Obamacare 2022 Rates for Portage County

Obamacare > Rates > Ohio > Portage 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 Portage County, OH.

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, 98 Plans and 2022 Rates for Portage County, Ohio

Below, you’ll find a summary of the 98 plans for Portage County, Ohio and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Ambetter from Buckeye Health

Local: 1-877-687-1189 | Toll Free: 1-877-687-1189 | TTY: 1-877-941-9236
Toc - Plan #1 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$334.63
$379.80
$427.65
$597.64
$908.17 		$590.62
$635.79
$683.64
$853.63 		$846.61
$891.78
$939.63
$1,109.62 		$1,102.60
$1,147.77
$1,195.62
$1,365.61 		$255.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.26
$759.60
$855.30
$1,195.28
$1,816.34 		$925.25
$1,015.59
$1,111.29
$1,451.27 		$1,181.24
$1,271.58
$1,367.28
$1,707.26 		$1,437.23
$1,527.57
$1,623.27
$1,963.25 		$255.99
Toc - Plan #2 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$330.82
$375.47
$422.77
$590.82
$897.81 		$583.89
$628.54
$675.84
$843.89 		$836.96
$881.61
$928.91
$1,096.96 		$1,090.03
$1,134.68
$1,181.98
$1,350.03 		$253.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$661.64
$750.94
$845.54
$1,181.64
$1,795.62 		$914.71
$1,004.01
$1,098.61
$1,434.71 		$1,167.78
$1,257.08
$1,351.68
$1,687.78 		$1,420.85
$1,510.15
$1,604.75
$1,940.85 		$253.07
Toc - Plan #3 Ambetter from Buckeye Health
Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$374.75
$425.34
$478.92
$669.29
$1,017.06 		$661.43
$712.02
$765.60
$955.97 		$948.11
$998.70
$1,052.28
$1,242.65 		$1,234.79
$1,285.38
$1,338.96
$1,529.33 		$286.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.50
$850.68
$957.84
$1,338.58
$2,034.12 		$1,036.18
$1,137.36
$1,244.52
$1,625.26 		$1,322.86
$1,424.04
$1,531.20
$1,911.94 		$1,609.54
$1,710.72
$1,817.88
$2,198.62 		$286.68
Toc - Plan #4 Ambetter from Buckeye Health
Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$263.89
$299.51
$337.24
$471.30
$716.18 		$465.76
$501.38
$539.11
$673.17 		$667.63
$703.25
$740.98
$875.04 		$869.50
$905.12
$942.85
$1,076.91 		$201.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527.78
$599.02
$674.48
$942.60
$1,432.36 		$729.65
$800.89
$876.35
$1,144.47 		$931.52
$1,002.76
$1,078.22
$1,346.34 		$1,133.39
$1,204.63
$1,280.09
$1,548.21 		$201.87
Toc - Plan #5 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$287.92
$326.78
$367.95
$514.21
$781.39 		$508.17
$547.03
$588.20
$734.46 		$728.42
$767.28
$808.45
$954.71 		$948.67
$987.53
$1,028.70
$1,174.96 		$220.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.84
$653.56
$735.90
$1,028.42
$1,562.78 		$796.09
$873.81
$956.15
$1,248.67 		$1,016.34
$1,094.06
$1,176.40
$1,468.92 		$1,236.59
$1,314.31
$1,396.65
$1,689.17 		$220.25
Toc - Plan #6 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$276.24
$313.52
$353.02
$493.35
$749.69 		$487.56
$524.84
$564.34
$704.67 		$698.88
$736.16
$775.66
$915.99 		$910.20
$947.48
$986.98
$1,127.31 		$211.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.48
$627.04
$706.04
$986.70
$1,499.38 		$763.80
$838.36
$917.36
$1,198.02 		$975.12
$1,049.68
$1,128.68
$1,409.34 		$1,186.44
$1,261.00
$1,340.00
$1,620.66 		$211.32
Toc - Plan #7 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 24

