		$1,071.80
$1,176.46
$1,287.32
$1,681.16 		$1,368.34
$1,473.00
$1,583.86
$1,977.70 		$1,664.88
$1,769.54
$1,880.40
$2,274.24 		$296.54
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Home Silver $0 Deductible with UNC Health Alliance

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 		$386.76
$438.97
$494.28
$690.75
$1,049.67 		$682.63
$734.84
$790.15
$986.62 		$978.50
$1,030.71
$1,086.02
$1,282.49 		$1,274.37
$1,326.58
$1,381.89
$1,578.36 		$295.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.52
$877.94
$988.56
$1,381.50
$2,099.34 		$1,069.39
$1,173.81
$1,284.43
$1,677.37 		$1,365.26
$1,469.68
$1,580.30
$1,973.24 		$1,661.13
$1,765.55
$1,876.17
$2,269.11 		$295.87
Toc - Plan #4 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Home Silver 5300 + 3 Free PCP with UNC Health Alliance

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 		$358.16
$406.51
$457.73
$639.67
$972.05 		$632.15
$680.50
$731.72
$913.66 		$906.14
$954.49
$1,005.71
$1,187.65 		$1,180.13
$1,228.48
$1,279.70
$1,461.64 		$273.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.32
$813.02
$915.46
$1,279.34
$1,944.10 		$990.31
$1,087.01
$1,189.45
$1,553.33 		$1,264.30
$1,361.00
$1,463.44
$1,827.32 		$1,538.29
$1,634.99
$1,737.43
$2,101.31 		$273.99
Toc - Plan #5 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Home Silver 2800 + $15 PCP with UNC Health Alliance

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 		$373.88
$424.35
$477.82
$667.75
$1,014.71 		$659.90
$710.37
$763.84
$953.77 		$945.92
$996.39
$1,049.86
$1,239.79 		$1,231.94
$1,282.41
$1,335.88
$1,525.81 		$286.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.76
$848.70
$955.64
$1,335.50
$2,029.42 		$1,033.78
$1,134.72
$1,241.66
$1,621.52 		$1,319.80
$1,420.74
$1,527.68
$1,907.54 		$1,605.82
$1,706.76
$1,813.70
$2,193.56 		$286.02
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Home Silver 6000 + 3 Free PCP with UNC Health Alliance

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 		$371.71
$421.89
$475.05
$663.87
$1,008.82 		$656.07
$706.25
$759.41
$948.23 		$940.43
$990.61
$1,043.77
$1,232.59 		$1,224.79
$1,274.97
$1,328.13
$1,516.95 		$284.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.42
$843.78
$950.10
$1,327.74
$2,017.64 		$1,027.78
$1,128.14
$1,234.46
$1,612.10 		$1,312.14
$1,412.50
$1,518.82
$1,896.46 		$1,596.50
$1,696.86
$1,803.18
$2,180.82 		$284.36
Toc - Plan #7 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Home Bronze 7000 Copay with UNC Health Alliance

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 		$278.81
$316.45
$356.32
$497.95
$756.69 		$492.10
$529.74
$569.61
$711.24 		$705.39
$743.03
$782.90
$924.53 		$918.68
$956.32
$996.19
$1,137.82 		$213.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.62
$632.90
$712.64
$995.90
$1,513.38 		$770.91
$846.19
$925.93
$1,209.19 		$984.20
$1,059.48
$1,139.22
$1,422.48 		$1,197.49
$1,272.77
$1,352.51
$1,635.77 		$213.29
Toc - Plan #8 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Home Bronze 7000 + 3 Free PCP with UNC Health Alliance

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 		$261.63
$296.95
$334.36
$467.27
$710.06 		$461.78
$497.10
$534.51
$667.42 		$661.93
$697.25
$734.66
$867.57 		$862.08
$897.40
$934.81
$1,067.72 		$200.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.26
$593.90
$668.72
$934.54
$1,420.12 		$723.41
$794.05
$868.87
$1,134.69 		$923.56
$994.20
$1,069.02
$1,334.84 		$1,123.71
$1,194.35
$1,269.17
$1,534.99 		$200.15
Toc - Plan #9 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Home Bronze 7000 HSA Eligible with UNC Health Alliance

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 		$271.10
$307.70
$346.47
$484.18
$735.77 		$478.49
$515.09
$553.86
$691.57 		$685.88
$722.48
$761.25
$898.96 		$893.27
$929.87
$968.64
$1,106.35 		$207.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.20
$615.40
$692.94
$968.36
$1,471.54 		$749.59
$822.79
$900.33
$1,175.75 		$956.98
$1,030.18
$1,107.72
$1,383.14 		$1,164.37
$1,237.57
$1,315.11
$1,590.53 		$207.39
Toc - Plan #10 Blue Cross and Blue Shield of NC
Bronze

(POS) Blue Home Bronze 8700 with UNC Health Alliance

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 		$258.80
$293.74
$330.75
$462.22
$702.38 		$456.78
$491.72
$528.73
$660.20 		$654.76
$689.70
$726.71
$858.18 		$852.74
$887.68
$924.69
$1,056.16 		$197.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.60
$587.48
$661.50
$924.44
$1,404.76 		$715.58
$785.46
$859.48
$1,122.42 		$913.56
$983.44
$1,057.46
$1,320.40 		$1,111.54
$1,181.42
$1,255.44
$1,518.38 		$197.98
Toc - Plan #11 Blue Cross and Blue Shield of NC
Catastrophic

(POS) Blue Home Catastrophic with UNC Health Alliance

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 		$185.22
$210.22
$236.71
$330.80
$502.69 		$326.91
$351.91
$378.40
$472.49 		$468.60
$493.60
$520.09
$614.18 		$610.29
$635.29
$661.78
$755.87 		$141.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$370.44
$420.44
$473.42
$661.60
$1,005.38 		$512.13
$562.13
$615.11
$803.29 		$653.82
$703.82
$756.80
$944.98 		$795.51
$845.51
$898.49
$1,086.67 		$141.69

