Obamacare 2022 Rates for Pickens County

Obamacare > Rates > South Carolina > Pickens 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 Pickens County, SC.

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, 64 Plans and 2022 Rates for Pickens County, South Carolina

Below, you’ll find a summary of the 64 plans for Pickens County, South 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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Bright HealthCare

Local: 1-855-521-9353 | Toll Free: 1-855-521-9353 | TTY: 1-855-521-9353
Toc - Plan #1 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: 1-855-521-9353

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 		$458.75
$520.68
$586.28
$819.33
$1,245.05 		$809.70
$871.63
$937.23
$1,170.28 		$1,160.65
$1,222.58
$1,288.18
$1,521.23 		$1,511.60
$1,573.53
$1,639.13
$1,872.18 		$350.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.50
$1,041.36
$1,172.56
$1,638.66
$2,490.10 		$1,268.45
$1,392.31
$1,523.51
$1,989.61 		$1,619.40
$1,743.26
$1,874.46
$2,340.56 		$1,970.35
$2,094.21
$2,225.41
$2,691.51 		$350.95
Toc - Plan #2 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: 1-855-521-9353

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 		$405.43
$460.16
$518.14
$724.10
$1,100.33 		$715.58
$770.31
$828.29
$1,034.25 		$1,025.73
$1,080.46
$1,138.44
$1,344.40 		$1,335.88
$1,390.61
$1,448.59
$1,654.55 		$310.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.86
$920.32
$1,036.28
$1,448.20
$2,200.66 		$1,121.01
$1,230.47
$1,346.43
$1,758.35 		$1,431.16
$1,540.62
$1,656.58
$2,068.50 		$1,741.31
$1,850.77
$1,966.73
$2,378.65 		$310.15
Toc - Plan #3 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: 1-855-521-9353

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 		$411.11
$466.61
$525.40
$734.24
$1,115.76 		$725.61
$781.11
$839.90
$1,048.74 		$1,040.11
$1,095.61
$1,154.40
$1,363.24 		$1,354.61
$1,410.11
$1,468.90
$1,677.74 		$314.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.22
$933.22
$1,050.80
$1,468.48
$2,231.52 		$1,136.72
$1,247.72
$1,365.30
$1,782.98 		$1,451.22
$1,562.22
$1,679.80
$2,097.48 		$1,765.72
$1,876.72
$1,994.30
$2,411.98 		$314.50
Toc - Plan #4 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: 1-855-521-9353

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 		$444.69
$504.72
$568.31
$794.22
$1,206.89 		$784.88
$844.91
$908.50
$1,134.41 		$1,125.07
$1,185.10
$1,248.69
$1,474.60 		$1,465.26
$1,525.29
$1,588.88
$1,814.79 		$340.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.38
$1,009.44
$1,136.62
$1,588.44
$2,413.78 		$1,229.57
$1,349.63
$1,476.81
$1,928.63 		$1,569.76
$1,689.82
$1,817.00
$2,268.82 		$1,909.95
$2,030.01
$2,157.19
$2,609.01 		$340.19
Toc - Plan #5 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: 1-855-521-9353

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 		$306.23
$347.57
$391.36
$546.92
$831.10 		$540.49
$581.83
$625.62
$781.18 		$774.75
$816.09
$859.88
$1,015.44 		$1,009.01
$1,050.35
$1,094.14
$1,249.70 		$234.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.46
$695.14
$782.72
$1,093.84
$1,662.20 		$846.72
$929.40
$1,016.98
$1,328.10 		$1,080.98
$1,163.66
$1,251.24
$1,562.36 		$1,315.24
$1,397.92
$1,485.50
$1,796.62 		$234.26
Toc - Plan #6 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: 1-855-521-9353

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 		$315.23
$357.79
$402.87
$563.01
$855.54 		$556.38
$598.94
$644.02
$804.16 		$797.53
$840.09
$885.17
$1,045.31 		$1,038.68
$1,081.24
$1,126.32
$1,286.46 		$241.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.46
$715.58
$805.74
$1,126.02
$1,711.08 		$871.61
$956.73
$1,046.89
$1,367.17 		$1,112.76
$1,197.88
$1,288.04
$1,608.32 		$1,353.91
$1,439.03
$1,529.19
$1,849.47 		$241.15
Toc - Plan #7 Bright HealthCare
Expanded Bronze

(HMO) Bronze 5300 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9353

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 		$330.10
$374.66
$421.87
$589.56
$895.89 		$582.63
$627.19
$674.40
$842.09 		$835.16
$879.72
$926.93
$1,094.62 		$1,087.69
$1,132.25
$1,179.46
$1,347.15 		$252.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.20
$749.32
$843.74
$1,179.12
$1,791.78 		$912.73
$1,001.85
$1,096.27
$1,431.65 		$1,165.26
$1,254.38
$1,348.80
$1,684.18 		$1,417.79
$1,506.91
$1,601.33
$1,936.71 		$252.53
Toc - Plan #8 Bright HealthCare
Catastrophic

(HMO) Catastrophic 8700 Direct ($0 Primary Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9353