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.89
$386.90
$435.65
$608.81
$925.15 		$601.66
$647.67
$696.42
$869.58 		$862.43
$908.44
$957.19
$1,130.35 		$1,123.20
$1,169.21
$1,217.96
$1,391.12 		$260.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.78
$773.80
$871.30
$1,217.62
$1,850.30 		$942.55
$1,034.57
$1,132.07
$1,478.39 		$1,203.32
$1,295.34
$1,392.84
$1,739.16 		$1,464.09
$1,556.11
$1,653.61
$1,999.93 		$260.77
Toc - Plan #8 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$283.60
$321.88
$362.43
$506.50
$769.67 		$500.55
$538.83
$579.38
$723.45 		$717.50
$755.78
$796.33
$940.40 		$934.45
$972.73
$1,013.28
$1,157.35 		$216.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.20
$643.76
$724.86
$1,013.00
$1,539.34 		$784.15
$860.71
$941.81
$1,229.95 		$1,001.10
$1,077.66
$1,158.76
$1,446.90 		$1,218.05
$1,294.61
$1,375.71
$1,663.85 		$216.95
Toc - Plan #9 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$306.56
$347.93
$391.77
$547.50
$831.97 		$541.07
$582.44
$626.28
$782.01 		$775.58
$816.95
$860.79
$1,016.52 		$1,010.09
$1,051.46
$1,095.30
$1,251.03 		$234.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.12
$695.86
$783.54
$1,095.00
$1,663.94 		$847.63
$930.37
$1,018.05
$1,329.51 		$1,082.14
$1,164.88
$1,252.56
$1,564.02 		$1,316.65
$1,399.39
$1,487.07
$1,798.53 		$234.51
Toc - Plan #10 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$321.08
$364.42
$410.33
$573.43
$871.39 		$566.70
$610.04
$655.95
$819.05 		$812.32
$855.66
$901.57
$1,064.67 		$1,057.94
$1,101.28
$1,147.19
$1,310.29 		$245.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.16
$728.84
$820.66
$1,146.86
$1,742.78 		$887.78
$974.46
$1,066.28
$1,392.48 		$1,133.40
$1,220.08
$1,311.90
$1,638.10 		$1,379.02
$1,465.70
$1,557.52
$1,883.72 		$245.62
Toc - Plan #11 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$315.23
$357.77
$402.84
$562.97
$855.49 		$556.37
$598.91
$643.98
$804.11 		$797.51
$840.05
$885.12
$1,045.25 		$1,038.65
$1,081.19
$1,126.26
$1,286.39 		$241.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.46
$715.54
$805.68
$1,125.94
$1,710.98 		$871.60
$956.68
$1,046.82
$1,367.08 		$1,112.74
$1,197.82
$1,287.96
$1,608.22 		$1,353.88
$1,438.96
$1,529.10
$1,849.36 		$241.14
Toc - Plan #12 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$315.06
$357.58
$402.63
$562.68
$855.04 		$556.07
$598.59
$643.64
$803.69 		$797.08
$839.60
$884.65
$1,044.70 		$1,038.09
$1,080.61
$1,125.66
$1,285.71 		$241.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.12
$715.16
$805.26
$1,125.36
$1,710.08 		$871.13
$956.17
$1,046.27
$1,366.37 		$1,112.14
$1,197.18
$1,287.28
$1,607.38 		$1,353.15
$1,438.19
$1,528.29
$1,848.39 		$241.01
Toc - Plan #13 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.58
$364.99
$410.97
$574.33
$872.75 		$567.58
$610.99
$656.97
$820.33 		$813.58
$856.99
$902.97
$1,066.33 		$1,059.58
$1,102.99
$1,148.97
$1,312.33 		$246.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.16
$729.98
$821.94
$1,148.66
$1,745.50 		$889.16
$975.98
$1,067.94
$1,394.66 		$1,135.16
$1,221.98
$1,313.94
$1,640.66 		$1,381.16
$1,467.98
$1,559.94
$1,886.66 		$246.00
Toc - Plan #14 Ambetter from Buckeye Health
Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.23
$399.77
$450.14
$629.07
$955.94 		$621.68
$669.22
$719.59
$898.52 		$891.13
$938.67
$989.04
$1,167.97 		$1,160.58
$1,208.12
$1,258.49
$1,437.42 		$269.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.46
$799.54
$900.28
$1,258.14
$1,911.88 		$973.91
$1,068.99
$1,169.73
$1,527.59 		$1,243.36
$1,338.44
$1,439.18
$1,797.04 		$1,512.81
$1,607.89
$1,708.63
$2,066.49 		$269.45
Toc - Plan #15 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$342.48
$388.70
$437.67
$611.65
$929.46 		$604.47
$650.69
$699.66
$873.64 		$866.46
$912.68
$961.65
$1,135.63 		$1,128.45
$1,174.67
$1,223.64
$1,397.62 		$261.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.96
$777.40
$875.34
$1,223.30
$1,858.92 		$946.95
$1,039.39
$1,137.33
$1,485.29 		$1,208.94
$1,301.38
$1,399.32
$1,747.28 		$1,470.93
$1,563.37
$1,661.31
$2,009.27 		$261.99
Toc - Plan #16 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$346.43
$393.18
$442.72
$618.70
$940.17 		$611.44
$658.19
$707.73
$883.71 		$876.45
$923.20
$972.74
$1,148.72 		$1,141.46
$1,188.21
$1,237.75
$1,413.73 		$265.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.86
$786.36
$885.44
$1,237.40
$1,880.34 		$957.87
$1,051.37
$1,150.45
$1,502.41 		$1,222.88
$1,316.38
$1,415.46
$1,767.42 		$1,487.89
$1,581.39
$1,680.47
$2,032.43 		$265.01
Toc - Plan #17 Ambetter from Buckeye Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$387.96
$440.32
$495.80
$692.88
$1,052.90 		$684.74
$737.10
$792.58
$989.66 		$981.52
$1,033.88
$1,089.36
$1,286.44 		$1,278.30
$1,330.66
$1,386.14
$1,583.22 		$296.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.92
$880.64
$991.60
$1,385.76
$2,105.80 		$1,072.70
$1,177.42
$1,288.38
$1,682.54 		$1,369.48
$1,474.20
$1,585.16
$1,979.32 		$1,666.26
$1,770.98
$1,881.94
$2,276.10 		$296.78
Toc - Plan #18 Ambetter from Buckeye Health
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$273.19
$310.06
$349.13
$487.91
$741.42 		$482.18
$519.05
$558.12
$696.90 		$691.17
$728.04
$767.11
$905.89 		$900.16
$937.03
$976.10
$1,114.88 		$208.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.38
$620.12
$698.26
$975.82
$1,482.84 		$755.37
$829.11
$907.25
$1,184.81 		$964.36
$1,038.10
$1,116.24
$1,393.80 		$1,173.35
$1,247.09
$1,325.23
$1,602.79 		$208.99
Toc - Plan #19 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$298.07
$338.29
$380.92
$532.33
$808.92 		$526.08
$566.30
$608.93
$760.34 		$754.09
$794.31
$836.94
$988.35 		$982.10
$1,022.32
$1,064.95
$1,216.36 		$228.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.14
$676.58
$761.84
$1,064.66
$1,617.84 		$824.15
$904.59
$989.85
$1,292.67 		$1,052.16
$1,132.60
$1,217.86
$1,520.68 		$1,280.17
$1,360.61
$1,445.87
$1,748.69 		$228.01
Toc - Plan #20 Ambetter from Buckeye Health
Expanded Bronze

(HMO) Ambetter Essential Care 10 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$285.98
$324.57
$365.47
$510.74
$776.11 		$504.74
$543.33
$584.23
$729.50 		$723.50
$762.09
$802.99
$948.26 		$942.26
$980.85
$1,021.75
$1,167.02 		$218.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.96
$649.14
$730.94
$1,021.48
$1,552.22 		$790.72
$867.90
$949.70
$1,240.24 		$1,009.48
$1,086.66
$1,168.46
$1,459.00 		$1,228.24
$1,305.42
$1,387.22
$1,677.76 		$218.76
Toc - Plan #21 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.90
$400.53
$451.00
$630.27
$957.75 		$622.86
$670.49
$720.96
$900.23 		$892.82
$940.45
$990.92
$1,170.19 		$1,162.78
$1,210.41
$1,260.88
$1,440.15 		$269.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.80
$801.06
$902.00
$1,260.54
$1,915.50 		$975.76
$1,071.02
$1,171.96
$1,530.50 		$1,245.72
$1,340.98
$1,441.92
$1,800.46 		$1,515.68
$1,610.94
$1,711.88
$2,070.42 		$269.96
Toc - Plan #22 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$293.60
$333.22
$375.20
$524.35
$796.80 		$518.19
$557.81
$599.79
$748.94 		$742.78
$782.40
$824.38
$973.53 		$967.37
$1,006.99
$1,048.97
$1,198.12 		$224.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.20
$666.44
$750.40
$1,048.70
$1,593.60 		$811.79
$891.03
$974.99
$1,273.29 		$1,036.38
$1,115.62
$1,199.58
$1,497.88 		$1,260.97
$1,340.21
$1,424.17
$1,722.47 		$224.59
Toc - Plan #23 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$317.36
$360.19
$405.58
$566.79
$861.29 		$560.13
$602.96
$648.35
$809.56 		$802.90
$845.73
$891.12
$1,052.33 		$1,045.67
$1,088.50
$1,133.89
$1,295.10 		$242.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.72
$720.38
$811.16
$1,133.58
$1,722.58 		$877.49
$963.15
$1,053.93
$1,376.35 		$1,120.26
$1,205.92
$1,296.70
$1,619.12 		$1,363.03
$1,448.69
$1,539.47
$1,861.89 		$242.77
Toc - Plan #24 Ambetter from Buckeye Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$332.40
$377.26
$424.79
$593.64
$902.10 		$586.68
$631.54
$679.07
$847.92 		$840.96
$885.82
$933.35
$1,102.20 		$1,095.24
$1,140.10
$1,187.63
$1,356.48 		$254.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.80
$754.52
$849.58
$1,187.28
$1,804.20 		$919.08
$1,008.80
$1,103.86
$1,441.56 		$1,173.36
$1,263.08
$1,358.14
$1,695.84 		$1,427.64
$1,517.36
$1,612.42
$1,950.12 		$254.28
Toc - Plan #25 Ambetter from Buckeye Health
Silver