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Bright HealthCare

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

Toc - Plan #12 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 		$479.40
$544.12
$612.68
$856.21
$1,301.10 		$846.14
$910.86
$979.42
$1,222.95 		$1,212.88
$1,277.60
$1,346.16
$1,589.69 		$1,579.62
$1,644.34
$1,712.90
$1,956.43 		$366.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.80
$1,088.24
$1,225.36
$1,712.42
$2,602.20 		$1,325.54
$1,454.98
$1,592.10
$2,079.16 		$1,692.28
$1,821.72
$1,958.84
$2,445.90 		$2,059.02
$2,188.46
$2,325.58
$2,812.64 		$366.74
Toc - Plan #13 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 		$371.95
$422.16
$475.35
$664.30
$1,009.47 		$656.49
$706.70
$759.89
$948.84 		$941.03
$991.24
$1,044.43
$1,233.38 		$1,225.57
$1,275.78
$1,328.97
$1,517.92 		$284.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.90
$844.32
$950.70
$1,328.60
$2,018.94 		$1,028.44
$1,128.86
$1,235.24
$1,613.14 		$1,312.98
$1,413.40
$1,519.78
$1,897.68 		$1,597.52
$1,697.94
$1,804.32
$2,182.22 		$284.54
Toc - Plan #14 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 		$374.90
$425.51
$479.12
$669.56
$1,017.47 		$661.70
$712.31
$765.92
$956.36 		$948.50
$999.11
$1,052.72
$1,243.16 		$1,235.30
$1,285.91
$1,339.52
$1,529.96 		$286.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.80
$851.02
$958.24
$1,339.12
$2,034.94 		$1,036.60
$1,137.82
$1,245.04
$1,625.92 		$1,323.40
$1,424.62
$1,531.84
$1,912.72 		$1,610.20
$1,711.42
$1,818.64
$2,199.52 		$286.80
Toc - Plan #15 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 		$388.10
$440.50
$495.99
$693.15
$1,053.31 		$685.00
$737.40
$792.89
$990.05 		$981.90
$1,034.30
$1,089.79
$1,286.95 		$1,278.80
$1,331.20
$1,386.69
$1,583.85 		$296.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.20
$881.00
$991.98
$1,386.30
$2,106.62 		$1,073.10
$1,177.90
$1,288.88
$1,683.20 		$1,370.00
$1,474.80
$1,585.78
$1,980.10 		$1,666.90
$1,771.70
$1,882.68
$2,277.00 		$296.90
Toc - Plan #16 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 		$256.48
$291.10
$327.78
$458.06
$696.07 		$452.68
$487.30
$523.98
$654.26 		$648.88
$683.50
$720.18
$850.46 		$845.08
$879.70
$916.38
$1,046.66 		$196.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512.96
$582.20
$655.56
$916.12
$1,392.14 		$709.16
$778.40
$851.76
$1,112.32 		$905.36
$974.60
$1,047.96
$1,308.52 		$1,101.56
$1,170.80
$1,244.16
$1,504.72 		$196.20
Toc - Plan #17 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 		$265.30
$301.12
$339.06
$473.83
$720.03 		$468.26
$504.08
$542.02
$676.79 		$671.22
$707.04
$744.98
$879.75 		$874.18
$910.00
$947.94
$1,082.71 		$202.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.60
$602.24
$678.12
$947.66
$1,440.06 		$733.56
$805.20
$881.08
$1,150.62 		$936.52
$1,008.16
$1,084.04
$1,353.58 		$1,139.48
$1,211.12
$1,287.00
$1,556.54 		$202.96
Toc - Plan #18 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 		$278.45
$316.04
$355.86
$497.31
$755.72 		$491.47
$529.06
$568.88
$710.33 		$704.49
$742.08
$781.90
$923.35 		$917.51
$955.10
$994.92
$1,136.37 		$213.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.90
$632.08
$711.72
$994.62
$1,511.44 		$769.92
$845.10
$924.74
$1,207.64 		$982.94
$1,058.12
$1,137.76
$1,420.66 		$1,195.96
$1,271.14
$1,350.78
$1,633.68 		$213.02
Toc - Plan #19 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 		$184.66
$209.59
$235.99
$329.80
$501.17 		$325.92
$350.85
$377.25
$471.06 		$467.18
$492.11
$518.51
$612.32 		$608.44
$633.37
$659.77
$753.58 		$141.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$369.32
$419.18
$471.98
$659.60
$1,002.34 		$510.58
$560.44
$613.24
$800.86 		$651.84
$701.70
$754.50
$942.12 		$793.10
$842.96
$895.76
$1,083.38 		$141.26
Toc - Plan #20 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 		$296.02
$335.98
$378.31
$528.68
$803.38 		$522.47
$562.43
$604.76
$755.13 		$748.92
$788.88
$831.21
$981.58 		$975.37
$1,015.33
$1,057.66
$1,208.03 		$226.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.04
$671.96
$756.62
$1,057.36
$1,606.76 		$818.49
$898.41
$983.07
$1,283.81 		$1,044.94
$1,124.86
$1,209.52
$1,510.26 		$1,271.39
$1,351.31
$1,435.97
$1,736.71 		$226.45
Toc - Plan #21 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 		$378.42
$429.50
$483.62
$675.85
$1,027.02 		$667.91
$718.99
$773.11
$965.34 		$957.40
$1,008.48
$1,062.60
$1,254.83 		$1,246.89
$1,297.97
$1,352.09
$1,544.32 		$289.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.84
$859.00
$967.24
$1,351.70
$2,054.04 		$1,046.33
$1,148.49
$1,256.73
$1,641.19 		$1,335.82
$1,437.98
$1,546.22
$1,930.68 		$1,625.31
$1,727.47
$1,835.71
$2,220.17 		$289.49
Toc - Plan #22 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 		$277.05
$314.45
$354.07
$494.81
$751.91 		$488.99
$526.39
$566.01
$706.75 		$700.93
$738.33
$777.95
$918.69 		$912.87
$950.27
$989.89
$1,130.63 		$211.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.10
$628.90
$708.14
$989.62
$1,503.82 		$766.04
$840.84
$920.08
$1,201.56 		$977.98
$1,052.78
$1,132.02
$1,413.50 		$1,189.92
$1,264.72
$1,343.96
$1,625.44 		$211.94
Toc - Plan #23 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 		$390.05
$442.71
$498.49
$696.63
$1,058.60 		$688.44
$741.10
$796.88
$995.02 		$986.83
$1,039.49
$1,095.27
$1,293.41 		$1,285.22
$1,337.88
$1,393.66
$1,591.80 		$298.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.10
$885.42
$996.98
$1,393.26
$2,117.20 		$1,078.49
$1,183.81
$1,295.37
$1,691.65 		$1,376.88
$1,482.20
$1,593.76
$1,990.04 		$1,675.27
$1,780.59
$1,892.15
$2,288.43 		$298.39
Toc - Plan #24 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 		$530.15
$601.72
$677.53
$946.85
$1,438.83 		$935.72
$1,007.29
$1,083.10
$1,352.42 		$1,341.29
$1,412.86
$1,488.67
$1,757.99 		$1,746.86
$1,818.43
$1,894.24
$2,163.56 		$405.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,060.30
$1,203.44
$1,355.06
$1,893.70
$2,877.66 		$1,465.87
$1,609.01
$1,760.63
$2,299.27 		$1,871.44
$2,014.58
$2,166.20
$2,704.84 		$2,277.01
$2,420.15
$2,571.77
$3,110.41 		$405.57
Toc - Plan #25 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 		$248.18
$281.68
$317.17
$443.25
$673.56 		$438.04
$471.54
$507.03
$633.11 		$627.90
$661.40
$696.89
$822.97 		$817.76
$851.26
$886.75
$1,012.83 		$189.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$496.36
$563.36
$634.34
$886.50
$1,347.12 		$686.22
$753.22
$824.20
$1,076.36 		$876.08
$943.08
$1,014.06
$1,266.22 		$1,065.94
$1,132.94
$1,203.92
$1,456.08 		$189.86
Toc - Plan #26 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 		$366.80
$416.32
$468.77
$655.10
$995.49 		$647.40
$696.92
$749.37
$935.70 		$928.00
$977.52
$1,029.97
$1,216.30 		$1,208.60
$1,258.12
$1,310.57
$1,496.90 		$280.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.60
$832.64
$937.54
$1,310.20
$1,990.98 		$1,014.20
$1,113.24
$1,218.14
$1,590.80 		$1,294.80
$1,393.84
$1,498.74
$1,871.40 		$1,575.40
$1,674.44
$1,779.34
$2,152.00 		$280.60

