Obamacare 2022 Rates for Davis County

Obamacare > Rates > Utah > Davis 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 Davis County, UT.

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, 100 Plans and 2022 Rates for Davis County, Utah

Below, you’ll find a summary of the 100 plans for Davis County, Utah 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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Molina Healthcare

Local: 1-801-858-0400 | Toll Free: 1-888-858-3973

Toc - Plan #1 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$305.79
$425.05
$452.27
$650.43
$917.37 		$548.29
$667.55
$694.77
$892.93 		$790.79
$910.05
$937.27
$1,135.43 		$1,033.29
$1,152.55
$1,179.77
$1,377.93 		$242.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.58
$850.10
$904.54
$1,300.86
$1,834.74 		$854.08
$1,092.60
$1,147.04
$1,543.36 		$1,096.58
$1,335.10
$1,389.54
$1,785.86 		$1,339.08
$1,577.60
$1,632.04
$2,028.36 		$242.50
Toc - Plan #2 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$306.71
$426.32
$453.62
$652.37
$920.12 		$549.93
$669.54
$696.84
$895.59 		$793.15
$912.76
$940.06
$1,138.81 		$1,036.37
$1,155.98
$1,183.28
$1,382.03 		$243.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.42
$852.64
$907.24
$1,304.74
$1,840.24 		$856.64
$1,095.86
$1,150.46
$1,547.96 		$1,099.86
$1,339.08
$1,393.68
$1,791.18 		$1,343.08
$1,582.30
$1,636.90
$2,034.40 		$243.22
Toc - Plan #3 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

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 		$303.88
$422.40
$449.45
$646.36
$911.64 		$544.86
$663.38
$690.43
$887.34 		$785.84
$904.36
$931.41
$1,128.32 		$1,026.82
$1,145.34
$1,172.39
$1,369.30 		$240.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.76
$844.80
$898.90
$1,292.72
$1,823.28 		$848.74
$1,085.78
$1,139.88
$1,533.70 		$1,089.72
$1,326.76
$1,380.86
$1,774.68 		$1,330.70
$1,567.74
$1,621.84
$2,015.66 		$240.98
Toc - Plan #4 Molina Healthcare
Silver

(HMO) Constant Care Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$300.38
$417.53
$444.27
$638.91
$901.14 		$538.58
$655.73
$682.47
$877.11 		$776.78
$893.93
$920.67
$1,115.31 		$1,014.98
$1,132.13
$1,158.87
$1,353.51 		$238.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.76
$835.06
$888.54
$1,277.82
$1,802.28 		$838.96
$1,073.26
$1,126.74
$1,516.02 		$1,077.16
$1,311.46
$1,364.94
$1,754.22 		$1,315.36
$1,549.66
$1,603.14
$1,992.42 		$238.20
Toc - Plan #5 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$311.55
$433.05
$460.78
$662.66
$934.65 		$558.61
$680.11
$707.84
$909.72 		$805.67
$927.17
$954.90
$1,156.78 		$1,052.73
$1,174.23
$1,201.96
$1,403.84 		$247.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.10
$866.10
$921.56
$1,325.32
$1,869.30 		$870.16
$1,113.16
$1,168.62
$1,572.38 		$1,117.22
$1,360.22
$1,415.68
$1,819.44 		$1,364.28
$1,607.28
$1,662.74
$2,066.50 		$247.06
Toc - Plan #6 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$309.18
$429.76
$457.28
$657.63
$927.54 		$554.36
$674.94
$702.46
$902.81 		$799.54
$920.12
$947.64
$1,147.99 		$1,044.72
$1,165.30
$1,192.82
$1,393.17 		$245.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.36
$859.52
$914.56
$1,315.26
$1,855.08 		$863.54
$1,104.70
$1,159.74
$1,560.44 		$1,108.72
$1,349.88
$1,404.92
$1,805.62 		$1,353.90
$1,595.06
$1,650.10
$2,050.80 		$245.18
Toc - Plan #7 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-858-3973

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 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 		$304.37
$423.08
$450.17
$647.40
$913.11 		$545.74
$664.45
$691.54
$888.77 		$787.11
$905.82
$932.91
$1,130.14 		$1,028.48
$1,147.19
$1,174.28
$1,371.51 		$241.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.74
$846.16
$900.34
$1,294.80
$1,826.22 		$850.11
$1,087.53
$1,141.71
$1,536.17 		$1,091.48
$1,328.90
$1,383.08
$1,777.54 		$1,332.85
$1,570.27
$1,624.45
$2,018.91 		$241.37

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Regence BlueCross BlueShield of Utah