(HMO) Ambetter Balanced Care 30 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$326.33
$370.38
$417.04
$582.81
$885.64 		$575.97
$620.02
$666.68
$832.45 		$825.61
$869.66
$916.32
$1,082.09 		$1,075.25
$1,119.30
$1,165.96
$1,331.73 		$249.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.66
$740.76
$834.08
$1,165.62
$1,771.28 		$902.30
$990.40
$1,083.72
$1,415.26 		$1,151.94
$1,240.04
$1,333.36
$1,664.90 		$1,401.58
$1,489.68
$1,583.00
$1,914.54 		$249.64
Toc - Plan #26 Ambetter from Buckeye Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$332.92
$377.85
$425.45
$594.57
$903.51 		$587.59
$632.52
$680.12
$849.24 		$842.26
$887.19
$934.79
$1,103.91 		$1,096.93
$1,141.86
$1,189.46
$1,358.58 		$254.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.84
$755.70
$850.90
$1,189.14
$1,807.02 		$920.51
$1,010.37
$1,105.57
$1,443.81 		$1,175.18
$1,265.04
$1,360.24
$1,698.48 		$1,429.85
$1,519.71
$1,614.91
$1,953.15 		$254.67
Toc - Plan #27 Ambetter from Buckeye Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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 		$364.65
$413.86
$466.01
$651.24
$989.63 		$643.60
$692.81
$744.96
$930.19 		$922.55
$971.76
$1,023.91
$1,209.14 		$1,201.50
$1,250.71
$1,302.86
$1,488.09 		$278.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.30
$827.72
$932.02
$1,302.48
$1,979.26 		$1,008.25
$1,106.67
$1,210.97
$1,581.43 		$1,287.20
$1,385.62
$1,489.92
$1,860.38 		$1,566.15
$1,664.57
$1,768.87
$2,139.33 		$278.95

ADVERTISEMENT

Oscar Insurance Corporation of Ohio

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

Toc - Plan #28 Oscar Insurance Corporation of Ohio
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 		$335.84
$381.16
$429.19
$599.79
$911.44 		$592.75
$638.07
$686.10
$856.70 		$849.66
$894.98
$943.01
$1,113.61 		$1,106.57
$1,151.89
$1,199.92
$1,370.52 		$256.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.68
$762.32
$858.38
$1,199.58
$1,822.88 		$928.59
$1,019.23
$1,115.29
$1,456.49 		$1,185.50
$1,276.14
$1,372.20
$1,713.40 		$1,442.41
$1,533.05
$1,629.11
$1,970.31 		$256.91
Toc - Plan #29 Oscar Insurance Corporation of Ohio
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 		$342.13
$388.30
$437.22
$611.02
$928.50 		$603.85
$650.02
$698.94
$872.74 		$865.57
$911.74
$960.66
$1,134.46 		$1,127.29
$1,173.46
$1,222.38
$1,396.18 		$261.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.26
$776.60
$874.44
$1,222.04
$1,857.00 		$945.98
$1,038.32
$1,136.16
$1,483.76 		$1,207.70
$1,300.04
$1,397.88
$1,745.48 		$1,469.42
$1,561.76
$1,659.60
$2,007.20 		$261.72
Toc - Plan #30 Oscar Insurance Corporation of Ohio
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 		$337.16
$382.67
$430.88
$602.15
$915.03 		$595.08
$640.59
$688.80
$860.07 		$853.00
$898.51
$946.72
$1,117.99 		$1,110.92
$1,156.43
$1,204.64
$1,375.91 		$257.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.32
$765.34
$861.76
$1,204.30
$1,830.06 		$932.24
$1,023.26
$1,119.68
$1,462.22 		$1,190.16
$1,281.18
$1,377.60
$1,720.14 		$1,448.08
$1,539.10
$1,635.52
$1,978.06 		$257.92
Toc - Plan #31 Oscar Insurance Corporation of Ohio
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 		$393.21
$446.28
$502.51
$702.25
$1,067.14 		$694.01
$747.08
$803.31
$1,003.05 		$994.81
$1,047.88
$1,104.11
$1,303.85 		$1,295.61
$1,348.68
$1,404.91
$1,604.65 		$300.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.42
$892.56
$1,005.02
$1,404.50
$2,134.28 		$1,087.22
$1,193.36
$1,305.82
$1,705.30 		$1,388.02
$1,494.16
$1,606.62
$2,006.10 		$1,688.82
$1,794.96
$1,907.42
$2,306.90 		$300.80
Toc - Plan #32 Oscar Insurance Corporation of Ohio
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 		$403.75
$458.25
$515.99
$721.09
$1,095.76 		$712.61
$767.11
$824.85
$1,029.95 		$1,021.47
$1,075.97
$1,133.71
$1,338.81 		$1,330.33
$1,384.83
$1,442.57
$1,647.67 		$308.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.50
$916.50
$1,031.98
$1,442.18
$2,191.52 		$1,116.36
$1,225.36
$1,340.84
$1,751.04 		$1,425.22
$1,534.22
$1,649.70
$2,059.90 		$1,734.08
$1,843.08
$1,958.56
$2,368.76 		$308.86
Toc - Plan #33 Oscar Insurance Corporation of Ohio
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 		$393.82
$446.98
$503.29
$703.35
$1,068.80 		$695.09
$748.25
$804.56
$1,004.62 		$996.36
$1,049.52
$1,105.83
$1,305.89 		$1,297.63
$1,350.79
$1,407.10
$1,607.16 		$301.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.64
$893.96
$1,006.58
$1,406.70
$2,137.60 		$1,088.91
$1,195.23
$1,307.85
$1,707.97 		$1,390.18
$1,496.50
$1,609.12
$2,009.24 		$1,691.45
$1,797.77
$1,910.39
$2,310.51 		$301.27
Toc - Plan #34 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,450 $16,900 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 		$403.84
$458.35
$516.10
$721.24
$1,096.00 		$712.77
$767.28
$825.03
$1,030.17 		$1,021.70
$1,076.21
$1,133.96
$1,339.10 		$1,330.63
$1,385.14
$1,442.89
$1,648.03 		$308.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.68
$916.70
$1,032.20
$1,442.48
$2,192.00 		$1,116.61
$1,225.63
$1,341.13
$1,751.41 		$1,425.54
$1,534.56
$1,650.06
$2,060.34 		$1,734.47
$1,843.49
$1,958.99
$2,369.27 		$308.93
Toc - Plan #35 Oscar Insurance Corporation of Ohio
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 		$242.08
$274.75
$309.37
$432.34
$656.98 		$427.26
$459.93
$494.55
$617.52 		$612.44
$645.11
$679.73
$802.70 		$797.62
$830.29
$864.91
$987.88 		$185.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$484.16
$549.50
$618.74
$864.68
$1,313.96 		$669.34
$734.68
$803.92
$1,049.86 		$854.52
$919.86
$989.10
$1,235.04 		$1,039.70
$1,105.04
$1,174.28
$1,420.22 		$185.18
Toc - Plan #36 Oscar Insurance Corporation of Ohio
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 		$393.25
$446.33
$502.56
$702.33
$1,067.25 		$694.08
$747.16
$803.39
$1,003.16 		$994.91
$1,047.99
$1,104.22
$1,303.99 		$1,295.74
$1,348.82
$1,405.05
$1,604.82 		$300.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.50
$892.66
$1,005.12
$1,404.66
$2,134.50 		$1,087.33
$1,193.49
$1,305.95
$1,705.49 		$1,388.16
$1,494.32
$1,606.78
$2,006.32 		$1,688.99
$1,795.15
$1,907.61
$2,307.15 		$300.83
Toc - Plan #37 Oscar Insurance Corporation of Ohio
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 		$463.61
$526.19
$592.48
$827.99
$1,258.21 		$818.26
$880.84
$947.13
$1,182.64 		$1,172.91
$1,235.49
$1,301.78
$1,537.29 		$1,527.56
$1,590.14
$1,656.43
$1,891.94 		$354.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.22
$1,052.38
$1,184.96
$1,655.98
$2,516.42 		$1,281.87
$1,407.03
$1,539.61
$2,010.63 		$1,636.52
$1,761.68
$1,894.26
$2,365.28 		$1,991.17
$2,116.33
$2,248.91
$2,719.93 		$354.65
Toc - Plan #38 Oscar Insurance Corporation of Ohio
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 		$367.29
$416.86
$469.38
$655.96
$996.79 		$648.26
$697.83
$750.35
$936.93 		$929.23
$978.80
$1,031.32
$1,217.90 		$1,210.20
$1,259.77
$1,312.29
$1,498.87 		$280.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.58
$833.72
$938.76
$1,311.92
$1,993.58 		$1,015.55
$1,114.69
$1,219.73
$1,592.89 		$1,296.52
$1,395.66
$1,500.70
$1,873.86 		$1,577.49
$1,676.63
$1,781.67
$2,154.83 		$280.97
Toc - Plan #39 Oscar Insurance Corporation of Ohio
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 		$394.58
$447.84
$504.26
$704.71
$1,070.87 		$696.43
$749.69
$806.11
$1,006.56 		$998.28
$1,051.54
$1,107.96
$1,308.41 		$1,300.13
$1,353.39
$1,409.81
$1,610.26 		$301.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.16
$895.68
$1,008.52
$1,409.42
$2,141.74 		$1,091.01
$1,197.53
$1,310.37
$1,711.27 		$1,392.86
$1,499.38
$1,612.22
$2,013.12 		$1,694.71
$1,801.23
$1,914.07
$2,314.97 		$301.85
Toc - Plan #40 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite

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

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 		$407.17
$462.13
$520.36
$727.20
$1,105.04 		$718.65
$773.61
$831.84
$1,038.68 		$1,030.13
$1,085.09
$1,143.32
$1,350.16 		$1,341.61
$1,396.57
$1,454.80
$1,661.64 		$311.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.34
$924.26
$1,040.72
$1,454.40
$2,210.08 		$1,125.82
$1,235.74
$1,352.20
$1,765.88 		$1,437.30
$1,547.22
$1,663.68
$2,077.36 		$1,748.78
$1,858.70
$1,975.16
$2,388.84 		$311.48
Toc - Plan #41 Oscar Insurance Corporation of Ohio
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 		$433.73
$492.27
$554.29
$774.62
$1,177.12 		$765.53
$824.07
$886.09
$1,106.42 		$1,097.33
$1,155.87
$1,217.89
$1,438.22 		$1,429.13
$1,487.67
$1,549.69
$1,770.02 		$331.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.46
$984.54
$1,108.58
$1,549.24
$2,354.24 		$1,199.26
$1,316.34
$1,440.38
$1,881.04 		$1,531.06
$1,648.14
$1,772.18
$2,212.84 		$1,862.86
$1,979.94
$2,103.98
$2,544.64 		$331.80
Toc - Plan #42 Oscar Insurance Corporation of Ohio
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 		$467.07
$530.11
$596.90
$834.17
$1,267.60 		$824.37
$887.41
$954.20
$1,191.47 		$1,181.67
$1,244.71
$1,311.50
$1,548.77 		$1,538.97
$1,602.01
$1,668.80
$1,906.07 		$357.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.14
$1,060.22
$1,193.80
$1,668.34
$2,535.20 		$1,291.44
$1,417.52
$1,551.10
$2,025.64 		$1,648.74
$1,774.82
$1,908.40
$2,382.94 		$2,006.04
$2,132.12
$2,265.70
$2,740.24 		$357.30
Toc - Plan #43 Oscar Insurance Corporation of Ohio
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 		$354.35
$402.18
$452.85
$632.86
$961.69 		$625.42
$673.25
$723.92
$903.93 		$896.49
$944.32
$994.99
$1,175.00 		$1,167.56
$1,215.39
$1,266.06
$1,446.07 		$271.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.70
$804.36
$905.70
$1,265.72
$1,923.38 		$979.77
$1,075.43
$1,176.77
$1,536.79 		$1,250.84
$1,346.50
$1,447.84
$1,807.86 		$1,521.91
$1,617.57
$1,718.91
$2,078.93 		$271.07
Toc - Plan #44 Oscar Insurance Corporation of Ohio
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 		$381.47
$432.95
$487.50
$681.28
$1,035.28 		$673.29
$724.77
$779.32
$973.10 		$965.11
$1,016.59
$1,071.14
$1,264.92 		$1,256.93
$1,308.41
$1,362.96
$1,556.74 		$291.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.94
$865.90
$975.00
$1,362.56
$2,070.56 		$1,054.76
$1,157.72
$1,266.82
$1,654.38 		$1,346.58
$1,449.54
$1,558.64
$1,946.20 		$1,638.40
$1,741.36
$1,850.46
$2,238.02 		$291.82
Toc - Plan #45 Oscar Insurance Corporation of Ohio
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 		$356.51
$404.63
$455.61
$636.72
$967.55 		$629.24
$677.36
$728.34
$909.45 		$901.97
$950.09
$1,001.07
$1,182.18 		$1,174.70
$1,222.82
$1,273.80
$1,454.91 		$272.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.02
$809.26
$911.22
$1,273.44
$1,935.10 		$985.75
$1,081.99
$1,183.95
$1,546.17 		$1,258.48
$1,354.72
$1,456.68
$1,818.90 		$1,531.21
$1,627.45
$1,729.41
$2,091.63 		$272.73
Toc - Plan #46 Oscar Insurance Corporation of Ohio
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 		$386.81
$439.01
$494.32
$690.82
$1,049.76 		$682.71
$734.91
$790.22
$986.72 		$978.61
$1,030.81
$1,086.12
$1,282.62 		$1,274.51
$1,326.71
$1,382.02
$1,578.52 		$295.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.62
$878.02
$988.64
$1,381.64
$2,099.52 		$1,069.52
$1,173.92
$1,284.54
$1,677.54 		$1,365.42
$1,469.82
$1,580.44
$1,973.44 		$1,661.32
$1,765.72
$1,876.34
$2,269.34 		$295.90
Toc - Plan #47 Oscar Insurance Corporation of Ohio
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 		$427.88
$485.63
$546.82
$764.18
$1,161.24 		$755.20
$812.95
$874.14
$1,091.50 		$1,082.52
$1,140.27
$1,201.46
$1,418.82 		$1,409.84
$1,467.59
$1,528.78
$1,746.14 		$327.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.76
$971.26
$1,093.64
$1,528.36
$2,322.48 		$1,183.08
$1,298.58
$1,420.96
$1,855.68 		$1,510.40
$1,625.90
$1,748.28
$2,183.00 		$1,837.72
$1,953.22
$2,075.60
$2,510.32 		$327.32
Toc - Plan #48 Oscar Insurance Corporation of Ohio
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 		$412.19
$467.82
$526.77
$736.15
$1,118.66 		$727.51
$783.14
$842.09
$1,051.47 		$1,042.83
$1,098.46
$1,157.41
$1,366.79 		$1,358.15
$1,413.78
$1,472.73
$1,682.11 		$315.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.38
$935.64
$1,053.54
$1,472.30
$2,237.32 		$1,139.70
$1,250.96
$1,368.86
$1,787.62 		$1,455.02
$1,566.28
$1,684.18
$2,102.94 		$1,770.34
$1,881.60
$1,999.50
$2,418.26 		$315.32
Toc - Plan #49 Oscar Insurance Corporation of Ohio
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 		$422.34
$479.34
$539.73
$754.27
$1,146.19 		$745.42
$802.42
$862.81
$1,077.35 		$1,068.50
$1,125.50
$1,185.89
$1,400.43 		$1,391.58
$1,448.58
$1,508.97
$1,723.51 		$323.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.68
$958.68
$1,079.46
$1,508.54
$2,292.38 		$1,167.76
$1,281.76
$1,402.54
$1,831.62 		$1,490.84
$1,604.84
$1,725.62
$2,154.70 		$1,813.92
$1,927.92
$2,048.70
$2,477.78 		$323.08
Toc - Plan #50 Oscar Insurance Corporation of Ohio
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 		$433.67
$492.20
$554.22
$774.52
$1,176.95 		$765.42
$823.95
$885.97
$1,106.27 		$1,097.17
$1,155.70
$1,217.72
$1,438.02 		$1,428.92
$1,487.45
$1,549.47
$1,769.77 		$331.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.34
$984.40
$1,108.44
$1,549.04
$2,353.90 		$1,199.09
$1,316.15
$1,440.19
$1,880.79 		$1,530.84
$1,647.90
$1,771.94
$2,212.54 		$1,862.59
$1,979.65
$2,103.69
$2,544.29 		$331.75
Toc - Plan #51 Oscar Insurance Corporation of Ohio
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 		$418.31
$474.77
$534.58
$747.08
$1,135.26 		$738.31
$794.77
$854.58
$1,067.08 		$1,058.31
$1,114.77
$1,174.58
$1,387.08 		$1,378.31
$1,434.77
$1,494.58
$1,707.08 		$320.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.62
$949.54
$1,069.16
$1,494.16
$2,270.52 		$1,156.62
$1,269.54
$1,389.16
$1,814.16 		$1,476.62
$1,589.54
$1,709.16
$2,134.16 		$1,796.62
$1,909.54
$2,029.16
$2,454.16 		$320.00
Toc - Plan #52 Oscar Insurance Corporation of Ohio
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 		$446.32
$506.56
$570.38
$797.11
$1,211.28 		$787.75
$847.99
$911.81
$1,138.54 		$1,129.18
$1,189.42
$1,253.24
$1,479.97 		$1,470.61
$1,530.85
$1,594.67
$1,821.40 		$341.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.64
$1,013.12
$1,140.76
$1,594.22
$2,422.56 		$1,234.07
$1,354.55
$1,482.19
$1,935.65 		$1,575.50
$1,695.98
$1,823.62
$2,277.08 		$1,916.93
$2,037.41
$2,165.05
$2,618.51 		$341.43
Toc - Plan #53 Oscar Insurance Corporation of Ohio
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 		$502.02
$569.78
$641.57
$896.59
$1,362.45 		$886.06
$953.82
$1,025.61
$1,280.63 		$1,270.10
$1,337.86
$1,409.65
$1,664.67 		$1,654.14
$1,721.90
$1,793.69
$2,048.71 		$384.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,004.04
$1,139.56
$1,283.14
$1,793.18
$2,724.90 		$1,388.08
$1,523.60
$1,667.18
$2,177.22 		$1,772.12
$1,907.64
$2,051.22
$2,561.26 		$2,156.16
$2,291.68
$2,435.26
$2,945.30 		$384.04
Toc - Plan #54 Oscar Insurance Corporation of Ohio
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 		$481.75
$546.78
$615.67
$860.40
$1,307.46 		$850.28
$915.31
$984.20
$1,228.93 		$1,218.81
$1,283.84
$1,352.73
$1,597.46 		$1,587.34
$1,652.37
$1,721.26
$1,965.99 		$368.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$963.50
$1,093.56
$1,231.34
$1,720.80
$2,614.92 		$1,332.03
$1,462.09
$1,599.87
$2,089.33 		$1,700.56
$1,830.62
$1,968.40
$2,457.86 		$2,069.09
$2,199.15
$2,336.93
$2,826.39 		$368.53
Toc - Plan #55 Oscar Insurance Corporation of Ohio
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 		$459.17
$521.14
$586.80
$820.05
$1,246.15 		$810.42
$872.39
$938.05
$1,171.30 		$1,161.67
$1,223.64
$1,289.30
$1,522.55 		$1,512.92
$1,574.89
$1,640.55
$1,873.80 		$351.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.34
$1,042.28
$1,173.60
$1,640.10
$2,492.30 		$1,269.59
$1,393.53
$1,524.85
$1,991.35 		$1,620.84
$1,744.78
$1,876.10
$2,342.60 		$1,972.09
$2,096.03
$2,227.35
$2,693.85 		$351.25
Toc - Plan #56 Oscar Insurance Corporation of Ohio
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 		$389.03
$441.53
$497.16
$694.78
$1,055.79 		$686.63
$739.13
$794.76
$992.38 		$984.23
$1,036.73
$1,092.36
$1,289.98 		$1,281.83
$1,334.33
$1,389.96
$1,587.58 		$297.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.06
$883.06
$994.32
$1,389.56
$2,111.58 		$1,075.66
$1,180.66
$1,291.92
$1,687.16 		$1,373.26
$1,478.26
$1,589.52
$1,984.76 		$1,670.86
$1,775.86
$1,887.12
$2,282.36 		$297.60
Toc - Plan #57 Oscar Insurance Corporation of Ohio
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 		$398.35
$452.11
$509.08
$711.43
$1,081.09 		$703.08
$756.84
$813.81
$1,016.16 		$1,007.81
$1,061.57
$1,118.54
$1,320.89 		$1,312.54
$1,366.30
$1,423.27
$1,625.62 		$304.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.70
$904.22
$1,018.16
$1,422.86
$2,162.18 		$1,101.43
$1,208.95
$1,322.89
$1,727.59 		$1,406.16
$1,513.68
$1,627.62
$2,032.32 		$1,710.89
$1,818.41
$1,932.35
$2,337.05 		$304.73
Toc - Plan #58 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 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 		$400.65
$454.73
$512.02
$715.55
$1,087.34 		$707.14
$761.22
$818.51
$1,022.04 		$1,013.63
$1,067.71
$1,125.00
$1,328.53 		$1,320.12
$1,374.20
$1,431.49
$1,635.02 		$306.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.30
$909.46
$1,024.04
$1,431.10
$2,174.68 		$1,107.79
$1,215.95
$1,330.53
$1,737.59 		$1,414.28
$1,522.44
$1,637.02
$2,044.08 		$1,720.77
$1,828.93
$1,943.51
$2,350.57 		$306.49