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #27 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 		$568.60
$645.35
$726.66
$1,015.51
$1,543.16 		$1,003.57
$1,080.32
$1,161.63
$1,450.48 		$1,438.54
$1,515.29
$1,596.60
$1,885.45 		$1,873.51
$1,950.26
$2,031.57
$2,320.42 		$434.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,137.20
$1,290.70
$1,453.32
$2,031.02
$3,086.32 		$1,572.17
$1,725.67
$1,888.29
$2,465.99 		$2,007.14
$2,160.64
$2,323.26
$2,900.96 		$2,442.11
$2,595.61
$2,758.23
$3,335.93 		$434.97
Toc - Plan #28 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 		$812.02
$921.63
$1,037.75
$1,450.25
$2,203.79 		$1,433.21
$1,542.82
$1,658.94
$2,071.44 		$2,054.40
$2,164.01
$2,280.13
$2,692.63 		$2,675.59
$2,785.20
$2,901.32
$3,313.82 		$621.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,624.04
$1,843.26
$2,075.50
$2,900.50
$4,407.58 		$2,245.23
$2,464.45
$2,696.69
$3,521.69 		$2,866.42
$3,085.64
$3,317.88
$4,142.88 		$3,487.61
$3,706.83
$3,939.07
$4,764.07 		$621.19
Toc - Plan #29 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 		$805.07
$913.74
$1,028.87
$1,437.84
$2,184.93 		$1,420.94
$1,529.61
$1,644.74
$2,053.71 		$2,036.81
$2,145.48
$2,260.61
$2,669.58 		$2,652.68
$2,761.35
$2,876.48
$3,285.45 		$615.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,610.14
$1,827.48
$2,057.74
$2,875.68
$4,369.86 		$2,226.01
$2,443.35
$2,673.61
$3,491.55 		$2,841.88
$3,059.22
$3,289.48
$4,107.42 		$3,457.75
$3,675.09
$3,905.35
$4,723.29 		$615.87