Local: 1-888-231-8424 | Toll Free: 1-888-231-8424

Toc - Plan #8 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 3750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$3,750 $7,500 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 		$326.33
$453.60
$482.65
$694.10
$978.99 		$585.11
$712.38
$741.43
$952.88 		$843.89
$971.16
$1,000.21
$1,211.66 		$1,102.67
$1,229.94
$1,258.99
$1,470.44 		$258.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.66
$907.20
$965.30
$1,388.20
$1,957.98 		$911.44
$1,165.98
$1,224.08
$1,646.98 		$1,170.22
$1,424.76
$1,482.86
$1,905.76 		$1,429.00
$1,683.54
$1,741.64
$2,164.54 		$258.78
Toc - Plan #9 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze HDHP 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$245.54
$341.30
$363.16
$522.27
$736.62 		$440.26
$536.02
$557.88
$716.99 		$634.98
$730.74
$752.60
$911.71 		$829.70
$925.46
$947.32
$1,106.43 		$194.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$491.08
$682.60
$726.32
$1,044.54
$1,473.24 		$685.80
$877.32
$921.04
$1,239.26 		$880.52
$1,072.04
$1,115.76
$1,433.98 		$1,075.24
$1,266.76
$1,310.48
$1,628.70 		$194.72
Toc - Plan #10 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze Essential 8000 With 4 Copay No Deductible Office Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$225.91
$314.01
$334.11
$480.50
$677.72 		$405.05
$493.15
$513.25
$659.64 		$584.19
$672.29
$692.39
$838.78 		$763.33
$851.43
$871.53
$1,017.92 		$179.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$451.82
$628.02
$668.22
$961.00
$1,355.44 		$630.96
$807.16
$847.36
$1,140.14 		$810.10
$986.30
$1,026.50
$1,319.28 		$989.24
$1,165.44
$1,205.64
$1,498.42 		$179.14
Toc - Plan #11 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze Virtual Value 8500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$216.35
$300.73
$319.99
$460.18
$649.05 		$387.92
$472.30
$491.56
$631.75 		$559.49
$643.87
$663.13
$803.32 		$731.06
$815.44
$834.70
$974.89 		$171.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$432.70
$601.46
$639.98
$920.36
$1,298.10 		$604.27
$773.03
$811.55
$1,091.93 		$775.84
$944.60
$983.12
$1,263.50 		$947.41
$1,116.17
$1,154.69
$1,435.07 		$171.57
Toc - Plan #12 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 5000 Separate RX Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$318.06
$442.10
$470.41
$676.51
$954.17 		$570.28
$694.32
$722.63
$928.73 		$822.50
$946.54
$974.85
$1,180.95 		$1,074.72
$1,198.76
$1,227.07
$1,433.17 		$252.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.12
$884.20
$940.82
$1,353.02
$1,908.34 		$888.34
$1,136.42
$1,193.04
$1,605.24 		$1,140.56
$1,388.64
$1,445.26
$1,857.46 		$1,392.78
$1,640.86
$1,697.48
$2,109.68 		$252.22
Toc - Plan #13 Regence BlueCross BlueShield of Utah
Silver

(EPO) Silver 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$294.41
$409.23
$435.43
$626.21
$883.23 		$527.88
$642.70
$668.90
$859.68 		$761.35
$876.17
$902.37
$1,093.15 		$994.82
$1,109.64
$1,135.84
$1,326.62 		$233.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.82
$818.46
$870.86
$1,252.42
$1,766.46 		$822.29
$1,051.93
$1,104.33
$1,485.89 		$1,055.76
$1,285.40
$1,337.80
$1,719.36 		$1,289.23
$1,518.87
$1,571.27
$1,952.83 		$233.47
Toc - Plan #14 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) Bronze 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$223.91
$311.23
$331.16
$476.25
$671.72 		$401.47
$488.79
$508.72
$653.81 		$579.03
$666.35
$686.28
$831.37 		$756.59
$843.91
$863.84
$1,008.93 		$177.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447.82
$622.46
$662.32
$952.50
$1,343.44 		$625.38
$800.02
$839.88
$1,130.06 		$802.94
$977.58
$1,017.44
$1,307.62 		$980.50
$1,155.14
$1,195.00
$1,485.18 		$177.56
Toc - Plan #15 Regence BlueCross BlueShield of Utah
Gold

(EPO) Gold 2500 With Dental and Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$334.80
$465.38
$495.18
$712.13
$1,004.40 		$600.30
$730.88
$760.68
$977.63 		$865.80
$996.38
$1,026.18
$1,243.13 		$1,131.30
$1,261.88
$1,291.68
$1,508.63 		$265.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.60
$930.76
$990.36
$1,424.26
$2,008.80 		$935.10
$1,196.26
$1,255.86
$1,689.76 		$1,200.60
$1,461.76
$1,521.36
$1,955.26 		$1,466.10
$1,727.26
$1,786.86
$2,220.76 		$265.50
Toc - Plan #16 Regence BlueCross BlueShield of Utah
Silver

(EPO) SaveWell Silver 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$298.68
$415.17
$441.75
$635.30
$896.04 		$535.53
$652.02
$678.60
$872.15 		$772.38
$888.87
$915.45
$1,109.00 		$1,009.23
$1,125.72
$1,152.30
$1,345.85 		$236.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.36
$830.34
$883.50
$1,270.60
$1,792.08 		$834.21
$1,067.19
$1,120.35
$1,507.45 		$1,071.06
$1,304.04
$1,357.20
$1,744.30 		$1,307.91
$1,540.89
$1,594.05
$1,981.15 		$236.85
Toc - Plan #17 Regence BlueCross BlueShield of Utah
Silver

(EPO) SaveWell Silver 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$278.74
$387.45
$412.26
$592.88
$836.22 		$499.78
$608.49
$633.30
$813.92 		$720.82
$829.53
$854.34
$1,034.96 		$941.86
$1,050.57
$1,075.38
$1,256.00 		$221.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.48
$774.90
$824.52
$1,185.76
$1,672.44 		$778.52
$995.94
$1,045.56
$1,406.80 		$999.56
$1,216.98
$1,266.60
$1,627.84 		$1,220.60
$1,438.02
$1,487.64
$1,848.88 		$221.04
Toc - Plan #18 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) SaveWell Bronze HDHP 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$219.80
$305.52
$325.08
$467.51
$659.39 		$394.10
$479.82
$499.38
$641.81 		$568.40
$654.12
$673.68
$816.11 		$742.70
$828.42
$847.98
$990.41 		$174.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$439.60
$611.04
$650.16
$935.02
$1,318.78 		$613.90
$785.34
$824.46
$1,109.32 		$788.20
$959.64
$998.76
$1,283.62 		$962.50
$1,133.94
$1,173.06
$1,457.92 		$174.30
Toc - Plan #19 Regence BlueCross BlueShield of Utah
Expanded Bronze