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 		$254.05
$288.34
$324.67
$453.73
$689.49 		$448.40
$482.69
$519.02
$648.08 		$642.75
$677.04
$713.37
$842.43 		$837.10
$871.39
$907.72
$1,036.78 		$194.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508.10
$576.68
$649.34
$907.46
$1,378.98 		$702.45
$771.03
$843.69
$1,101.81 		$896.80
$965.38
$1,038.04
$1,296.16 		$1,091.15
$1,159.73
$1,232.39
$1,490.51 		$194.35
Toc - Plan #9 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: 1-855-521-9353

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 		$413.74
$469.59
$528.76
$738.94
$1,122.89 		$730.25
$786.10
$845.27
$1,055.45 		$1,046.76
$1,102.61
$1,161.78
$1,371.96 		$1,363.27
$1,419.12
$1,478.29
$1,688.47 		$316.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.48
$939.18
$1,057.52
$1,477.88
$2,245.78 		$1,143.99
$1,255.69
$1,374.03
$1,794.39 		$1,460.50
$1,572.20
$1,690.54
$2,110.90 		$1,777.01
$1,888.71
$2,007.05
$2,427.41 		$316.51
Toc - Plan #10 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: 1-855-521-9353

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$346.75
$393.56
$443.15
$619.29
$941.08 		$612.01
$658.82
$708.41
$884.55 		$877.27
$924.08
$973.67
$1,149.81 		$1,142.53
$1,189.34
$1,238.93
$1,415.07 		$265.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$693.50
$787.12
$886.30
$1,238.58
$1,882.16 		$958.76
$1,052.38
$1,151.56
$1,503.84 		$1,224.02
$1,317.64
$1,416.82
$1,769.10 		$1,489.28
$1,582.90
$1,682.08
$2,034.36 		$265.26
Toc - Plan #11 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: 1-855-521-9353

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 		$329.56
$374.05
$421.18
$588.60
$894.43 		$581.67
$626.16
$673.29
$840.71 		$833.78
$878.27
$925.40
$1,092.82 		$1,085.89
$1,130.38
$1,177.51
$1,344.93 		$252.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.12
$748.10
$842.36
$1,177.20
$1,788.86 		$911.23
$1,000.21
$1,094.47
$1,429.31 		$1,163.34
$1,252.32
$1,346.58
$1,681.42 		$1,415.45
$1,504.43
$1,598.69
$1,933.53 		$252.11
Toc - Plan #12 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: 1-855-521-9353

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 		$428.24
$486.06
$547.30
$764.84
$1,162.26 		$755.85
$813.67
$874.91
$1,092.45 		$1,083.46
$1,141.28
$1,202.52
$1,420.06 		$1,411.07
$1,468.89
$1,530.13
$1,747.67 		$327.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.48
$972.12
$1,094.60
$1,529.68
$2,324.52 		$1,184.09
$1,299.73
$1,422.21
$1,857.29 		$1,511.70
$1,627.34
$1,749.82
$2,184.90 		$1,839.31
$1,954.95
$2,077.43
$2,512.51 		$327.61
Toc - Plan #13 Bright HealthCare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9353

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 		$507.20
$575.67
$648.20
$905.86
$1,376.54 		$895.21
$963.68
$1,036.21
$1,293.87 		$1,283.22
$1,351.69
$1,424.22
$1,681.88 		$1,671.23
$1,739.70
$1,812.23
$2,069.89 		$388.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,014.40
$1,151.34
$1,296.40
$1,811.72
$2,753.08 		$1,402.41
$1,539.35
$1,684.41
$2,199.73 		$1,790.42
$1,927.36
$2,072.42
$2,587.74 		$2,178.43
$2,315.37
$2,460.43
$2,975.75 		$388.01
Toc - Plan #14 Bright HealthCare
Expanded Bronze

(HMO) Bronze 8700 ($25 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9353

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 		$303.71
$344.71
$388.14
$542.43
$824.27 		$536.05
$577.05
$620.48
$774.77 		$768.39
$809.39
$852.82
$1,007.11 		$1,000.73
$1,041.73
$1,085.16
$1,239.45 		$232.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.42
$689.42
$776.28
$1,084.86
$1,648.54 		$839.76
$921.76
$1,008.62
$1,317.20 		$1,072.10
$1,154.10
$1,240.96
$1,549.54 		$1,304.44
$1,386.44
$1,473.30
$1,781.88 		$232.34
Toc - Plan #15 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-521-9353

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 		$389.93
$442.57
$498.33
$696.42
$1,058.27 		$688.23
$740.87
$796.63
$994.72 		$986.53
$1,039.17
$1,094.93
$1,293.02 		$1,284.83
$1,337.47
$1,393.23
$1,591.32 		$298.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.86
$885.14
$996.66
$1,392.84
$2,116.54 		$1,078.16
$1,183.44
$1,294.96
$1,691.14 		$1,376.46
$1,481.74
$1,593.26
$1,989.44 		$1,674.76
$1,780.04
$1,891.56
$2,287.74 		$298.30