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5357 | Toll Free: 1-800-980-5357 | TTY: 1-800-980-5357
Toc - Plan #30 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 		$413.34
$469.14
$528.25
$738.23
$1,121.81 		$729.55
$785.35
$844.46
$1,054.44 		$1,045.76
$1,101.56
$1,160.67
$1,370.65 		$1,361.97
$1,417.77
$1,476.88
$1,686.86 		$316.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.68
$938.28
$1,056.50
$1,476.46
$2,243.62 		$1,142.89
$1,254.49
$1,372.71
$1,792.67 		$1,459.10
$1,570.70
$1,688.92
$2,108.88 		$1,775.31
$1,886.91
$2,005.13
$2,425.09 		$316.21
Toc - Plan #31 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 		$433.17
$491.64
$553.59
$773.63
$1,175.61 		$764.54
$823.01
$884.96
$1,105.00 		$1,095.91
$1,154.38
$1,216.33
$1,436.37 		$1,427.28
$1,485.75
$1,547.70
$1,767.74 		$331.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.34
$983.28
$1,107.18
$1,547.26
$2,351.22 		$1,197.71
$1,314.65
$1,438.55
$1,878.63 		$1,529.08
$1,646.02
$1,769.92
$2,210.00 		$1,860.45
$1,977.39
$2,101.29
$2,541.37 		$331.37
Toc - Plan #32 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 		$434.35
$492.99
$555.10
$775.75
$1,178.82 		$766.63
$825.27
$887.38
$1,108.03 		$1,098.91
$1,157.55
$1,219.66
$1,440.31 		$1,431.19
$1,489.83
$1,551.94
$1,772.59 		$332.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.70
$985.98
$1,110.20
$1,551.50
$2,357.64 		$1,200.98
$1,318.26
$1,442.48
$1,883.78 		$1,533.26
$1,650.54
$1,774.76
$2,216.06 		$1,865.54
$1,982.82
$2,107.04
$2,548.34 		$332.28
Toc - Plan #33 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 		$307.42
$348.92
$392.88
$549.05
$834.33 		$542.59
$584.09
$628.05
$784.22 		$777.76
$819.26
$863.22
$1,019.39 		$1,012.93
$1,054.43
$1,098.39
$1,254.56 		$235.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.84
$697.84
$785.76
$1,098.10
$1,668.66 		$850.01
$933.01
$1,020.93
$1,333.27 		$1,085.18
$1,168.18
$1,256.10
$1,568.44 		$1,320.35
$1,403.35
$1,491.27
$1,803.61 		$235.17
Toc - Plan #34 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 		$412.45
$468.14
$527.12
$736.64
$1,119.40 		$727.98
$783.67
$842.65
$1,052.17 		$1,043.51
$1,099.20
$1,158.18
$1,367.70 		$1,359.04
$1,414.73
$1,473.71
$1,683.23 		$315.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.90
$936.28
$1,054.24
$1,473.28
$2,238.80 		$1,140.43
$1,251.81
$1,369.77
$1,788.81 		$1,455.96
$1,567.34
$1,685.30
$2,104.34 		$1,771.49
$1,882.87
$2,000.83
$2,419.87 		$315.53
Toc - Plan #35 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 		$418.96
$475.52
$535.44
$748.27
$1,137.07 		$739.47
$796.03
$855.95
$1,068.78 		$1,059.98
$1,116.54
$1,176.46
$1,389.29 		$1,380.49
$1,437.05
$1,496.97
$1,709.80 		$320.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.92
$951.04
$1,070.88
$1,496.54
$2,274.14 		$1,158.43
$1,271.55
$1,391.39
$1,817.05 		$1,478.94
$1,592.06
$1,711.90
$2,137.56 		$1,799.45
$1,912.57
$2,032.41
$2,458.07 		$320.51
Toc - Plan #36 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 		$431.39
$489.63
$551.32
$770.46
$1,170.79 		$761.40
$819.64
$881.33
$1,100.47 		$1,091.41
$1,149.65
$1,211.34
$1,430.48 		$1,421.42
$1,479.66
$1,541.35
$1,760.49 		$330.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.78
$979.26
$1,102.64
$1,540.92
$2,341.58 		$1,192.79
$1,309.27
$1,432.65
$1,870.93 		$1,522.80
$1,639.28
$1,762.66
$2,200.94 		$1,852.81
$1,969.29
$2,092.67
$2,530.95 		$330.01
Toc - Plan #37 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 		$312.15
$354.29
$398.93
$557.50
$847.18 		$550.95
$593.09
$637.73
$796.30 		$789.75
$831.89
$876.53
$1,035.10 		$1,028.55
$1,070.69
$1,115.33
$1,273.90 		$238.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.30
$708.58
$797.86
$1,115.00
$1,694.36 		$863.10
$947.38
$1,036.66
$1,353.80 		$1,101.90
$1,186.18
$1,275.46
$1,592.60 		$1,340.70
$1,424.98
$1,514.26
$1,831.40 		$238.80
Toc - Plan #38 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 		$295.88
$335.82
$378.13
$528.44
$803.01 		$522.23
$562.17
$604.48
$754.79 		$748.58
$788.52
$830.83
$981.14 		$974.93
$1,014.87
$1,057.18
$1,207.49 		$226.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.76
$671.64
$756.26
$1,056.88
$1,606.02 		$818.11
$897.99
$982.61
$1,283.23 		$1,044.46
$1,124.34
$1,208.96
$1,509.58 		$1,270.81
$1,350.69
$1,435.31
$1,735.93 		$226.35
Toc - Plan #39 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 		$430.21
$488.28
$549.80
$768.35
$1,167.58 		$759.32
$817.39
$878.91
$1,097.46 		$1,088.43
$1,146.50
$1,208.02
$1,426.57 		$1,417.54
$1,475.61
$1,537.13
$1,755.68 		$329.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.42
$976.56
$1,099.60
$1,536.70
$2,335.16 		$1,189.53
$1,305.67
$1,428.71
$1,865.81 		$1,518.64
$1,634.78
$1,757.82
$2,194.92 		$1,847.75
$1,963.89
$2,086.93
$2,524.03 		$329.11
Toc - Plan #40 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 		$308.01
$349.59
$393.64
$550.10
$835.94 		$543.64
$585.22
$629.27
$785.73 		$779.27
$820.85
$864.90
$1,021.36 		$1,014.90
$1,056.48
$1,100.53
$1,256.99 		$235.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.02
$699.18
$787.28
$1,100.20
$1,671.88 		$851.65
$934.81
$1,022.91
$1,335.83 		$1,087.28
$1,170.44
$1,258.54
$1,571.46 		$1,322.91
$1,406.07
$1,494.17
$1,807.09 		$235.63