(EPO) SaveWell Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-231-8424

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 		$200.06
$278.08
$295.88
$425.52
$600.17 		$358.70
$436.72
$454.52
$584.16 		$517.34
$595.36
$613.16
$742.80 		$675.98
$754.00
$771.80
$901.44 		$158.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$400.12
$556.16
$591.76
$851.04
$1,200.34 		$558.76
$714.80
$750.40
$1,009.68 		$717.40
$873.44
$909.04
$1,168.32 		$876.04
$1,032.08
$1,067.68
$1,326.96 		$158.64

ADVERTISEMENT

BridgeSpan Health Company

Local: 1-855-857-9944 | Toll Free: 1-855-857-9944 | TTY: 1-800-735-2900
Toc - Plan #20 BridgeSpan Health Company
Gold

(HMO) Gold Starter HDHP 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9944

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$347.88
$483.55
$514.52
$739.94
$1,043.64 		$623.74
$759.41
$790.38
$1,015.80 		$899.60
$1,035.27
$1,066.24
$1,291.66 		$1,175.46
$1,311.13
$1,342.10
$1,567.52 		$275.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.76
$967.10
$1,029.04
$1,479.88
$2,087.28 		$971.62
$1,242.96
$1,304.90
$1,755.74 		$1,247.48
$1,518.82
$1,580.76
$2,031.60 		$1,523.34
$1,794.68
$1,856.62
$2,307.46 		$275.86
Toc - Plan #21 BridgeSpan Health Company
Silver

(HMO) BridgeSpan Silver Essential 4000 With 4 Copay No Deductible Office Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9944

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 		$327.34
$455.01
$484.14
$696.25
$982.02 		$586.92
$714.59
$743.72
$955.83 		$846.50
$974.17
$1,003.30
$1,215.41 		$1,106.08
$1,233.75
$1,262.88
$1,474.99 		$259.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.68
$910.02
$968.28
$1,392.50
$1,964.04 		$914.26
$1,169.60
$1,227.86
$1,652.08 		$1,173.84
$1,429.18
$1,487.44
$1,911.66 		$1,433.42
$1,688.76
$1,747.02
$2,171.24 		$259.58
Toc - Plan #22 BridgeSpan Health Company
Expanded Bronze

(HMO) Bronze HDHP 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9944

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$237.57
$330.22
$351.36
$505.30
$712.70 		$425.96
$518.61
$539.75
$693.69 		$614.35
$707.00
$728.14
$882.08 		$802.74
$895.39
$916.53
$1,070.47 		$188.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475.14
$660.44
$702.72
$1,010.60
$1,425.40 		$663.53
$848.83
$891.11
$1,198.99 		$851.92
$1,037.22
$1,079.50
$1,387.38 		$1,040.31
$1,225.61
$1,267.89
$1,575.77 		$188.39
Toc - Plan #23 BridgeSpan Health Company
Expanded Bronze

(HMO) Bronze Virtual Saver 8000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-857-9944

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 		$222.68
$309.53
$329.35
$473.65
$668.04 		$399.26
$486.11
$505.93
$650.23 		$575.84
$662.69
$682.51
$826.81 		$752.42
$839.27
$859.09
$1,003.39 		$176.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$445.36
$619.06
$658.70
$947.30
$1,336.08 		$621.94
$795.64
$835.28
$1,123.88 		$798.52
$972.22
$1,011.86
$1,300.46 		$975.10
$1,148.80
$1,188.44
$1,477.04 		$176.58

ADVERTISEMENT

Bright HealthCare

Local: 1-855-827-4448 | Toll Free: 1-855-827-4448 | TTY: 1-855-827-4448
Toc - Plan #24 Bright HealthCare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$312.31
$434.11
$461.90
$664.28
$936.92 		$559.97
$681.77
$709.56
$911.94 		$807.63
$929.43
$957.22
$1,159.60 		$1,055.29
$1,177.09
$1,204.88
$1,407.26 		$247.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.62
$868.22
$923.80
$1,328.56
$1,873.84 		$872.28
$1,115.88
$1,171.46
$1,576.22 		$1,119.94
$1,363.54
$1,419.12
$1,823.88 		$1,367.60
$1,611.20
$1,666.78
$2,071.54 		$247.66
Toc - Plan #25 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$298.91
$415.49
$442.09
$635.78
$896.73 		$535.95
$652.53
$679.13
$872.82 		$772.99
$889.57
$916.17
$1,109.86 		$1,010.03
$1,126.61
$1,153.21
$1,346.90 		$237.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.82
$830.98
$884.18
$1,271.56
$1,793.46 		$834.86
$1,068.02
$1,121.22
$1,508.60 		$1,071.90
$1,305.06
$1,358.26
$1,745.64 		$1,308.94
$1,542.10
$1,595.30
$1,982.68 		$237.04
Toc - Plan #26 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$301.16
$418.61
$445.42
$640.57
$903.48 		$539.98
$657.43
$684.24
$879.39 		$778.80
$896.25
$923.06
$1,118.21 		$1,017.62
$1,135.07
$1,161.88
$1,357.03 		$238.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.32
$837.22
$890.84
$1,281.14
$1,806.96 		$841.14
$1,076.04
$1,129.66
$1,519.96 		$1,079.96
$1,314.86
$1,368.48
$1,758.78 		$1,318.78
$1,553.68
$1,607.30
$1,997.60 		$238.82
Toc - Plan #27 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$314.44
$437.08
$465.06
$668.82
$943.32 		$563.79
$686.43
$714.41
$918.17 		$813.14
$935.78
$963.76
$1,167.52 		$1,062.49
$1,185.13
$1,213.11
$1,416.87 		$249.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.88
$874.16
$930.12
$1,337.64
$1,886.64 		$878.23
$1,123.51
$1,179.47
$1,586.99 		$1,127.58
$1,372.86
$1,428.82
$1,836.34 		$1,376.93
$1,622.21
$1,678.17
$2,085.69 		$249.35
Toc - Plan #28 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$305.34
$424.43
$451.60
$649.47
$916.02 		$547.48
$666.57
$693.74
$891.61 		$789.62
$908.71
$935.88
$1,133.75 		$1,031.76
$1,150.85
$1,178.02
$1,375.89 		$242.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.68
$848.86
$903.20
$1,298.94
$1,832.04 		$852.82
$1,091.00
$1,145.34
$1,541.08 		$1,094.96
$1,333.14
$1,387.48
$1,783.22 		$1,337.10
$1,575.28
$1,629.62
$2,025.36 		$242.14
Toc - Plan #29 Bright HealthCare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$187.85
$261.11
$277.83
$399.55
$563.54 		$336.81
$410.07
$426.79
$548.51 		$485.77
$559.03
$575.75
$697.47 		$634.73
$707.99
$724.71
$846.43 		$148.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$375.70
$522.22
$555.66
$799.10
$1,127.08 		$524.66
$671.18
$704.62
$948.06 		$673.62
$820.14
$853.58
$1,097.02 		$822.58
$969.10
$1,002.54
$1,245.98 		$148.96
Toc - Plan #30 Bright HealthCare
Expanded Bronze