ADVERTISEMENT

SummaCare

Local: 1-330-996-8675 | Toll Free: 1-888-996-8675 | TTY: 1-800-750-0750
Toc - Plan #59 SummaCare
Catastrophic

(HMO) SummaCare Value with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$175.79
$199.52
$224.65
$313.95
$477.08 		$310.27
$334.00
$359.13
$448.43 		$444.75
$468.48
$493.61
$582.91 		$579.23
$602.96
$628.09
$717.39 		$134.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$351.58
$399.04
$449.30
$627.90
$954.16 		$486.06
$533.52
$583.78
$762.38 		$620.54
$668.00
$718.26
$896.86 		$755.02
$802.48
$852.74
$1,031.34 		$134.48
Toc - Plan #60 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 8700 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$234.08
$265.67
$299.14
$418.04
$635.26 		$413.14
$444.73
$478.20
$597.10 		$592.20
$623.79
$657.26
$776.16 		$771.26
$802.85
$836.32
$955.22 		$179.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$468.16
$531.34
$598.28
$836.08
$1,270.52 		$647.22
$710.40
$777.34
$1,015.14 		$826.28
$889.46
$956.40
$1,194.20 		$1,005.34
$1,068.52
$1,135.46
$1,373.26 		$179.06
Toc - Plan #61 SummaCare
Silver

(HMO) SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$326.77
$370.87
$417.60
$583.59
$886.82 		$576.74
$620.84
$667.57
$833.56 		$826.71
$870.81
$917.54
$1,083.53 		$1,076.68
$1,120.78
$1,167.51
$1,333.50 		$249.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.54
$741.74
$835.20
$1,167.18
$1,773.64 		$903.51
$991.71
$1,085.17
$1,417.15 		$1,153.48
$1,241.68
$1,335.14
$1,667.12 		$1,403.45
$1,491.65
$1,585.11
$1,917.09 		$249.97
Toc - Plan #62 SummaCare
Silver