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #41 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 		$396.14
$449.62
$506.27
$707.51
$1,075.13 		$699.19
$752.67
$809.32
$1,010.56 		$1,002.24
$1,055.72
$1,112.37
$1,313.61 		$1,305.29
$1,358.77
$1,415.42
$1,616.66 		$303.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.28
$899.24
$1,012.54
$1,415.02
$2,150.26 		$1,095.33
$1,202.29
$1,315.59
$1,718.07 		$1,398.38
$1,505.34
$1,618.64
$2,021.12 		$1,701.43
$1,808.39
$1,921.69
$2,324.17 		$303.05
Toc - Plan #42 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 		$343.07
$389.39
$438.44
$612.72
$931.09 		$605.52
$651.84
$700.89
$875.17 		$867.97
$914.29
$963.34
$1,137.62 		$1,130.42
$1,176.74
$1,225.79
$1,400.07 		$262.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.14
$778.78
$876.88
$1,225.44
$1,862.18 		$948.59
$1,041.23
$1,139.33
$1,487.89 		$1,211.04
$1,303.68
$1,401.78
$1,750.34 		$1,473.49
$1,566.13
$1,664.23
$2,012.79 		$262.45
Toc - Plan #43 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 		$572.23
$649.48
$731.31
$1,022.00
$1,553.03 		$1,009.99
$1,087.24
$1,169.07
$1,459.76 		$1,447.75
$1,525.00
$1,606.83
$1,897.52 		$1,885.51
$1,962.76
$2,044.59
$2,335.28 		$437.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,144.46
$1,298.96
$1,462.62
$2,044.00
$3,106.06 		$1,582.22
$1,736.72
$1,900.38
$2,481.76 		$2,019.98
$2,174.48
$2,338.14
$2,919.52 		$2,457.74
$2,612.24
$2,775.90
$3,357.28 		$437.76
Toc - Plan #44 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 		$547.96
$621.93
$700.29
$978.66
$1,487.16 		$967.15
$1,041.12
$1,119.48
$1,397.85 		$1,386.34
$1,460.31
$1,538.67
$1,817.04 		$1,805.53
$1,879.50
$1,957.86
$2,236.23 		$419.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,095.92
$1,243.86
$1,400.58
$1,957.32
$2,974.32 		$1,515.11
$1,663.05
$1,819.77
$2,376.51 		$1,934.30
$2,082.24
$2,238.96
$2,795.70 		$2,353.49
$2,501.43
$2,658.15
$3,214.89 		$419.19
Toc - Plan #45 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 		$477.11
$541.52
$609.74
$852.11
$1,294.87 		$842.10
$906.51
$974.73
$1,217.10 		$1,207.09
$1,271.50
$1,339.72
$1,582.09 		$1,572.08
$1,636.49
$1,704.71
$1,947.08 		$364.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.22
$1,083.04
$1,219.48
$1,704.22
$2,589.74 		$1,319.21
$1,448.03
$1,584.47
$2,069.21 		$1,684.20
$1,813.02
$1,949.46
$2,434.20 		$2,049.19
$2,178.01
$2,314.45
$2,799.19 		$364.99

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #46 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7300 (Duke Health and Wake Med)

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 		$366.37
$415.83
$468.23
$654.34
$994.34 		$646.65
$696.11
$748.51
$934.62 		$926.93
$976.39
$1,028.79
$1,214.90 		$1,207.21
$1,256.67
$1,309.07
$1,495.18 		$280.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.74
$831.66
$936.46
$1,308.68
$1,988.68 		$1,013.02
$1,111.94
$1,216.74
$1,588.96 		$1,293.30
$1,392.22
$1,497.02
$1,869.24 		$1,573.58
$1,672.50
$1,777.30
$2,149.52 		$280.28
Toc - Plan #47 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8700 (Duke Health and Wake Med) ($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 		$350.44
$397.75
$447.87
$625.89
$951.11 		$618.53
$665.84
$715.96
$893.98 		$886.62
$933.93
$984.05
$1,162.07 		$1,154.71
$1,202.02
$1,252.14
$1,430.16 		$268.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.88
$795.50
$895.74
$1,251.78
$1,902.22 		$968.97
$1,063.59
$1,163.83
$1,519.87 		$1,237.06
$1,331.68
$1,431.92
$1,787.96 		$1,505.15
$1,599.77
$1,700.01
$2,056.05 		$268.09
Toc - Plan #48 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500 (Duke Health and Wake Med)

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 		$396.88
$450.46
$507.21
$708.83
$1,077.13 		$700.49
$754.07
$810.82
$1,012.44 		$1,004.10
$1,057.68
$1,114.43
$1,316.05 		$1,307.71
$1,361.29
$1,418.04
$1,619.66 		$303.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.76
$900.92
$1,014.42
$1,417.66
$2,154.26 		$1,097.37
$1,204.53
$1,318.03
$1,721.27 		$1,400.98
$1,508.14
$1,621.64
$2,024.88 		$1,704.59
$1,811.75
$1,925.25
$2,328.49 		$303.61
Toc - Plan #49 Cigna Healthcare
Gold

(HMO) Cigna Connect 2000A (Duke Health and Wake Med)

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
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$573.72
$651.17
$733.21
$1,024.66
$1,557.07 		$1,012.61
$1,090.06
$1,172.10
$1,463.55 		$1,451.50
$1,528.95
$1,610.99
$1,902.44 		$1,890.39
$1,967.84
$2,049.88
$2,341.33 		$438.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,147.44
$1,302.34
$1,466.42
$2,049.32
$3,114.14 		$1,586.33
$1,741.23
$1,905.31
$2,488.21 		$2,025.22
$2,180.12
$2,344.20
$2,927.10 		$2,464.11
$2,619.01
$2,783.09
$3,365.99 		$438.89
Toc - Plan #50 Cigna Healthcare
Silver

(HMO) Cigna Connect 4500 (Duke Health and Wake Med)

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 		$395.70
$449.12
$505.71
$706.72
$1,073.93 		$698.41
$751.83
$808.42
$1,009.43 		$1,001.12
$1,054.54
$1,111.13
$1,312.14 		$1,303.83
$1,357.25
$1,413.84
$1,614.85 		$302.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.40
$898.24
$1,011.42
$1,413.44
$2,147.86 		$1,094.11
$1,200.95
$1,314.13
$1,716.15 		$1,396.82
$1,503.66
$1,616.84
$2,018.86 		$1,699.53
$1,806.37
$1,919.55
$2,321.57 		$302.71
Toc - Plan #51 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5900 (Duke Health and Wake Med)

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 		$371.65
$421.83
$474.97
$663.77
$1,008.67 		$655.97
$706.15
$759.29
$948.09 		$940.29
$990.47
$1,043.61
$1,232.41 		$1,224.61
$1,274.79
$1,327.93
$1,516.73 		$284.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.30
$843.66
$949.94
$1,327.54
$2,017.34 		$1,027.62
$1,127.98
$1,234.26
$1,611.86 		$1,311.94
$1,412.30
$1,518.58
$1,896.18 		$1,596.26
$1,696.62
$1,802.90
$2,180.50 		$284.32
Toc - Plan #52 Cigna Healthcare
Silver

(HMO) Cigna Connect 5500 (Duke Health and Wake Med)