(EPO) Bronze 5300 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$206.28
$286.73
$305.09
$438.76
$618.84 		$369.86
$450.31
$468.67
$602.34 		$533.44
$613.89
$632.25
$765.92 		$697.02
$777.47
$795.83
$929.50 		$163.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$412.56
$573.46
$610.18
$877.52
$1,237.68 		$576.14
$737.04
$773.76
$1,041.10 		$739.72
$900.62
$937.34
$1,204.68 		$903.30
$1,064.20
$1,100.92
$1,368.26 		$163.58
Toc - Plan #31 Bright HealthCare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$195.60
$271.88
$289.29
$416.03
$586.79 		$350.71
$426.99
$444.40
$571.14 		$505.82
$582.10
$599.51
$726.25 		$660.93
$737.21
$754.62
$881.36 		$155.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$391.20
$543.76
$578.58
$832.06
$1,173.58 		$546.31
$698.87
$733.69
$987.17 		$701.42
$853.98
$888.80
$1,142.28 		$856.53
$1,009.09
$1,043.91
$1,297.39 		$155.11
Toc - Plan #32 Bright HealthCare
Expanded Bronze

(EPO) 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: 1-855-827-4448

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 		$226.27
$314.52
$334.66
$481.28
$678.81 		$405.70
$493.95
$514.09
$660.71 		$585.13
$673.38
$693.52
$840.14 		$764.56
$852.81
$872.95
$1,019.57 		$179.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.54
$629.04
$669.32
$962.56
$1,357.62 		$631.97
$808.47
$848.75
$1,141.99 		$811.40
$987.90
$1,028.18
$1,321.42 		$990.83
$1,167.33
$1,207.61
$1,500.85 		$179.43
Toc - Plan #33 Bright HealthCare
Catastrophic

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$160.02
$222.43
$236.67
$340.36
$480.06 		$286.92
$349.33
$363.57
$467.26 		$413.82
$476.23
$490.47
$594.16 		$540.72
$603.13
$617.37
$721.06 		$126.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$320.04
$444.86
$473.34
$680.72
$960.12 		$446.94
$571.76
$600.24
$807.62 		$573.84
$698.66
$727.14
$934.52 		$700.74
$825.56
$854.04
$1,061.42 		$126.90
Toc - Plan #34 Bright HealthCare
Expanded Bronze

(EPO) Bronze 8700 ($25 Generic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$184.12
$255.93
$272.31
$391.62
$552.36 		$330.13
$401.94
$418.32
$537.63 		$476.14
$547.95
$564.33
$683.64 		$622.15
$693.96
$710.34
$829.65 		$146.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$368.24
$511.86
$544.62
$783.24
$1,104.72 		$514.25
$657.87
$690.63
$929.25 		$660.26
$803.88
$836.64
$1,075.26 		$806.27
$949.89
$982.65
$1,221.27 		$146.01
Toc - Plan #35 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-827-4448

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 		$293.54
$408.02
$434.14
$624.35
$880.61 		$526.31
$640.79
$666.91
$857.12 		$759.08
$873.56
$899.68
$1,089.89 		$991.85
$1,106.33
$1,132.45
$1,322.66 		$232.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.08
$816.04
$868.28
$1,248.70
$1,761.22 		$819.85
$1,048.81
$1,101.05
$1,481.47 		$1,052.62
$1,281.58
$1,333.82
$1,714.24 		$1,285.39
$1,514.35
$1,566.59
$1,947.01 		$232.77
Toc - Plan #36 Bright HealthCare
Gold

(EPO) 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: 1-855-827-4448

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 		$354.85
$493.25
$524.83
$754.78
$1,064.55 		$636.25
$774.65
$806.23
$1,036.18 		$917.65
$1,056.05
$1,087.63
$1,317.58 		$1,199.05
$1,337.45
$1,369.03
$1,598.98 		$281.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.70
$986.50
$1,049.66
$1,509.56
$2,129.10 		$991.10
$1,267.90
$1,331.06
$1,790.96 		$1,272.50
$1,549.30
$1,612.46
$2,072.36 		$1,553.90
$1,830.70
$1,893.86
$2,353.76 		$281.40
Toc - Plan #37 Bright HealthCare
Silver