ADVERTISEMENT

BlueCross BlueShield of South Carolina

Local: 1-855-404-6752 | Toll Free: 1-855-404-6752 | TTY: 1-855-889-4325
Toc - Plan #16 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$447.20
$507.58
$571.53
$798.71
$1,213.71 		$789.31
$849.69
$913.64
$1,140.82 		$1,131.42
$1,191.80
$1,255.75
$1,482.93 		$1,473.53
$1,533.91
$1,597.86
$1,825.04 		$342.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.40
$1,015.16
$1,143.06
$1,597.42
$2,427.42 		$1,236.51
$1,357.27
$1,485.17
$1,939.53 		$1,578.62
$1,699.38
$1,827.28
$2,281.64 		$1,920.73
$2,041.49
$2,169.39
$2,623.75 		$342.11
Toc - Plan #17 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 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 		$470.76
$534.31
$601.63
$840.78
$1,277.64 		$830.89
$894.44
$961.76
$1,200.91 		$1,191.02
$1,254.57
$1,321.89
$1,561.04 		$1,551.15
$1,614.70
$1,682.02
$1,921.17 		$360.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.52
$1,068.62
$1,203.26
$1,681.56
$2,555.28 		$1,301.65
$1,428.75
$1,563.39
$2,041.69 		$1,661.78
$1,788.88
$1,923.52
$2,401.82 		$2,021.91
$2,149.01
$2,283.65
$2,761.95 		$360.13
Toc - Plan #18 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$6,600 $13,200 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 		$459.08
$521.06
$586.71
$819.93
$1,245.96 		$810.28
$872.26
$937.91
$1,171.13 		$1,161.48
$1,223.46
$1,289.11
$1,522.33 		$1,512.68
$1,574.66
$1,640.31
$1,873.53 		$351.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.16
$1,042.12
$1,173.42
$1,639.86
$2,491.92 		$1,269.36
$1,393.32
$1,524.62
$1,991.06 		$1,620.56
$1,744.52
$1,875.82
$2,342.26 		$1,971.76
$2,095.72
$2,227.02
$2,693.46 		$351.20
Toc - Plan #19 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.65
$327.62
$368.90
$515.53
$783.40 		$509.47
$548.44
$589.72
$736.35 		$730.29
$769.26
$810.54
$957.17 		$951.11
$990.08
$1,031.36
$1,177.99 		$220.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.30
$655.24
$737.80
$1,031.06
$1,566.80 		$798.12
$876.06
$958.62
$1,251.88 		$1,018.94
$1,096.88
$1,179.44
$1,472.70 		$1,239.76
$1,317.70
$1,400.26
$1,693.52 		$220.82
Toc - Plan #20 BlueCross BlueShield of South Carolina
Bronze

(EPO) BlueEssentials Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.80
$327.78
$369.08
$515.79
$783.79 		$509.73
$548.71
$590.01
$736.72 		$730.66
$769.64
$810.94
$957.65 		$951.59
$990.57
$1,031.87
$1,178.58 		$220.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.60
$655.56
$738.16
$1,031.58
$1,567.58 		$798.53
$876.49
$959.09
$1,252.51 		$1,019.46
$1,097.42
$1,180.02
$1,473.44 		$1,240.39
$1,318.35
$1,400.95
$1,694.37 		$220.93
Toc - Plan #21 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$430.31
$488.40
$549.94
$768.53
$1,167.86 		$759.50
$817.59
$879.13
$1,097.72 		$1,088.69
$1,146.78
$1,208.32
$1,426.91 		$1,417.88
$1,475.97
$1,537.51
$1,756.10 		$329.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.62
$976.80
$1,099.88
$1,537.06
$2,335.72 		$1,189.81
$1,305.99
$1,429.07
$1,866.25 		$1,519.00
$1,635.18
$1,758.26
$2,195.44 		$1,848.19
$1,964.37
$2,087.45
$2,524.63 		$329.19
Toc - Plan #22 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials HD Gold 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$3,400 $6,800 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 		$433.68
$492.22
$554.24
$774.55
$1,177.00 		$765.44
$823.98
$886.00
$1,106.31 		$1,097.20
$1,155.74
$1,217.76
$1,438.07 		$1,428.96
$1,487.50
$1,549.52
$1,769.83 		$331.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.36
$984.44
$1,108.48
$1,549.10
$2,354.00 		$1,199.12
$1,316.20
$1,440.24
$1,880.86 		$1,530.88
$1,647.96
$1,772.00
$2,212.62 		$1,862.64
$1,979.72
$2,103.76
$2,544.38 		$331.76
Toc - Plan #23 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials HD Silver 6