(HMO) SummaCare Silver 5000 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$321.15
$364.49
$410.42
$573.56
$871.57 		$566.82
$610.16
$656.09
$819.23 		$812.49
$855.83
$901.76
$1,064.90 		$1,058.16
$1,101.50
$1,147.43
$1,310.57 		$245.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.30
$728.98
$820.84
$1,147.12
$1,743.14 		$887.97
$974.65
$1,066.51
$1,392.79 		$1,133.64
$1,220.32
$1,312.18
$1,638.46 		$1,379.31
$1,465.99
$1,557.85
$1,884.13 		$245.67
Toc - Plan #63 SummaCare
Silver

(HMO) SummaCare Silver 5000 40 with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$292.59
$332.08
$373.92
$522.55
$794.07 		$516.42
$555.91
$597.75
$746.38 		$740.25
$779.74
$821.58
$970.21 		$964.08
$1,003.57
$1,045.41
$1,194.04 		$223.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.18
$664.16
$747.84
$1,045.10
$1,588.14 		$809.01
$887.99
$971.67
$1,268.93 		$1,032.84
$1,111.82
$1,195.50
$1,492.76 		$1,256.67
$1,335.65
$1,419.33
$1,716.59 		$223.83
Toc - Plan #64 SummaCare
Gold

(HMO) SummaCare Gold 2000 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$340.81
$386.81
$435.54
$608.67
$924.94 		$601.52
$647.52
$696.25
$869.38 		$862.23
$908.23
$956.96
$1,130.09 		$1,122.94
$1,168.94
$1,217.67
$1,390.80 		$260.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.62
$773.62
$871.08
$1,217.34
$1,849.88 		$942.33
$1,034.33
$1,131.79
$1,478.05 		$1,203.04
$1,295.04
$1,392.50
$1,738.76 		$1,463.75
$1,555.75
$1,653.21
$1,999.47 		$260.71
Toc - Plan #65 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$258.42
$293.30
$330.25
$461.52
$701.32 		$456.10
$490.98
$527.93
$659.20 		$653.78
$688.66
$725.61
$856.88 		$851.46
$886.34
$923.29
$1,054.56 		$197.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$516.84
$586.60
$660.50
$923.04
$1,402.64 		$714.52
$784.28
$858.18
$1,120.72 		$912.20
$981.96
$1,055.86
$1,318.40 		$1,109.88
$1,179.64
$1,253.54
$1,516.08 		$197.68
Toc - Plan #66 SummaCare
Silver

(HMO) SummaCare Silver 6000 with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$277.38
$314.81
$354.48
$495.38
$752.78 		$489.57
$527.00
$566.67
$707.57 		$701.76
$739.19
$778.86
$919.76 		$913.95
$951.38
$991.05
$1,131.95 		$212.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.76
$629.62
$708.96
$990.76
$1,505.56 		$766.95
$841.81
$921.15
$1,202.95 		$979.14
$1,054.00
$1,133.34
$1,415.14 		$1,191.33
$1,266.19
$1,345.53
$1,627.33 		$212.19
Toc - Plan #67 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 8700 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$233.37
$264.87
$298.24
$416.79
$633.35 		$411.89
$443.39
$476.76
$595.31 		$590.41
$621.91
$655.28
$773.83 		$768.93
$800.43
$833.80
$952.35 		$178.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$466.74
$529.74
$596.48
$833.58
$1,266.70 		$645.26
$708.26
$775.00
$1,012.10 		$823.78
$886.78
$953.52
$1,190.62 		$1,002.30
$1,065.30
$1,132.04
$1,369.14 		$178.52
Toc - Plan #68 SummaCare
Bronze

(HMO) SummaCare Bronze 8000 with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$220.27
$249.99
$281.49
$393.38
$597.78 		$388.77
$418.49
$449.99
$561.88 		$557.27
$586.99
$618.49
$730.38 		$725.77
$755.49
$786.99
$898.88 		$168.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$440.54
$499.98
$562.98
$786.76
$1,195.56 		$609.04
$668.48
$731.48
$955.26 		$777.54
$836.98
$899.98
$1,123.76 		$946.04
$1,005.48
$1,068.48
$1,292.26 		$168.50
Toc - Plan #69 SummaCare
Silver

(HMO) SummaCare Silver 5000 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$320.45
$363.70
$409.52
$572.30
$869.67 		$565.58
$608.83
$654.65
$817.43 		$810.71
$853.96
$899.78
$1,062.56 		$1,055.84
$1,099.09
$1,144.91
$1,307.69 		$245.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.90
$727.40
$819.04
$1,144.60
$1,739.34 		$886.03
$972.53
$1,064.17
$1,389.73 		$1,131.16
$1,217.66
$1,309.30
$1,634.86 		$1,376.29
$1,462.79
$1,554.43
$1,879.99 		$245.13
Toc - Plan #70 SummaCare
Silver

(HMO) SummaCare Silver 5000 40 with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$291.66
$331.02
$372.73
$520.88
$791.53 		$514.77
$554.13
$595.84
$743.99 		$737.88
$777.24
$818.95
$967.10 		$960.99
$1,000.35
$1,042.06
$1,190.21 		$223.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.32
$662.04
$745.46
$1,041.76
$1,583.06 		$806.43
$885.15
$968.57
$1,264.87 		$1,029.54
$1,108.26
$1,191.68
$1,487.98 		$1,252.65
$1,331.37
$1,414.79
$1,711.09 		$223.11
Toc - Plan #71 SummaCare
Gold

(HMO) SummaCare Gold 2000 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$339.88
$385.75
$434.35
$607.00
$922.39 		$599.88
$645.75
$694.35
$867.00 		$859.88
$905.75
$954.35
$1,127.00 		$1,119.88
$1,165.75
$1,214.35
$1,387.00 		$260.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.76
$771.50
$868.70
$1,214.00
$1,844.78 		$939.76
$1,031.50
$1,128.70
$1,474.00 		$1,199.76
$1,291.50
$1,388.70
$1,734.00 		$1,459.76
$1,551.50
$1,648.70
$1,994.00 		$260.00
Toc - Plan #72 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 7000 HSA with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$257.48
$292.23
$329.05
$459.85
$698.78 		$454.45
$489.20
$526.02
$656.82 		$651.42
$686.17
$722.99
$853.79 		$848.39
$883.14
$919.96
$1,050.76 		$196.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514.96
$584.46
$658.10
$919.70
$1,397.56 		$711.93
$781.43
$855.07
$1,116.67 		$908.90
$978.40
$1,052.04
$1,313.64 		$1,105.87
$1,175.37
$1,249.01
$1,510.61 		$196.97
Toc - Plan #73 SummaCare
Silver

(HMO) SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$325.83
$369.81
$416.40
$581.92
$884.28 		$575.08
$619.06
$665.65
$831.17 		$824.33
$868.31
$914.90
$1,080.42 		$1,073.58
$1,117.56
$1,164.15
$1,329.67 		$249.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.66
$739.62
$832.80
$1,163.84
$1,768.56 		$900.91
$988.87
$1,082.05
$1,413.09 		$1,150.16
$1,238.12
$1,331.30
$1,662.34 		$1,399.41
$1,487.37
$1,580.55
$1,911.59 		$249.25
Toc - Plan #74 SummaCare
Silver