(EPO) 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: 1-855-827-4448

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 		$317.48
$441.29
$469.55
$675.27
$952.43 		$569.24
$693.05
$721.31
$927.03 		$821.00
$944.81
$973.07
$1,178.79 		$1,072.76
$1,196.57
$1,224.83
$1,430.55 		$251.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.96
$882.58
$939.10
$1,350.54
$1,904.86 		$886.72
$1,134.34
$1,190.86
$1,602.30 		$1,138.48
$1,386.10
$1,442.62
$1,854.06 		$1,390.24
$1,637.86
$1,694.38
$2,105.82 		$251.76
Toc - Plan #38 Bright HealthCare
Expanded Bronze

(EPO) 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: 1-855-827-4448

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 		$207.73
$288.74
$307.23
$441.84
$623.19 		$372.46
$453.47
$471.96
$606.57 		$537.19
$618.20
$636.69
$771.30 		$701.92
$782.93
$801.42
$936.03 		$164.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$415.46
$577.48
$614.46
$883.68
$1,246.38 		$580.19
$742.21
$779.19
$1,048.41 		$744.92
$906.94
$943.92
$1,213.14 		$909.65
$1,071.67
$1,108.65
$1,377.87 		$164.73

ADVERTISEMENT

University of Utah Health Plans

Local: 1-801-213-4111x1 | Toll Free: 1-888-271-5870 | TTY: 1-800-346-4128
Toc - Plan #39 University of Utah Health Plans
Gold

(EPO) Healthy Premier Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$416.35
$578.73
$615.78
$885.58
$1,249.05 		$746.52
$908.90
$945.95
$1,215.75 		$1,076.69
$1,239.07
$1,276.12
$1,545.92 		$1,406.86
$1,569.24
$1,606.29
$1,876.09 		$330.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.70
$1,157.46
$1,231.56
$1,771.16
$2,498.10 		$1,162.87
$1,487.63
$1,561.73
$2,101.33 		$1,493.04
$1,817.80
$1,891.90
$2,431.50 		$1,823.21
$2,147.97
$2,222.07
$2,761.67 		$330.17
Toc - Plan #40 University of Utah Health Plans
Silver

(EPO) Healthy Premier Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.17
$560.41
$596.29
$857.54
$1,209.51 		$722.88
$880.12
$916.00
$1,177.25 		$1,042.59
$1,199.83
$1,235.71
$1,496.96 		$1,362.30
$1,519.54
$1,555.42
$1,816.67 		$319.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.34
$1,120.82
$1,192.58
$1,715.08
$2,419.02 		$1,126.05
$1,440.53
$1,512.29
$2,034.79 		$1,445.76
$1,760.24
$1,832.00
$2,354.50 		$1,765.47
$2,079.95
$2,151.71
$2,674.21 		$319.71
Toc - Plan #41 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

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 		$257.21
$357.52
$380.41
$547.09
$771.63 		$461.18
$561.49
$584.38
$751.06 		$665.15
$765.46
$788.35
$955.03 		$869.12
$969.43
$992.32
$1,159.00 		$203.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514.42
$715.04
$760.82
$1,094.18
$1,543.26 		$718.39
$919.01
$964.79
$1,298.15 		$922.36
$1,122.98
$1,168.76
$1,502.12 		$1,126.33
$1,326.95
$1,372.73
$1,706.09 		$203.97
Toc - Plan #42 University of Utah Health Plans
Gold

(EPO) Healthy Preferred Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$378.50
$526.12
$559.80
$805.07
$1,135.50 		$678.65
$826.27
$859.95
$1,105.22 		$978.80
$1,126.42
$1,160.10
$1,405.37 		$1,278.95
$1,426.57
$1,460.25
$1,705.52 		$300.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.00
$1,052.24
$1,119.60
$1,610.14
$2,271.00 		$1,057.15
$1,352.39
$1,419.75
$1,910.29 		$1,357.30
$1,652.54
$1,719.90
$2,210.44 		$1,657.45
$1,952.69
$2,020.05
$2,510.59 		$300.15
Toc - Plan #43 University of Utah Health Plans
Silver

(EPO) Healthy Preferred Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.52
$509.46
$542.08
$779.59
$1,099.56 		$657.17
$800.11
$832.73
$1,070.24 		$947.82
$1,090.76
$1,123.38
$1,360.89 		$1,238.47
$1,381.41
$1,414.03
$1,651.54 		$290.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.04
$1,018.92
$1,084.16
$1,559.18
$2,199.12 		$1,023.69
$1,309.57
$1,374.81
$1,849.83 		$1,314.34
$1,600.22
$1,665.46
$2,140.48 		$1,604.99
$1,890.87
$1,956.11
$2,431.13 		$290.65
Toc - Plan #44 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