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$4,800 $9,600 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 		$469.99
$533.44
$600.64
$839.40
$1,275.55 		$829.53
$892.98
$960.18
$1,198.94 		$1,189.07
$1,252.52
$1,319.72
$1,558.48 		$1,548.61
$1,612.06
$1,679.26
$1,918.02 		$359.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.98
$1,066.88
$1,201.28
$1,678.80
$2,551.10 		$1,299.52
$1,426.42
$1,560.82
$2,038.34 		$1,659.06
$1,785.96
$1,920.36
$2,397.88 		$2,018.60
$2,145.50
$2,279.90
$2,757.42 		$359.54
Toc - Plan #24 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials HD Bronze 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 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 		$300.13
$340.65
$383.57
$536.03
$814.55 		$529.73
$570.25
$613.17
$765.63 		$759.33
$799.85
$842.77
$995.23 		$988.93
$1,029.45
$1,072.37
$1,224.83 		$229.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.26
$681.30
$767.14
$1,072.06
$1,629.10 		$829.86
$910.90
$996.74
$1,301.66 		$1,059.46
$1,140.50
$1,226.34
$1,531.26 		$1,289.06
$1,370.10
$1,455.94
$1,760.86 		$229.60
Toc - Plan #25 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$293.82
$333.48
$375.50
$524.76
$797.43 		$518.59
$558.25
$600.27
$749.53 		$743.36
$783.02
$825.04
$974.30 		$968.13
$1,007.79
$1,049.81
$1,199.07 		$224.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.64
$666.96
$751.00
$1,049.52
$1,594.86 		$812.41
$891.73
$975.77
$1,274.29 		$1,037.18
$1,116.50
$1,200.54
$1,499.06 		$1,261.95
$1,341.27
$1,425.31
$1,723.83 		$224.77
Toc - Plan #26 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials HD Bronze 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$301.14
$341.79
$384.86
$537.83
$817.29 		$531.51
$572.16
$615.23
$768.20 		$761.88
$802.53
$845.60
$998.57 		$992.25
$1,032.90
$1,075.97
$1,228.94 		$230.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.28
$683.58
$769.72
$1,075.66
$1,634.58 		$832.65
$913.95
$1,000.09
$1,306.03 		$1,063.02
$1,144.32
$1,230.46
$1,536.40 		$1,293.39
$1,374.69
$1,460.83
$1,766.77 		$230.37
Toc - Plan #27 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 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 		$446.58
$506.86
$570.72
$797.59
$1,212.01 		$788.21
$848.49
$912.35
$1,139.22 		$1,129.84
$1,190.12
$1,253.98
$1,480.85 		$1,471.47
$1,531.75
$1,595.61
$1,822.48 		$341.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$893.16
$1,013.72
$1,141.44
$1,595.18
$2,424.02 		$1,234.79
$1,355.35
$1,483.07
$1,936.81 		$1,576.42
$1,696.98
$1,824.70
$2,278.44 		$1,918.05
$2,038.61
$2,166.33
$2,620.07 		$341.63
Toc - Plan #28 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$420.56
$477.34
$537.48
$751.12
$1,141.40 		$742.29
$799.07
$859.21
$1,072.85 		$1,064.02
$1,120.80
$1,180.94
$1,394.58 		$1,385.75
$1,442.53
$1,502.67
$1,716.31 		$321.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.12
$954.68
$1,074.96
$1,502.24
$2,282.80 		$1,162.85
$1,276.41
$1,396.69
$1,823.97 		$1,484.58
$1,598.14
$1,718.42
$2,145.70 		$1,806.31
$1,919.87
$2,040.15
$2,467.43 		$321.73
Toc - Plan #29 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueEssentials Silver 14

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$435.46
$494.24
$556.52
$777.73
$1,181.83 		$768.59
$827.37
$889.65
$1,110.86 		$1,101.72
$1,160.50
$1,222.78
$1,443.99 		$1,434.85
$1,493.63
$1,555.91
$1,777.12 		$333.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.92
$988.48
$1,113.04
$1,555.46
$2,363.66 		$1,204.05
$1,321.61
$1,446.17
$1,888.59 		$1,537.18
$1,654.74
$1,779.30
$2,221.72 		$1,870.31
$1,987.87
$2,112.43
$2,554.85 		$333.13
Toc - Plan #30 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueEssentials Bronze 6

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$345.45
$392.08
$441.48
$616.97
$937.55 		$609.72
$656.35
$705.75
$881.24 		$873.99
$920.62
$970.02
$1,145.51 		$1,138.26
$1,184.89
$1,234.29
$1,409.78 		$264.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.90
$784.16
$882.96
$1,233.94
$1,875.10 		$955.17
$1,048.43
$1,147.23
$1,498.21 		$1,219.44
$1,312.70
$1,411.50
$1,762.48 		$1,483.71
$1,576.97
$1,675.77
$2,026.75 		$264.27
Toc - Plan #31 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueEssentials Gold 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$250 $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 		$410.44
$465.85
$524.54
$733.05
$1,113.94 		$724.43
$779.84
$838.53
$1,047.04 		$1,038.42
$1,093.83
$1,152.52
$1,361.03 		$1,352.41
$1,407.82
$1,466.51
$1,675.02 		$313.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.88
$931.70
$1,049.08
$1,466.10
$2,227.88 		$1,134.87
$1,245.69
$1,363.07
$1,780.09 		$1,448.86
$1,559.68
$1,677.06
$2,094.08 		$1,762.85
$1,873.67
$1,991.05
$2,408.07 		$313.99
Toc - Plan #32 BlueCross BlueShield of South Carolina
Catastrophic

(EPO) BlueEssentials Catastrophic 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$182.41
$207.03
$233.12
$325.78
$495.05 		$321.95
$346.57
$372.66
$465.32 		$461.49
$486.11
$512.20
$604.86 		$601.03
$625.65
$651.74
$744.40 		$139.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$364.82
$414.06
$466.24
$651.56
$990.10 		$504.36
$553.60
$605.78
$791.10 		$643.90
$693.14
$745.32
$930.64 		$783.44
$832.68
$884.86
$1,070.18 		$139.54
Toc - Plan #33 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueExclusive Reedy Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.22
$483.76
$544.71
$761.23
$1,156.77 		$752.28
$809.82
$870.77
$1,087.29 		$1,078.34
$1,135.88
$1,196.83
$1,413.35 		$1,404.40
$1,461.94
$1,522.89
$1,739.41 		$326.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.44
$967.52
$1,089.42
$1,522.46
$2,313.54 		$1,178.50
$1,293.58
$1,415.48
$1,848.52 		$1,504.56
$1,619.64
$1,741.54
$2,174.58 		$1,830.62
$1,945.70
$2,067.60
$2,500.64 		$326.06
Toc - Plan #34 BlueCross BlueShield of South Carolina
Silver