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 		$394.52
$447.78
$504.20
$704.62
$1,070.74 		$696.33
$749.59
$806.01
$1,006.43 		$998.14
$1,051.40
$1,107.82
$1,308.24 		$1,299.95
$1,353.21
$1,409.63
$1,610.05 		$301.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.04
$895.56
$1,008.40
$1,409.24
$2,141.48 		$1,090.85
$1,197.37
$1,310.21
$1,711.05 		$1,392.66
$1,499.18
$1,612.02
$2,012.86 		$1,694.47
$1,800.99
$1,913.83
$2,314.67 		$301.81
Toc - Plan #53 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500 Enhanced Diabetes Care (Duke Health and Wake Med)

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 		$395.53
$448.92
$505.48
$706.41
$1,073.46 		$698.11
$751.50
$808.06
$1,008.99 		$1,000.69
$1,054.08
$1,110.64
$1,311.57 		$1,303.27
$1,356.66
$1,413.22
$1,614.15 		$302.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.06
$897.84
$1,010.96
$1,412.82
$2,146.92 		$1,093.64
$1,200.42
$1,313.54
$1,715.40 		$1,396.22
$1,503.00
$1,616.12
$2,017.98 		$1,698.80
$1,805.58
$1,918.70
$2,320.56 		$302.58
Toc - Plan #54 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7000 (with Duke Health and Wake Med)

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$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 		$364.32
$413.51
$465.60
$650.68
$988.77 		$643.03
$692.22
$744.31
$929.39 		$921.74
$970.93
$1,023.02
$1,208.10 		$1,200.45
$1,249.64
$1,301.73
$1,486.81 		$278.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.64
$827.02
$931.20
$1,301.36
$1,977.54 		$1,007.35
$1,105.73
$1,209.91
$1,580.07 		$1,286.06
$1,384.44
$1,488.62
$1,858.78 		$1,564.77
$1,663.15
$1,767.33
$2,137.49 		$278.71
Toc - Plan #55 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care (Duke Health and Wake Med)

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 		$394.74
$448.03
$504.48
$705.01
$1,071.33 		$696.72
$750.01
$806.46
$1,006.99 		$998.70
$1,051.99
$1,108.44
$1,308.97 		$1,300.68
$1,353.97
$1,410.42
$1,610.95 		$301.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.48
$896.06
$1,008.96
$1,410.02
$2,142.66 		$1,091.46
$1,198.04
$1,310.94
$1,712.00 		$1,393.44
$1,500.02
$1,612.92
$2,013.98 		$1,695.42
$1,802.00
$1,914.90
$2,315.96 		$301.98