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 		$233.82
$325.01
$345.82
$497.34
$701.46 		$419.24
$510.43
$531.24
$682.76 		$604.66
$695.85
$716.66
$868.18 		$790.08
$881.27
$902.08
$1,053.60 		$185.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$467.64
$650.02
$691.64
$994.68
$1,402.92 		$653.06
$835.44
$877.06
$1,180.10 		$838.48
$1,020.86
$1,062.48
$1,365.52 		$1,023.90
$1,206.28
$1,247.90
$1,550.94 		$185.42
Toc - Plan #45 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$286.57
$398.33
$423.84
$609.53
$859.71 		$513.82
$625.58
$651.09
$836.78 		$741.07
$852.83
$878.34
$1,064.03 		$968.32
$1,080.08
$1,105.59
$1,291.28 		$227.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.14
$796.66
$847.68
$1,219.06
$1,719.42 		$800.39
$1,023.91
$1,074.93
$1,446.31 		$1,027.64
$1,251.16
$1,302.18
$1,673.56 		$1,254.89
$1,478.41
$1,529.43
$1,900.81 		$227.25
Toc - Plan #46 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$5,650 $11,300 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 		$260.52
$362.12
$385.31
$554.13
$781.56 		$467.11
$568.71
$591.90
$760.72 		$673.70
$775.30
$798.49
$967.31 		$880.29
$981.89
$1,005.08
$1,173.90 		$206.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.04
$724.24
$770.62
$1,108.26
$1,563.12 		$727.63
$930.83
$977.21
$1,314.85 		$934.22
$1,137.42
$1,183.80
$1,521.44 		$1,140.81
$1,344.01
$1,390.39
$1,728.03 		$206.59
Toc - Plan #47 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Expanded Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$286.14
$397.73
$423.20
$608.62
$858.42 		$513.05
$624.64
$650.11
$835.53 		$739.96
$851.55
$877.02
$1,062.44 		$966.87
$1,078.46
$1,103.93
$1,289.35 		$226.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.28
$795.46
$846.40
$1,217.24
$1,716.84 		$799.19
$1,022.37
$1,073.31
$1,444.15 		$1,026.10
$1,249.28
$1,300.22
$1,671.06 		$1,253.01
$1,476.19
$1,527.13
$1,897.97 		$226.91
Toc - Plan #48 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Expanded Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$260.13
$361.58
$384.73
$553.30
$780.39 		$466.41
$567.86
$591.01
$759.58 		$672.69
$774.14
$797.29
$965.86 		$878.97
$980.42
$1,003.57
$1,172.14 		$206.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520.26
$723.16
$769.46
$1,106.60
$1,560.78 		$726.54
$929.44
$975.74
$1,312.88 		$932.82
$1,135.72
$1,182.02
$1,519.16 		$1,139.10
$1,342.00
$1,388.30
$1,725.44 		$206.28
Toc - Plan #49 University of Utah Health Plans
Silver

(EPO) Healthy Premier Silver 2300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,300 $16,600 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 		$406.42
$564.92
$601.10
$864.46
$1,219.26 		$728.71
$887.21
$923.39
$1,186.75 		$1,051.00
$1,209.50
$1,245.68
$1,509.04 		$1,373.29
$1,531.79
$1,567.97
$1,831.33 		$322.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.84
$1,129.84
$1,202.20
$1,728.92
$2,438.52 		$1,135.13
$1,452.13
$1,524.49
$2,051.21 		$1,457.42
$1,774.42
$1,846.78
$2,373.50 		$1,779.71
$2,096.71
$2,169.07
$2,695.79 		$322.29
Toc - Plan #50 University of Utah Health Plans
Silver

(EPO) Healthy Preferred Silver 2300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,300 $16,600 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 		$369.47
$513.56
$546.45
$785.86
$1,108.41 		$662.46
$806.55
$839.44
$1,078.85 		$955.45
$1,099.54
$1,132.43
$1,371.84 		$1,248.44
$1,392.53
$1,425.42
$1,664.83 		$292.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.94
$1,027.12
$1,092.90
$1,571.72
$2,216.82 		$1,031.93
$1,320.11
$1,385.89
$1,864.71 		$1,324.92
$1,613.10
$1,678.88
$2,157.70 		$1,617.91
$1,906.09
$1,971.87
$2,450.69 		$292.99
Toc - Plan #51 University of Utah Health Plans
Gold

(EPO) Healthy Preferred Wasatch Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$8,300 $16,600 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 		$360.93
$501.69
$533.82
$767.70
$1,082.79 		$647.15
$787.91
$820.04
$1,053.92 		$933.37
$1,074.13
$1,106.26
$1,340.14 		$1,219.59
$1,360.35
$1,392.48
$1,626.36 		$286.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.86
$1,003.38
$1,067.64
$1,535.40
$2,165.58 		$1,008.08
$1,289.60
$1,353.86
$1,821.62 		$1,294.30
$1,575.82
$1,640.08
$2,107.84 		$1,580.52
$1,862.04
$1,926.30
$2,394.06 		$286.22
Toc - Plan #52 University of Utah Health Plans
Silver

(EPO) Healthy Preferred Wasatch Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 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 		$356.63
$495.72
$527.46
$758.55
$1,069.89 		$639.44
$778.53
$810.27
$1,041.36 		$922.25
$1,061.34
$1,093.08
$1,324.17 		$1,205.06
$1,344.15
$1,375.89
$1,606.98 		$282.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.26
$991.44
$1,054.92
$1,517.10
$2,139.78 		$996.07
$1,274.25
$1,337.73
$1,799.91 		$1,278.88
$1,557.06
$1,620.54
$2,082.72 		$1,561.69
$1,839.87
$1,903.35
$2,365.53 		$282.81
Toc - Plan #53 University of Utah Health Plans
Bronze

(EPO) Healthy Preferred Wasatch Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

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 		$223.75
$311.01
$330.93
$475.92
$671.25 		$401.18
$488.44
$508.36
$653.35 		$578.61
$665.87
$685.79
$830.78 		$756.04
$843.30
$863.22
$1,008.21 		$177.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447.50
$622.02
$661.86
$951.84
$1,342.50 		$624.93
$799.45
$839.29
$1,129.27 		$802.36
$976.88
$1,016.72
$1,306.70 		$979.79
$1,154.31
$1,194.15
$1,484.13 		$177.43
Toc - Plan #54 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Premier Bronze w.3 Copays Before Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$257.60
$358.06
$380.99
$547.92
$772.80 		$461.88
$562.34
$585.27
$752.20 		$666.16
$766.62
$789.55
$956.48 		$870.44
$970.90
$993.83
$1,160.76 		$204.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$515.20
$716.12
$761.98
$1,095.84
$1,545.60 		$719.48
$920.40
$966.26
$1,300.12 		$923.76
$1,124.68
$1,170.54
$1,504.40 		$1,128.04
$1,328.96
$1,374.82
$1,708.68 		$204.28
Toc - Plan #55 University of Utah Health Plans
Expanded Bronze

(EPO) Healthy Preferred Bronze w.3 Copays Before Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-271-5870