(EPO) BlueExclusive Reedy Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$424.39
$481.68
$542.37
$757.96
$1,151.80 		$749.05
$806.34
$867.03
$1,082.62 		$1,073.71
$1,131.00
$1,191.69
$1,407.28 		$1,398.37
$1,455.66
$1,516.35
$1,731.94 		$324.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.78
$963.36
$1,084.74
$1,515.92
$2,303.60 		$1,173.44
$1,288.02
$1,409.40
$1,840.58 		$1,498.10
$1,612.68
$1,734.06
$2,165.24 		$1,822.76
$1,937.34
$2,058.72
$2,489.90 		$324.66
Toc - Plan #35 BlueCross BlueShield of South Carolina
Expanded Bronze

(EPO) BlueExclusive Reedy Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.30
$318.14
$358.23
$500.62
$760.74 		$494.73
$532.57
$572.66
$715.05 		$709.16
$747.00
$787.09
$929.48 		$923.59
$961.43
$1,001.52
$1,143.91 		$214.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.60
$636.28
$716.46
$1,001.24
$1,521.48 		$775.03
$850.71
$930.89
$1,215.67 		$989.46
$1,065.14
$1,145.32
$1,430.10 		$1,203.89
$1,279.57
$1,359.75
$1,644.53 		$214.43
Toc - Plan #36 BlueCross BlueShield of South Carolina
Gold

(EPO) BlueExclusive Reedy Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-404-6752

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 		$396.02
$449.48
$506.11
$707.29
$1,074.79 		$698.97
$752.43
$809.06
$1,010.24 		$1,001.92
$1,055.38
$1,112.01
$1,313.19 		$1,304.87
$1,358.33
$1,414.96
$1,616.14 		$302.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.04
$898.96
$1,012.22
$1,414.58
$2,149.58 		$1,094.99
$1,201.91
$1,315.17
$1,717.53 		$1,397.94
$1,504.86
$1,618.12
$2,020.48 		$1,700.89
$1,807.81
$1,921.07
$2,323.43 		$302.95

ADVERTISEMENT

Ambetter from Absolute Total Care

Local: 1-833-270-5443 | Toll Free: 1-833-270-5443

Toc - Plan #37 Ambetter from Absolute Total Care
Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$356.24
$404.32
$455.26
$636.22
$966.80 		$628.75
$676.83
$727.77
$908.73 		$901.26
$949.34
$1,000.28
$1,181.24 		$1,173.77
$1,221.85
$1,272.79
$1,453.75 		$272.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.48
$808.64
$910.52
$1,272.44
$1,933.60 		$984.99
$1,081.15
$1,183.03
$1,544.95 		$1,257.50
$1,353.66
$1,455.54
$1,817.46 		$1,530.01
$1,626.17
$1,728.05
$2,089.97 		$272.51
Toc - Plan #38 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$490.95
$557.22
$627.43
$876.82
$1,332.42 		$866.52
$932.79
$1,003.00
$1,252.39 		$1,242.09
$1,308.36
$1,378.57
$1,627.96 		$1,617.66
$1,683.93
$1,754.14
$2,003.53 		$375.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$981.90
$1,114.44
$1,254.86
$1,753.64
$2,664.84 		$1,357.47
$1,490.01
$1,630.43
$2,129.21 		$1,733.04
$1,865.58
$2,006.00
$2,504.78 		$2,108.61
$2,241.15
$2,381.57
$2,880.35 		$375.57
Toc - Plan #39 Ambetter from Absolute Total Care
Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$547.31
$621.19
$699.45
$977.48
$1,485.38 		$966.00
$1,039.88
$1,118.14
$1,396.17 		$1,384.69
$1,458.57
$1,536.83
$1,814.86 		$1,803.38
$1,877.26
$1,955.52
$2,233.55 		$418.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,094.62
$1,242.38
$1,398.90
$1,954.96
$2,970.76 		$1,513.31
$1,661.07
$1,817.59
$2,373.65 		$1,932.00
$2,079.76
$2,236.28
$2,792.34 		$2,350.69
$2,498.45
$2,654.97
$3,211.03 		$418.69
Toc - Plan #40 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$484.67
$550.09
$619.39
$865.60
$1,315.36 		$855.43
$920.85
$990.15
$1,236.36 		$1,226.19
$1,291.61
$1,360.91
$1,607.12 		$1,596.95
$1,662.37
$1,731.67
$1,977.88 		$370.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.34
$1,100.18
$1,238.78
$1,731.20
$2,630.72 		$1,340.10
$1,470.94
$1,609.54
$2,101.96 		$1,710.86
$1,841.70
$1,980.30
$2,472.72 		$2,081.62
$2,212.46
$2,351.06
$2,843.48 		$370.76
Toc - Plan #41 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$386.97
$439.20
$494.54
$691.11
$1,050.21 		$683.00
$735.23
$790.57
$987.14 		$979.03
$1,031.26
$1,086.60
$1,283.17 		$1,275.06
$1,327.29
$1,382.63
$1,579.20 		$296.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.94
$878.40
$989.08
$1,382.22
$2,100.42 		$1,069.97
$1,174.43
$1,285.11
$1,678.25 		$1,366.00
$1,470.46
$1,581.14
$1,974.28 		$1,662.03
$1,766.49
$1,877.17
$2,270.31 		$296.03
Toc - Plan #42 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care 10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$375.04
$425.66
$479.29
$669.81
$1,017.83 		$661.94
$712.56
$766.19
$956.71 		$948.84
$999.46
$1,053.09
$1,243.61 		$1,235.74
$1,286.36
$1,339.99
$1,530.51 		$286.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.08
$851.32
$958.58
$1,339.62
$2,035.66 		$1,036.98
$1,138.22
$1,245.48
$1,626.52 		$1,323.88
$1,425.12
$1,532.38
$1,913.42 		$1,610.78
$1,712.02
$1,819.28
$2,200.32 		$286.90
Toc - Plan #43 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 29