(HMO) SummaCare Silver 6000 with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$276.68
$314.02
$353.58
$494.13
$750.87 		$488.33
$525.67
$565.23
$705.78 		$699.98
$737.32
$776.88
$917.43 		$911.63
$948.97
$988.53
$1,129.08 		$211.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.36
$628.04
$707.16
$988.26
$1,501.74 		$765.01
$839.69
$918.81
$1,199.91 		$976.66
$1,051.34
$1,130.46
$1,411.56 		$1,188.31
$1,262.99
$1,342.11
$1,623.21 		$211.65
Toc - Plan #75 SummaCare
Bronze

(HMO) SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

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 		$221.20
$251.05
$282.69
$395.05
$600.32 		$390.41
$420.26
$451.90
$564.26 		$559.62
$589.47
$621.11
$733.47 		$728.83
$758.68
$790.32
$902.68 		$169.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$442.40
$502.10
$565.38
$790.10
$1,200.64 		$611.61
$671.31
$734.59
$959.31 		$780.82
$840.52
$903.80
$1,128.52 		$950.03
$1,009.73
$1,073.01
$1,297.73 		$169.21

ADVERTISEMENT

CareSource

Local: 1-800-479-9502 | Toll Free: 1-800-479-9502 | TTY: 1-800-750-0750
Toc - Plan #76 CareSource
Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$268.62
$304.88
$343.29
$479.75
$729.03 		$474.11
$510.37
$548.78
$685.24 		$679.60
$715.86
$754.27
$890.73 		$885.09
$921.35
$959.76
$1,096.22 		$205.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.24
$609.76
$686.58
$959.50
$1,458.06 		$742.73
$815.25
$892.07
$1,164.99 		$948.22
$1,020.74
$1,097.56
$1,370.48 		$1,153.71
$1,226.23
$1,303.05
$1,575.97 		$205.49
Toc - Plan #77 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

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 		$328.46
$372.80
$419.77
$586.63
$891.44 		$579.73
$624.07
$671.04
$837.90 		$831.00
$875.34
$922.31
$1,089.17 		$1,082.27
$1,126.61
$1,173.58
$1,340.44 		$251.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.92
$745.60
$839.54
$1,173.26
$1,782.88 		$908.19
$996.87
$1,090.81
$1,424.53 		$1,159.46
$1,248.14
$1,342.08
$1,675.80 		$1,410.73
$1,499.41
$1,593.35
$1,927.07 		$251.27
Toc - Plan #78 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$447.89
$508.35
$572.40
$799.92
$1,215.56 		$790.52
$850.98
$915.03
$1,142.55 		$1,133.15
$1,193.61
$1,257.66
$1,485.18 		$1,475.78
$1,536.24
$1,600.29
$1,827.81 		$342.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.78
$1,016.70
$1,144.80
$1,599.84
$2,431.12 		$1,238.41
$1,359.33
$1,487.43
$1,942.47 		$1,581.04
$1,701.96
$1,830.06
$2,285.10 		$1,923.67
$2,044.59
$2,172.69
$2,627.73 		$342.63
Toc - Plan #79 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$347.29
$394.17
$443.83
$620.25
$942.53 		$612.96
$659.84
$709.50
$885.92 		$878.63
$925.51
$975.17
$1,151.59 		$1,144.30
$1,191.18
$1,240.84
$1,417.26 		$265.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.58
$788.34
$887.66
$1,240.50
$1,885.06 		$960.25
$1,054.01
$1,153.33
$1,506.17 		$1,225.92
$1,319.68
$1,419.00
$1,771.84 		$1,491.59
$1,585.35
$1,684.67
$2,037.51 		$265.67
Toc - Plan #80 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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 		$237.77
$269.86
$303.86
$424.65
$645.30 		$419.66
$451.75
$485.75
$606.54 		$601.55
$633.64
$667.64
$788.43 		$783.44
$815.53
$849.53
$970.32 		$181.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475.54
$539.72
$607.72
$849.30
$1,290.60 		$657.43
$721.61
$789.61
$1,031.19 		$839.32
$903.50
$971.50
$1,213.08 		$1,021.21
$1,085.39
$1,153.39
$1,394.97 		$181.89
Toc - Plan #81 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,100 $10,200 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 		$358.84
$407.28
$458.59
$640.88
$973.87 		$633.35
$681.79
$733.10
$915.39 		$907.86
$956.30
$1,007.61
$1,189.90 		$1,182.37
$1,230.81
$1,282.12
$1,464.41 		$274.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.68
$814.56
$917.18
$1,281.76
$1,947.74 		$992.19
$1,089.07
$1,191.69
$1,556.27 		$1,266.70
$1,363.58
$1,466.20
$1,830.78 		$1,541.21
$1,638.09
$1,740.71
$2,105.29 		$274.51
Toc - Plan #82 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

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 		$225.91
$256.40
$288.71
$403.47
$613.11 		$398.73
$429.22
$461.53
$576.29 		$571.55
$602.04
$634.35
$749.11 		$744.37
$774.86
$807.17
$921.93 		$172.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$451.82
$512.80
$577.42
$806.94
$1,226.22 		$624.64
$685.62
$750.24
$979.76 		$797.46
$858.44
$923.06
$1,152.58 		$970.28
$1,031.26
$1,095.88
$1,325.40 		$172.82
Toc - Plan #83 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$334.50
$379.66
$427.49
$597.41
$907.83 		$590.39
$635.55
$683.38
$853.30 		$846.28
$891.44
$939.27
$1,109.19 		$1,102.17
$1,147.33
$1,195.16
$1,365.08 		$255.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.00
$759.32
$854.98
$1,194.82
$1,815.66 		$924.89
$1,015.21
$1,110.87
$1,450.71 		$1,180.78
$1,271.10
$1,366.76
$1,706.60 		$1,436.67
$1,526.99
$1,622.65
$1,962.49 		$255.89
Toc - Plan #84 CareSource
Gold

(HMO) CareSource Marketplace Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$455.19
$516.64
$581.73
$812.96
$1,235.38 		$803.41
$864.86
$929.95
$1,161.18 		$1,151.63
$1,213.08
$1,278.17
$1,509.40 		$1,499.85
$1,561.30
$1,626.39
$1,857.62 		$348.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.38
$1,033.28
$1,163.46
$1,625.92
$2,470.76 		$1,258.60
$1,381.50
$1,511.68
$1,974.14 		$1,606.82
$1,729.72
$1,859.90
$2,322.36 		$1,955.04
$2,077.94
$2,208.12
$2,670.58 		$348.22
Toc - Plan #85 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.33
$401.02
$451.55
$631.04
$958.92 		$623.62
$671.31
$721.84
$901.33 		$893.91
$941.60
$992.13
$1,171.62 		$1,164.20
$1,211.89
$1,262.42
$1,441.91 		$270.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.66
$802.04
$903.10
$1,262.08
$1,917.84 		$976.95
$1,072.33
$1,173.39
$1,532.37 		$1,247.24
$1,342.62
$1,443.68
$1,802.66 		$1,517.53
$1,612.91
$1,713.97
$2,072.95 		$270.29
Toc - Plan #86 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.02
$275.83
$310.58
$434.03
$659.55 		$428.93
$461.74
$496.49
$619.94 		$614.84
$647.65
$682.40
$805.85 		$800.75
$833.56
$868.31
$991.76 		$185.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.04
$551.66
$621.16
$868.06
$1,319.10 		$671.95
$737.57
$807.07
$1,053.97 		$857.86
$923.48
$992.98
$1,239.88 		$1,043.77
$1,109.39
$1,178.89
$1,425.79 		$185.91
Toc - Plan #87 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

Annual Out of Pocket Expenses:

Individual Family
$5,100 $10,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.88
$414.13
$466.31
$651.66
$990.27 		$644.01
$693.26
$745.44
$930.79 		$923.14
$972.39
$1,024.57
$1,209.92 		$1,202.27
$1,251.52
$1,303.70
$1,489.05 		$279.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.76
$828.26
$932.62
$1,303.32
$1,980.54 		$1,008.89
$1,107.39
$1,211.75
$1,582.45 		$1,288.02
$1,386.52
$1,490.88
$1,861.58 		$1,567.15
$1,665.65
$1,770.01
$2,140.71 		$279.13
Toc - Plan #88 CareSource
Bronze

(HMO) CareSource Marketplace Bronze Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-479-9502

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 		$230.90
$262.07
$295.08
$412.38
$626.65 		$407.54
$438.71
$471.72
$589.02 		$584.18
$615.35
$648.36
$765.66 		$760.82
$791.99
$825.00
$942.30 		$176.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$461.80
$524.14
$590.16
$824.76
$1,253.30 		$638.44
$700.78
$766.80
$1,001.40 		$815.08
$877.42
$943.44
$1,178.04 		$991.72
$1,054.06
$1,120.08
$1,354.68 		$176.64

ADVERTISEMENT

MedMutual

Local: 1-888-308-0357 | Toll Free: 1-888-308-0357

Toc - Plan #89 MedMutual
Silver

(HMO) Market HMO 3000 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$397.66
$451.34
$508.21
$710.22
$1,079.25 		$701.87
$755.55
$812.42
$1,014.43 		$1,006.08
$1,059.76
$1,116.63
$1,318.64 		$1,310.29
$1,363.97
$1,420.84
$1,622.85 		$304.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.32
$902.68
$1,016.42
$1,420.44
$2,158.50 		$1,099.53
$1,206.89
$1,320.63
$1,724.65 		$1,403.74
$1,511.10
$1,624.84
$2,028.86 		$1,707.95
$1,815.31
$1,929.05
$2,333.07 		$304.21
Toc - Plan #90 MedMutual
Silver

(HMO) Market HMO 4000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$376.54
$427.37
$481.22
$672.50
$1,021.93 		$664.59
$715.42
$769.27
$960.55 		$952.64
$1,003.47
$1,057.32
$1,248.60 		$1,240.69
$1,291.52
$1,345.37
$1,536.65 		$288.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.08
$854.74
$962.44
$1,345.00
$2,043.86 		$1,041.13
$1,142.79
$1,250.49
$1,633.05 		$1,329.18
$1,430.84
$1,538.54
$1,921.10 		$1,617.23
$1,718.89
$1,826.59
$2,209.15 		$288.05
Toc - Plan #91 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$298.02
$338.25
$380.87
$532.27
$808.83 		$526.01
$566.24
$608.86
$760.26 		$754.00
$794.23
$836.85
$988.25 		$981.99
$1,022.22
$1,064.84
$1,216.24 		$227.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.04
$676.50
$761.74
$1,064.54
$1,617.66 		$824.03
$904.49
$989.73
$1,292.53 		$1,052.02
$1,132.48
$1,217.72
$1,520.52 		$1,280.01
$1,360.47
$1,445.71
$1,748.51 		$227.99
Toc - Plan #92 MedMutual
Bronze

(HMO) Market HMO 8700 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$287.61
$326.44
$367.57
$513.67
$780.58 		$507.63
$546.46
$587.59
$733.69 		$727.65
$766.48
$807.61
$953.71 		$947.67
$986.50
$1,027.63
$1,173.73 		$220.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.22
$652.88
$735.14
$1,027.34
$1,561.16 		$795.24
$872.90
$955.16
$1,247.36 		$1,015.26
$1,092.92
$1,175.18
$1,467.38 		$1,235.28
$1,312.94
$1,395.20
$1,687.40 		$220.02
Toc - Plan #93 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$178.16
$202.21
$227.69
$318.19
$483.52 		$314.45
$338.50
$363.98
$454.48 		$450.74
$474.79
$500.27
$590.77 		$587.03
$611.08
$636.56
$727.06 		$136.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$356.32
$404.42
$455.38
$636.38
$967.04 		$492.61
$540.71
$591.67
$772.67 		$628.90
$677.00
$727.96
$908.96 		$765.19
$813.29
$864.25
$1,045.25 		$136.29
Toc - Plan #94 MedMutual
Silver

(HMO) Market HMO 6500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$397.36
$451.01
$507.83
$709.69
$1,078.44 		$701.34
$754.99
$811.81
$1,013.67 		$1,005.32
$1,058.97
$1,115.79
$1,317.65 		$1,309.30
$1,362.95
$1,419.77
$1,621.63 		$303.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.72
$902.02
$1,015.66
$1,419.38
$2,156.88 		$1,098.70
$1,206.00
$1,319.64
$1,723.36 		$1,402.68
$1,509.98
$1,623.62
$2,027.34 		$1,706.66
$1,813.96
$1,927.60
$2,331.32 		$303.98
Toc - Plan #95 MedMutual
Expanded Bronze

(HMO) Market HMO $0 Deductible Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$337.58
$383.15
$431.43
$602.92
$916.19 		$595.83
$641.40
$689.68
$861.17 		$854.08
$899.65
$947.93
$1,119.42 		$1,112.33
$1,157.90
$1,206.18
$1,377.67 		$258.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.16
$766.30
$862.86
$1,205.84
$1,832.38 		$933.41
$1,024.55
$1,121.11
$1,464.09 		$1,191.66
$1,282.80
$1,379.36
$1,722.34 		$1,449.91
$1,541.05
$1,637.61
$1,980.59 		$258.25
Toc - Plan #96 MedMutual
Silver

(HMO) Market HMO $0 Deductible Silver - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$411.34
$466.87
$525.69
$734.65
$1,116.38 		$726.02
$781.55
$840.37
$1,049.33 		$1,040.70
$1,096.23
$1,155.05
$1,364.01 		$1,355.38
$1,410.91
$1,469.73
$1,678.69 		$314.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.68
$933.74
$1,051.38
$1,469.30
$2,232.76 		$1,137.36
$1,248.42
$1,366.06
$1,783.98 		$1,452.04
$1,563.10
$1,680.74
$2,098.66 		$1,766.72
$1,877.78
$1,995.42
$2,413.34 		$314.68
Toc - Plan #97 MedMutual
Expanded Bronze

(HMO) Market HMO 8000 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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 		$288.50
$327.45
$368.71
$515.27
$783.00 		$509.21
$548.16
$589.42
$735.98 		$729.92
$768.87
$810.13
$956.69 		$950.63
$989.58
$1,030.84
$1,177.40 		$220.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.00
$654.90
$737.42
$1,030.54
$1,566.00 		$797.71
$875.61
$958.13
$1,251.25 		$1,018.42
$1,096.32
$1,178.84
$1,471.96 		$1,239.13
$1,317.03
$1,399.55
$1,692.67 		$220.71
Toc - Plan #98 MedMutual
Gold

(HMO) Market HMO 2500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,750 $11,500 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 		$516.63
$586.37
$660.25
$922.70
$1,402.13 		$911.85
$981.59
$1,055.47
$1,317.92 		$1,307.07
$1,376.81
$1,450.69
$1,713.14 		$1,702.29
$1,772.03
$1,845.91
$2,108.36 		$395.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,033.26
$1,172.74
$1,320.50
$1,845.40
$2,804.26 		$1,428.48
$1,567.96
$1,715.72
$2,240.62 		$1,823.70
$1,963.18
$2,110.94
$2,635.84 		$2,218.92
$2,358.40
$2,506.16
$3,031.06 		$395.22

‡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 Portage County here.

Portage County is in “Rating Area 12” of Ohio.

Currently, there are 98 plans offered in Rating Area 12.

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2022 Obamacare Plans for Portage County, OH

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