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$234.19
$325.52
$346.37
$498.12
$702.57 		$419.90
$511.23
$532.08
$683.83 		$605.61
$696.94
$717.79
$869.54 		$791.32
$882.65
$903.50
$1,055.25 		$185.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$468.38
$651.04
$692.74
$996.24
$1,405.14 		$654.09
$836.75
$878.45
$1,181.95 		$839.80
$1,022.46
$1,064.16
$1,367.66 		$1,025.51
$1,208.17
$1,249.87
$1,553.37 		$185.71

ADVERTISEMENT

SelectHealth

Local: 1-801-442-5038 | Toll Free: 1-800-538-5038

Toc - Plan #56 SelectHealth
Silver

(HMO) Med Silver 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.26
$486.85
$518.03
$744.99
$1,050.77 		$628.01
$764.60
$795.78
$1,022.74 		$905.76
$1,042.35
$1,073.53
$1,300.49 		$1,183.51
$1,320.10
$1,351.28
$1,578.24 		$277.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.52
$973.70
$1,036.06
$1,489.98
$2,101.54 		$978.27
$1,251.45
$1,313.81
$1,767.73 		$1,256.02
$1,529.20
$1,591.56
$2,045.48 		$1,533.77
$1,806.95
$1,869.31
$2,323.23 		$277.75
Toc - Plan #57 SelectHealth
Gold

(HMO) Med Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$420.13
$583.98
$621.37
$893.62
$1,260.39 		$753.29
$917.14
$954.53
$1,226.78 		$1,086.45
$1,250.30
$1,287.69
$1,559.94 		$1,419.61
$1,583.46
$1,620.85
$1,893.10 		$333.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.26
$1,167.96
$1,242.74
$1,787.24
$2,520.78 		$1,173.42
$1,501.12
$1,575.90
$2,120.40 		$1,506.58
$1,834.28
$1,909.06
$2,453.56 		$1,839.74
$2,167.44
$2,242.22
$2,786.72 		$333.16
Toc - Plan #58 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 7800 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$226.66
$315.06
$335.23
$482.11
$679.98 		$406.40
$494.80
$514.97
$661.85 		$586.14
$674.54
$694.71
$841.59 		$765.88
$854.28
$874.45
$1,021.33 		$179.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$453.32
$630.12
$670.46
$964.22
$1,359.96 		$633.06
$809.86
$850.20
$1,143.96 		$812.80
$989.60
$1,029.94
$1,323.70 		$992.54
$1,169.34
$1,209.68
$1,503.44 		$179.74
Toc - Plan #59 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 6900 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$230.59
$320.52
$341.05
$490.47
$691.77 		$413.45
$503.38
$523.91
$673.33 		$596.31
$686.24
$706.77
$856.19 		$779.17
$869.10
$889.63
$1,039.05 		$182.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$461.18
$641.04
$682.10
$980.94
$1,383.54 		$644.04
$823.90
$864.96
$1,163.80 		$826.90
$1,006.76
$1,047.82
$1,346.66 		$1,009.76
$1,189.62
$1,230.68
$1,529.52 		$182.86
Toc - Plan #60 SelectHealth
Catastrophic

(HMO) Med Catastrophic 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$193.03
$268.32
$285.50
$410.58
$579.09 		$346.11
$421.40
$438.58
$563.66 		$499.19
$574.48
$591.66
$716.74 		$652.27
$727.56
$744.74
$869.82 		$153.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$386.06
$536.64
$571.00
$821.16
$1,158.18 		$539.14
$689.72
$724.08
$974.24 		$692.22
$842.80
$877.16
$1,127.32 		$845.30
$995.88
$1,030.24
$1,280.40 		$153.08
Toc - Plan #61 SelectHealth
Gold

(HMO) Value Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$371.80
$516.80
$549.89
$790.82
$1,115.40 		$666.64
$811.64
$844.73
$1,085.66 		$961.48
$1,106.48
$1,139.57
$1,380.50 		$1,256.32
$1,401.32
$1,434.41
$1,675.34 		$294.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.60
$1,033.60
$1,099.78
$1,581.64
$2,230.80 		$1,038.44
$1,328.44
$1,394.62
$1,876.48 		$1,333.28
$1,623.28
$1,689.46
$2,171.32 		$1,628.12
$1,918.12
$1,984.30
$2,466.16 		$294.84
Toc - Plan #62 SelectHealth
Silver

(HMO) Value Silver 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.96
$430.85
$458.44
$659.29
$929.88 		$555.76
$676.65
$704.24
$905.09 		$801.56
$922.45
$950.04
$1,150.89 		$1,047.36
$1,168.25
$1,195.84
$1,396.69 		$245.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.92
$861.70
$916.88
$1,318.58
$1,859.76 		$865.72
$1,107.50
$1,162.68
$1,564.38 		$1,111.52
$1,353.30
$1,408.48
$1,810.18 		$1,357.32
$1,599.10
$1,654.28
$2,055.98 		$245.80
Toc - Plan #63 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 7800 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$200.59
$278.82
$296.67
$426.65
$601.76 		$359.66
$437.89
$455.74
$585.72 		$518.73
$596.96
$614.81
$744.79 		$677.80
$756.03
$773.88
$903.86 		$159.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$401.18
$557.64
$593.34
$853.30
$1,203.52 		$560.25
$716.71
$752.41
$1,012.37 		$719.32
$875.78
$911.48
$1,171.44 		$878.39
$1,034.85
$1,070.55
$1,330.51 		$159.07
Toc - Plan #64 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 6900 HSA Qualified