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$478.43
$543.01
$611.43
$854.46
$1,298.44 		$844.42
$909.00
$977.42
$1,220.45 		$1,210.41
$1,274.99
$1,343.41
$1,586.44 		$1,576.40
$1,640.98
$1,709.40
$1,952.43 		$365.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.86
$1,086.02
$1,222.86
$1,708.92
$2,596.88 		$1,322.85
$1,452.01
$1,588.85
$2,074.91 		$1,688.84
$1,818.00
$1,954.84
$2,440.90 		$2,054.83
$2,183.99
$2,320.83
$2,806.89 		$365.99
Toc - Plan #44 Ambetter from Absolute Total Care
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$419.57
$476.20
$536.20
$749.33
$1,138.69 		$740.53
$797.16
$857.16
$1,070.29 		$1,061.49
$1,118.12
$1,178.12
$1,391.25 		$1,382.45
$1,439.08
$1,499.08
$1,712.21 		$320.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.14
$952.40
$1,072.40
$1,498.66
$2,277.38 		$1,160.10
$1,273.36
$1,393.36
$1,819.62 		$1,481.06
$1,594.32
$1,714.32
$2,140.58 		$1,802.02
$1,915.28
$2,035.28
$2,461.54 		$320.96
Toc - Plan #45 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$441.51
$501.11
$564.24
$788.53
$1,198.24 		$779.26
$838.86
$901.99
$1,126.28 		$1,117.01
$1,176.61
$1,239.74
$1,464.03 		$1,454.76
$1,514.36
$1,577.49
$1,801.78 		$337.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.02
$1,002.22
$1,128.48
$1,577.06
$2,396.48 		$1,220.77
$1,339.97
$1,466.23
$1,914.81 		$1,558.52
$1,677.72
$1,803.98
$2,252.56 		$1,896.27
$2,015.47
$2,141.73
$2,590.31 		$337.75
Toc - Plan #46 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$457.52
$519.27
$584.70
$817.11
$1,241.68 		$807.51
$869.26
$934.69
$1,167.10 		$1,157.50
$1,219.25
$1,284.68
$1,517.09 		$1,507.49
$1,569.24
$1,634.67
$1,867.08 		$349.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.04
$1,038.54
$1,169.40
$1,634.22
$2,483.36 		$1,265.03
$1,388.53
$1,519.39
$1,984.21 		$1,615.02
$1,738.52
$1,869.38
$2,334.20 		$1,965.01
$2,088.51
$2,219.37
$2,684.19 		$349.99
Toc - Plan #47 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$457.81
$519.61
$585.07
$817.64
$1,242.48 		$808.03
$869.83
$935.29
$1,167.86 		$1,158.25
$1,220.05
$1,285.51
$1,518.08 		$1,508.47
$1,570.27
$1,635.73
$1,868.30 		$350.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.62
$1,039.22
$1,170.14
$1,635.28
$2,484.96 		$1,265.84
$1,389.44
$1,520.36
$1,985.50 		$1,616.06
$1,739.66
$1,870.58
$2,335.72 		$1,966.28
$2,089.88
$2,220.80
$2,685.94 		$350.22
Toc - Plan #48 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$469.84
$533.26
$600.45
$839.12
$1,275.12 		$829.26
$892.68
$959.87
$1,198.54 		$1,188.68
$1,252.10
$1,319.29
$1,557.96 		$1,548.10
$1,611.52
$1,678.71
$1,917.38 		$359.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.68
$1,066.52
$1,200.90
$1,678.24
$2,550.24 		$1,299.10
$1,425.94
$1,560.32
$2,037.66 		$1,658.52
$1,785.36
$1,919.74
$2,397.08 		$2,017.94
$2,144.78
$2,279.16
$2,756.50 		$359.42
Toc - Plan #49 Ambetter from Absolute Total Care
Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$512.65
$581.85
$655.16
$915.58
$1,391.31 		$904.82
$974.02
$1,047.33
$1,307.75 		$1,296.99
$1,366.19
$1,439.50
$1,699.92 		$1,689.16
$1,758.36
$1,831.67
$2,092.09 		$392.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,025.30
$1,163.70
$1,310.32
$1,831.16
$2,782.62 		$1,417.47
$1,555.87
$1,702.49
$2,223.33 		$1,809.64
$1,948.04
$2,094.66
$2,615.50 		$2,201.81
$2,340.21
$2,486.83
$3,007.67 		$392.17
Toc - Plan #50 Ambetter from Absolute Total Care
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$571.08
$648.16
$729.83
$1,019.93
$1,549.88 		$1,007.95
$1,085.03
$1,166.70
$1,456.80 		$1,444.82
$1,521.90
$1,603.57
$1,893.67 		$1,881.69
$1,958.77
$2,040.44
$2,330.54 		$436.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,142.16
$1,296.32
$1,459.66
$2,039.86
$3,099.76 		$1,579.03
$1,733.19
$1,896.53
$2,476.73 		$2,015.90
$2,170.06
$2,333.40
$2,913.60 		$2,452.77