ADVERTISEMENT

Ambetter of North Carolina

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

Toc - Plan #56 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 		$356.97
$405.15
$456.20
$637.53
$968.79 		$630.05
$678.23
$729.28
$910.61 		$903.13
$951.31
$1,002.36
$1,183.69 		$1,176.21
$1,224.39
$1,275.44
$1,456.77 		$273.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.94
$810.30
$912.40
$1,275.06
$1,937.58 		$987.02
$1,083.38
$1,185.48
$1,548.14 		$1,260.10
$1,356.46
$1,458.56
$1,821.22 		$1,533.18
$1,629.54
$1,731.64
$2,094.30 		$273.08
Toc - Plan #57 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 		$391.57
$444.42
$500.42
$699.33
$1,062.70 		$691.11
$743.96
$799.96
$998.87 		$990.65
$1,043.50
$1,099.50
$1,298.41 		$1,290.19
$1,343.04
$1,399.04
$1,597.95 		$299.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.14
$888.84
$1,000.84
$1,398.66
$2,125.40 		$1,082.68
$1,188.38
$1,300.38
$1,698.20 		$1,382.22
$1,487.92
$1,599.92
$1,997.74 		$1,681.76
$1,787.46
$1,899.46
$2,297.28 		$299.54
Toc - Plan #58 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 		$500.73
$568.31
$639.92
$894.28
$1,358.95 		$883.78
$951.36
$1,022.97
$1,277.33 		$1,266.83
$1,334.41
$1,406.02
$1,660.38 		$1,649.88
$1,717.46
$1,789.07
$2,043.43 		$383.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,001.46
$1,136.62
$1,279.84
$1,788.56
$2,717.90 		$1,384.51
$1,519.67
$1,662.89
$2,171.61 		$1,767.56
$1,902.72
$2,045.94
$2,554.66 		$2,150.61
$2,285.77
$2,428.99
$2,937.71 		$383.05
Toc - Plan #59 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 		$541.64
$614.75
$692.20
$967.34
$1,469.97 		$955.98
$1,029.09
$1,106.54
$1,381.68 		$1,370.32
$1,443.43
$1,520.88
$1,796.02 		$1,784.66
$1,857.77
$1,935.22
$2,210.36 		$414.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,083.28
$1,229.50
$1,384.40
$1,934.68
$2,939.94 		$1,497.62
$1,643.84
$1,798.74
$2,349.02 		$1,911.96
$2,058.18
$2,213.08
$2,763.36 		$2,326.30
$2,472.52
$2,627.42
$3,177.70 		$414.34
Toc - Plan #60 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 		$494.87
$561.67
$632.43
$883.82
$1,343.05 		$873.44
$940.24
$1,011.00
$1,262.39 		$1,252.01
$1,318.81
$1,389.57
$1,640.96 		$1,630.58
$1,697.38
$1,768.14
$2,019.53 		$378.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$989.74
$1,123.34
$1,264.86
$1,767.64
$2,686.10 		$1,368.31
$1,501.91
$1,643.43
$2,146.21 		$1,746.88
$1,880.48
$2,022.00
$2,524.78 		$2,125.45
$2,259.05
$2,400.57
$2,903.35 		$378.57
Toc - Plan #61 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 		$384.41
$436.29
$491.26
$686.54
$1,043.26 		$678.48
$730.36
$785.33
$980.61 		$972.55
$1,024.43
$1,079.40
$1,274.68 		$1,266.62
$1,318.50
$1,373.47
$1,568.75 		$294.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.82
$872.58
$982.52
$1,373.08
$2,086.52 		$1,062.89
$1,166.65
$1,276.59
$1,667.15 		$1,356.96
$1,460.72
$1,570.66
$1,961.22 		$1,651.03
$1,754.79
$1,864.73
$2,255.29 		$294.07
Toc - Plan #62 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 		$408.19
$463.29
$521.66
$729.02
$1,107.81 		$720.45
$775.55
$833.92
$1,041.28 		$1,032.71
$1,087.81
$1,146.18
$1,353.54 		$1,344.97
$1,400.07
$1,458.44
$1,665.80 		$312.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.38
$926.58
$1,043.32
$1,458.04
$2,215.62 		$1,128.64
$1,238.84
$1,355.58
$1,770.30 		$1,440.90
$1,551.10
$1,667.84
$2,082.56 		$1,753.16
$1,863.36
$1,980.10
$2,394.82 		$312.26
Toc - Plan #63 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 		$417.46
$473.80
$533.50
$745.56
$1,132.95 		$736.81
$793.15
$852.85
$1,064.91 		$1,056.16
$1,112.50
$1,172.20
$1,384.26 		$1,375.51
$1,431.85
$1,491.55
$1,703.61 		$319.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.92
$947.60
$1,067.00
$1,491.12
$2,265.90 		$1,154.27
$1,266.95
$1,386.35
$1,810.47 		$1,473.62
$1,586.30
$1,705.70
$2,129.82 		$1,792.97
$1,905.65
$2,025.05
$2,449.17 		$319.35
Toc - Plan #64 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 		$438.44
$497.62
$560.31
$783.03
$1,189.89 		$773.84
$833.02
$895.71
$1,118.43 		$1,109.24
$1,168.42
$1,231.11
$1,453.83 		$1,444.64
$1,503.82
$1,566.51
$1,789.23 		$335.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.88
$995.24
$1,120.62
$1,566.06
$2,379.78 		$1,212.28
$1,330.64
$1,456.02
$1,901.46 		$1,547.68
$1,666.04
$1,791.42
$2,236.86 		$1,883.08
$2,001.44
$2,126.82
$2,572.26 		$335.40
Toc - Plan #65 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 		$474.24
$538.25
$606.07
$846.97
$1,287.06 		$837.03
$901.04
$968.86
$1,209.76 		$1,199.82
$1,263.83
$1,331.65
$1,572.55 		$1,562.61
$1,626.62
$1,694.44
$1,935.34 		$362.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$948.48
$1,076.50
$1,212.14
$1,693.94
$2,574.12 		$1,311.27
$1,439.29
$1,574.93
$2,056.73 		$1,674.06
$1,802.08
$1,937.72
$2,419.52 		$2,036.85
$2,164.87
$2,300.51
$2,782.31 		$362.79
Toc - Plan #66 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 		$474.29
$538.31
$606.13
$847.06
$1,287.19 		$837.11
$901.13
$968.95
$1,209.88 		$1,199.93
$1,263.95
$1,331.77
$1,572.70 		$1,562.75
$1,626.77
$1,694.59
$1,935.52 		$362.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$948.58
$1,076.62
$1,212.26
$1,694.12
$2,574.38 		$1,311.40
$1,439.44
$1,575.08
$2,056.94 		$1,674.22
$1,802.26
$1,937.90
$2,419.76 		$2,037.04
$2,165.08
$2,300.72
$2,782.58 		$362.82
Toc - Plan #67 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 		$480.45
$545.30
$614.00
$858.06
$1,303.91 		$847.99
$912.84
$981.54
$1,225.60 		$1,215.53
$1,280.38
$1,349.08
$1,593.14 		$1,583.07
$1,647.92
$1,716.62
$1,960.68 		$367.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$960.90
$1,090.60
$1,228.00
$1,716.12
$2,607.82 		$1,328.44
$1,458.14
$1,595.54
$2,083.66 		$1,695.98
$1,825.68
$1,963.08
$2,451.20 		$2,063.52
$2,193.22
$2,330.62
$2,818.74 		$367.54
Toc - Plan #68 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 		$507.99
$576.55
$649.20
$907.25
$1,378.65 		$896.59
$965.15
$1,037.80
$1,295.85 		$1,285.19
$1,353.75
$1,426.40
$1,684.45 		$1,673.79
$1,742.35
$1,815.00
$2,073.05 		$388.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,015.98
$1,153.10
$1,298.40
$1,814.50
$2,757.30 		$1,404.58
$1,541.70
$1,687.00