$2,606.93
$2,770.27
$3,350.47 		$436.87
Toc - Plan #51 Ambetter from Absolute Total Care
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$371.71
$421.88
$475.03
$663.85
$1,008.78 		$656.06
$706.23
$759.38
$948.20 		$940.41
$990.58
$1,043.73
$1,232.55 		$1,224.76
$1,274.93
$1,328.08
$1,516.90 		$284.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.42
$843.76
$950.06
$1,327.70
$2,017.56 		$1,027.77
$1,128.11
$1,234.41
$1,612.05 		$1,312.12
$1,412.46
$1,518.76
$1,896.40 		$1,596.47
$1,696.81
$1,803.11
$2,180.75 		$284.35
Toc - Plan #52 Ambetter from Absolute Total Care
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$512.27
$581.42
$654.67
$914.90
$1,390.28 		$904.15
$973.30
$1,046.55
$1,306.78 		$1,296.03
$1,365.18
$1,438.43
$1,698.66 		$1,687.91
$1,757.06
$1,830.31
$2,090.54 		$391.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.54
$1,162.84
$1,309.34
$1,829.80
$2,780.56 		$1,416.42
$1,554.72
$1,701.22
$2,221.68 		$1,808.30
$1,946.60
$2,093.10
$2,613.56 		$2,200.18
$2,338.48
$2,484.98
$3,005.44 		$391.88
Toc - Plan #53 Ambetter from Absolute Total Care
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$505.71
$573.97
$646.29
$903.19
$1,372.48 		$892.57
$960.83
$1,033.15
$1,290.05 		$1,279.43
$1,347.69
$1,420.01
$1,676.91 		$1,666.29
$1,734.55
$1,806.87
$2,063.77 		$386.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.42
$1,147.94
$1,292.58
$1,806.38
$2,744.96 		$1,398.28
$1,534.80
$1,679.44
$2,193.24 		$1,785.14
$1,921.66
$2,066.30
$2,580.10 		$2,172.00
$2,308.52
$2,453.16
$2,966.96 		$386.86
Toc - Plan #54 Ambetter from Absolute Total Care
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$403.77
$458.27
$516.01
$721.12
$1,095.82 		$712.65
$767.15
$824.89
$1,030.00 		$1,021.53
$1,076.03
$1,133.77
$1,338.88 		$1,330.41
$1,384.91
$1,442.65
$1,647.76 		$308.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.54
$916.54
$1,032.02
$1,442.24
$2,191.64 		$1,116.42
$1,225.42
$1,340.90
$1,751.12 		$1,425.30
$1,534.30
$1,649.78
$2,060.00 		$1,734.18
$1,843.18
$1,958.66
$2,368.88 		$308.88
Toc - Plan #55 Ambetter from Absolute Total Care
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$391.33
$444.14
$500.10
$698.89
$1,062.03 		$690.69
$743.50
$799.46
$998.25 		$990.05
$1,042.86
$1,098.82
$1,297.61 		$1,289.41
$1,342.22
$1,398.18
$1,596.97 		$299.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.66
$888.28
$1,000.20
$1,397.78
$2,124.06 		$1,082.02
$1,187.64
$1,299.56
$1,697.14 		$1,381.38
$1,487.00
$1,598.92
$1,996.50 		$1,680.74
$1,786.36
$1,898.28
$2,295.86 		$299.36
Toc - Plan #56 Ambetter from Absolute Total Care
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$437.79
$496.88
$559.48
$781.87
$1,188.13 		$772.69
$831.78
$894.38
$1,116.77 		$1,107.59
$1,166.68
$1,229.28
$1,451.67 		$1,442.49
$1,501.58
$1,564.18
$1,786.57 		$334.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$875.58
$993.76
$1,118.96
$1,563.74
$2,376.26 		$1,210.48
$1,328.66
$1,453.86
$1,898.64 		$1,545.38
$1,663.56
$1,788.76
$2,233.54 		$1,880.28
$1,998.46
$2,123.66
$2,568.44 		$334.90
Toc - Plan #57 Ambetter from Absolute Total Care
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$460.69
$522.87
$588.74
$822.77
$1,250.28 		$813.11
$875.29
$941.16
$1,175.19 		$1,165.53
$1,227.71
$1,293.58
$1,527.61 		$1,517.95
$1,580.13
$1,646.00
$1,880.03 		$352.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.38
$1,045.74
$1,177.48
$1,645.54
$2,500.56 		$1,273.80
$1,398.16
$1,529.90
$1,997.96 		$1,626.22
$1,750.58
$1,882.32
$2,350.38 		$1,978.64
$2,103.00
$2,234.74
$2,702.80 		$352.42
Toc - Plan #58 Ambetter from Absolute Total Care
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$477.39
$541.82
$610.09
$852.59
$1,295.60 		$842.58
$907.01
$975.28
$1,217.78 		$1,207.77
$1,272.20
$1,340.47
$1,582.97 		$1,572.96
$1,637.39
$1,705.66
$1,948.16 		$365.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.78
$1,083.64
$1,220.18
$1,705.18
$2,591.20 		$1,319.97
$1,448.83
$1,585.37
$2,070.37 		$1,685.16
$1,814.02
$1,950.56
$2,435.56 		$2,050.35
$2,179.21
$2,315.75
$2,800.75 		$365.19
Toc - Plan #59 Ambetter from Absolute Total Care
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$477.69
$542.17
$610.48
$853.14
$1,296.43 		$843.12
$907.60
$975.91
$1,218.57 		$1,208.55
$1,273.03
$1,341.34
$1,584.00 		$1,573.98
$1,638.46
$1,706.77
$1,949.43 		$365.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$955.38
$1,084.34
$1,220.96
$1,706.28
$2,592.86 		$1,320.81
$1,449.77
$1,586.39
$2,071.71 		$1,686.24
$1,815.20
$1,951.82
$2,437.14 		$2,051.67
$2,180.63
$2,317.25
$2,802.57 		$365.43
Toc - Plan #60 Ambetter from Absolute Total Care
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$490.24
$556.42
$626.52
$875.56
$1,330.49 		$865.27
$931.45
$1,001.55
$1,250.59 		$1,240.30
$1,306.48
$1,376.58
$1,625.62 		$1,615.33
$1,681.51
$1,751.61
$2,000.65 		$375.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$980.48
$1,112.84
$1,253.04
$1,751.12
$2,660.98 		$1,355.51
$1,487.87
$1,628.07
$2,126.15 		$1,730.54
$1,862.90
$2,003.10
$2,501.18 		$2,105.57
$2,237.93
$2,378.13
$2,876.21 		$375.03
Toc - Plan #61 Ambetter from Absolute Total Care
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$534.91
$607.11
$683.61
$955.34
$1,451.73 		$944.11
$1,016.31
$1,092.81
$1,364.54 		$1,353.31
$1,425.51
$1,502.01
$1,773.74 		$1,762.51
$1,834.71
$1,911.21
$2,182.94 		$409.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,069.82
$1,214.22
$1,367.22
$1,910.68
$2,903.46 		$1,479.02
$1,623.42
$1,776.42
$2,319.88 		$1,888.22
$2,032.62
$2,185.62
$2,729.08 		$2,297.42
$2,441.82
$2,594.82
$3,138.28 		$409.20
Toc - Plan #62 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Balanced Care 29 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$499.21
$566.59
$637.98
$891.57
$1,354.82 		$881.10
$948.48
$1,019.87
$1,273.46 		$1,262.99
$1,330.37
$1,401.76
$1,655.35 		$1,644.88
$1,712.26
$1,783.65
$2,037.24 		$381.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.42
$1,133.18
$1,275.96
$1,783.14
$2,709.64 		$1,380.31
$1,515.07
$1,657.85
$2,165.03 		$1,762.20
$1,896.96
$2,039.74
$2,546.92 		$2,144.09
$2,278.85
$2,421.63
$2,928.81 		$381.89
Toc - Plan #63 Ambetter from Absolute Total Care
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.52
$420.53
$473.52
$661.74
$1,005.58 		$653.96
$703.97
$756.96
$945.18 		$937.40
$987.41
$1,040.40
$1,228.62 		$1,220.84
$1,270.85
$1,323.84
$1,512.06 		$283.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.04
$841.06
$947.04
$1,323.48
$2,011.16 		$1,024.48
$1,124.50
$1,230.48
$1,606.92 		$1,307.92
$1,407.94
$1,513.92
$1,890.36 		$1,591.36
$1,691.38
$1,797.36
$2,173.80 		$283.44
Toc - Plan #64 Ambetter from Absolute Total Care
Silver

(HMO) Ambetter Virtual Access Silver ($0 Virtual Primary Care + $0 Virtual Urgent Care + $0 Preferred Labs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-270-5443

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 		$462.87
$525.35
$591.54
$826.67
$1,256.20 		$816.96
$879.44
$945.63
$1,180.76 		$1,171.05
$1,233.53
$1,299.72
$1,534.85 		$1,525.14
$1,587.62
$1,653.81
$1,888.94 		$354.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.74
$1,050.70
$1,183.08
$1,653.34
$2,512.40 		$1,279.83
$1,404.79
$1,537.17
$2,007.43 		$1,633.92
$1,758.88
$1,891.26
$2,361.52 		$1,988.01
$2,112.97
$2,245.35
$2,715.61 		$354.09

‡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 Pickens County here.

Pickens County is in “Rating Area 39” of South Carolina.

Currently, there are 64 plans offered in Rating Area 39.

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2022 Obamacare Plans for Pickens County, SC

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