$2,203.10 		$1,793.18
$1,930.30
$2,075.60
$2,591.70 		$2,181.78
$2,318.90
$2,464.20
$2,980.30 		$388.60
Toc - Plan #69 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 		$372.84
$423.16
$476.48
$665.88
$1,011.86 		$658.06
$708.38
$761.70
$951.10 		$943.28
$993.60
$1,046.92
$1,236.32 		$1,228.50
$1,278.82
$1,332.14
$1,521.54 		$285.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.68
$846.32
$952.96
$1,331.76
$2,023.72 		$1,030.90
$1,131.54
$1,238.18
$1,616.98 		$1,316.12
$1,416.76
$1,523.40
$1,902.20 		$1,601.34
$1,701.98
$1,808.62
$2,187.42 		$285.22
Toc - Plan #70 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 		$408.98
$464.18
$522.66
$730.42
$1,109.94 		$721.84
$777.04
$835.52
$1,043.28 		$1,034.70
$1,089.90
$1,148.38
$1,356.14 		$1,347.56
$1,402.76
$1,461.24
$1,669.00 		$312.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.96
$928.36
$1,045.32
$1,460.84
$2,219.88 		$1,130.82
$1,241.22
$1,358.18
$1,773.70 		$1,443.68
$1,554.08
$1,671.04
$2,086.56 		$1,756.54
$1,866.94
$1,983.90
$2,399.42 		$312.86
Toc - Plan #71 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 		$522.99
$593.58
$668.36
$934.04
$1,419.36 		$923.07
$993.66
$1,068.44
$1,334.12 		$1,323.15
$1,393.74
$1,468.52
$1,734.20 		$1,723.23
$1,793.82
$1,868.60
$2,134.28 		$400.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,045.98
$1,187.16
$1,336.72
$1,868.08
$2,838.72 		$1,446.06
$1,587.24
$1,736.80
$2,268.16 		$1,846.14
$1,987.32
$2,136.88
$2,668.24 		$2,246.22
$2,387.40
$2,536.96
$3,068.32 		$400.08
Toc - Plan #72 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 		$565.71
$642.07
$722.97
$1,010.35
$1,535.32 		$998.47
$1,074.83
$1,155.73
$1,443.11 		$1,431.23
$1,507.59
$1,588.49
$1,875.87 		$1,863.99
$1,940.35
$2,021.25
$2,308.63 		$432.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,131.42
$1,284.14
$1,445.94
$2,020.70
$3,070.64 		$1,564.18
$1,716.90
$1,878.70
$2,453.46 		$1,996.94
$2,149.66
$2,311.46
$2,886.22 		$2,429.70
$2,582.42
$2,744.22
$3,318.98 		$432.76
Toc - Plan #73 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 		$516.87
$586.63
$660.55
$923.11
$1,402.75 		$912.27
$982.03
$1,055.95
$1,318.51 		$1,307.67
$1,377.43
$1,451.35
$1,713.91 		$1,703.07
$1,772.83
$1,846.75
$2,109.31 		$395.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,033.74
$1,173.26
$1,321.10
$1,846.22
$2,805.50 		$1,429.14
$1,568.66
$1,716.50
$2,241.62 		$1,824.54
$1,964.06
$2,111.90
$2,637.02 		$2,219.94
$2,359.46
$2,507.30
$3,032.42 		$395.40
Toc - Plan #74 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 		$401.50
$455.69
$513.10
$717.06
$1,089.64 		$708.64
$762.83
$820.24
$1,024.20 		$1,015.78
$1,069.97
$1,127.38
$1,331.34 		$1,322.92
$1,377.11
$1,434.52
$1,638.48 		$307.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.00
$911.38
$1,026.20
$1,434.12
$2,179.28 		$1,110.14
$1,218.52
$1,333.34
$1,741.26 		$1,417.28
$1,525.66
$1,640.48
$2,048.40 		$1,724.42
$1,832.80
$1,947.62
$2,355.54 		$307.14
Toc - Plan #75 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 		$426.34
$483.89
$544.85
$761.43
$1,157.06 		$752.48
$810.03
$870.99
$1,087.57 		$1,078.62
$1,136.17
$1,197.13
$1,413.71 		$1,404.76
$1,462.31
$1,523.27
$1,739.85 		$326.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.68
$967.78
$1,089.70
$1,522.86
$2,314.12 		$1,178.82
$1,293.92
$1,415.84
$1,849.00 		$1,504.96
$1,620.06
$1,741.98
$2,175.14 		$1,831.10
$1,946.20
$2,068.12
$2,501.28 		$326.14
Toc - Plan #76 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 		$436.02
$494.87
$557.22
$778.71
$1,183.32 		$769.56
$828.41
$890.76
$1,112.25 		$1,103.10
$1,161.95
$1,224.30
$1,445.79 		$1,436.64
$1,495.49
$1,557.84
$1,779.33 		$333.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.04
$989.74
$1,114.44
$1,557.42
$2,366.64 		$1,205.58
$1,323.28
$1,447.98
$1,890.96 		$1,539.12
$1,656.82
$1,781.52
$2,224.50 		$1,872.66
$1,990.36
$2,115.06
$2,558.04 		$333.54
Toc - Plan #77 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 		$457.93
$519.74
$585.22
$817.84
$1,242.79 		$808.24
$870.05
$935.53
$1,168.15 		$1,158.55
$1,220.36
$1,285.84
$1,518.46 		$1,508.86
$1,570.67
$1,636.15
$1,868.77 		$350.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.86
$1,039.48
$1,170.44
$1,635.68
$2,485.58 		$1,266.17
$1,389.79
$1,520.75
$1,985.99 		$1,616.48
$1,740.10
$1,871.06
$2,336.30 		$1,966.79
$2,090.41
$2,221.37
$2,686.61 		$350.31
Toc - Plan #78 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 		$495.37
$562.24
$633.08
$884.72
$1,344.42 		$874.32
$941.19
$1,012.03
$1,263.67 		$1,253.27
$1,320.14
$1,390.98
$1,642.62 		$1,632.22
$1,699.09
$1,769.93
$2,021.57 		$378.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$990.74
$1,124.48
$1,266.16
$1,769.44
$2,688.84 		$1,369.69
$1,503.43
$1,645.11
$2,148.39 		$1,748.64
$1,882.38
$2,024.06
$2,527.34 		$2,127.59
$2,261.33
$2,403.01
$2,906.29 		$378.95
Toc - Plan #79 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 		$501.81
$569.54
$641.30
$896.21
$1,361.88 		$885.68
$953.41
$1,025.17
$1,280.08 		$1,269.55
$1,337.28
$1,409.04
$1,663.95 		$1,653.42
$1,721.15
$1,792.91
$2,047.82 		$383.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.62
$1,139.08
$1,282.60
$1,792.42
$2,723.76 		$1,387.49
$1,522.95
$1,666.47
$2,176.29 		$1,771.36
$1,906.82
$2,050.34
$2,560.16 		$2,155.23
$2,290.69
$2,434.21
$2,944.03 		$383.87
Toc - Plan #80 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 		$530.57
$602.19
$678.06
$947.58
$1,439.94 		$936.45
$1,008.07
$1,083.94
$1,353.46 		$1,342.33
$1,413.95
$1,489.82
$1,759.34 		$1,748.21
$1,819.83
$1,895.70
$2,165.22 		$405.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,061.14
$1,204.38
$1,356.12
$1,895.16
$2,879.88 		$1,467.02
$1,610.26
$1,762.00
$2,301.04 		$1,872.90
$2,016.14
$2,167.88
$2,706.92 		$2,278.78
$2,422.02
$2,573.76
$3,112.80 		$405.88

‡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 Orange County here.

Orange County is in “Rating Area 11” of North Carolina.

Currently, there are 80 plans offered in Rating Area 11.

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2022 Obamacare Plans for Orange County, NC

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