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$204.07
$283.65
$301.81
$434.05
$612.20 		$365.89
$445.47
$463.63
$595.87 		$527.71
$607.29
$625.45
$757.69 		$689.53
$769.11
$787.27
$919.51 		$161.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$408.14
$567.30
$603.62
$868.10
$1,224.40 		$569.96
$729.12
$765.44
$1,029.92 		$731.78
$890.94
$927.26
$1,191.74 		$893.60
$1,052.76
$1,089.08
$1,353.56 		$161.82
Toc - Plan #65 SelectHealth
Catastrophic

(HMO) Value Catastrophic 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$170.83
$237.45
$252.65
$363.35
$512.48 		$306.30
$372.92
$388.12
$498.82 		$441.77
$508.39
$523.59
$634.29 		$577.24
$643.86
$659.06
$769.76 		$135.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$341.66
$474.90
$505.30
$726.70
$1,024.96 		$477.13
$610.37
$640.77
$862.17 		$612.60
$745.84
$776.24
$997.64 		$748.07
$881.31
$911.71
$1,133.11 		$135.47
Toc - Plan #66 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 5900 Copay Plan - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$245.42
$341.13
$362.98
$522.01
$736.26 		$440.04
$535.75
$557.60
$716.63 		$634.66
$730.37
$752.22
$911.25 		$829.28
$924.99
$946.84
$1,105.87 		$194.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$490.84
$682.26
$725.96
$1,044.02
$1,472.52 		$685.46
$876.88
$920.58
$1,238.64 		$880.08
$1,071.50
$1,115.20
$1,433.26 		$1,074.70
$1,266.12
$1,309.82
$1,627.88 		$194.62
Toc - Plan #67 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 5900 Copay Plan - no deductible for all office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277.32
$385.48
$410.16
$589.86
$831.96 		$497.24
$605.40
$630.08
$809.78 		$717.16
$825.32
$850.00
$1,029.70 		$937.08
$1,045.24
$1,069.92
$1,249.62 		$219.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.64
$770.96
$820.32
$1,179.72
$1,663.92 		$774.56
$990.88
$1,040.24
$1,399.64 		$994.48
$1,210.80
$1,260.16
$1,619.56 		$1,214.40
$1,430.72
$1,480.08
$1,839.48 		$219.92
Toc - Plan #68 SelectHealth
Expanded Bronze

(HMO) Value Expanded Bronze 8700 - $0 PCP Office Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.87
$338.98
$360.69
$518.72
$731.61 		$437.26
$532.37
$554.08
$712.11 		$630.65
$725.76
$747.47
$905.50 		$824.04
$919.15
$940.86
$1,098.89 		$193.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$487.74
$677.96
$721.38
$1,037.44
$1,463.22 		$681.13
$871.35
$914.77
$1,230.83 		$874.52
$1,064.74
$1,108.16
$1,424.22 		$1,067.91
$1,258.13
$1,301.55
$1,617.61 		$193.39
Toc - Plan #69 SelectHealth
Expanded Bronze

(HMO) Med Expanded Bronze 8700 - $0 PCP Office Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$275.57
$383.05
$407.58
$586.15
$826.71 		$494.10
$601.58
$626.11
$804.68 		$712.63
$820.11
$844.64
$1,023.21 		$931.16
$1,038.64
$1,063.17
$1,241.74 		$218.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.14
$766.10
$815.16
$1,172.30
$1,653.42 		$769.67
$984.63
$1,033.69
$1,390.83 		$988.20
$1,203.16
$1,252.22
$1,609.36 		$1,206.73
$1,421.69
$1,470.75
$1,827.89 		$218.53
Toc - Plan #70 SelectHealth
Gold

(HMO) Signature Gold 1500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$362.57
$503.97
$536.24
$771.19
$1,087.71 		$650.09
$791.49
$823.76
$1,058.71 		$937.61
$1,079.01
$1,111.28
$1,346.23 		$1,225.13
$1,366.53
$1,398.80
$1,633.75 		$287.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.14
$1,007.94
$1,072.48
$1,542.38
$2,175.42 		$1,012.66
$1,295.46
$1,360.00
$1,829.90 		$1,300.18
$1,582.98
$1,647.52
$2,117.42 		$1,587.70
$1,870.50
$1,935.04
$2,404.94 		$287.52
Toc - Plan #71 SelectHealth
Expanded Bronze

(HMO) Signature Expanded Bronze 8700 - $0 PCP Office Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$237.82
$330.57
$351.74
$505.84
$713.46 		$426.41
$519.16
$540.33
$694.43 		$615.00
$707.75
$728.92
$883.02 		$803.59
$896.34
$917.51
$1,071.61 		$188.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$475.64
$661.14
$703.48
$1,011.68
$1,426.92 		$664.23
$849.73
$892.07
$1,200.27 		$852.82
$1,038.32
$1,080.66
$1,388.86 		$1,041.41
$1,226.91
$1,269.25
$1,577.45 		$188.59
Toc - Plan #72 SelectHealth
Silver

(HMO) Signature Silver 2500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.27
$420.15
$447.06
$642.93
$906.81 		$541.97
$659.85
$686.76
$882.63 		$781.67
$899.55
$926.46
$1,122.33 		$1,021.37
$1,139.25
$1,166.16
$1,362.03 		$239.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.54
$840.30
$894.12
$1,285.86
$1,813.62 		$844.24
$1,080.00
$1,133.82
$1,525.56 		$1,083.94
$1,319.70
$1,373.52
$1,765.26 		$1,323.64
$1,559.40
$1,613.22
$2,004.96 		$239.70
Toc - Plan #73 SelectHealth
Expanded Bronze

(HMO) Signature Expanded Bronze 7800 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$195.61
$271.89
$289.30
$416.06
$586.82 		$350.73
$427.01
$444.42
$571.18 		$505.85
$582.13
$599.54
$726.30 		$660.97
$737.25
$754.66
$881.42 		$155.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$391.22
$543.78
$578.60
$832.12
$1,173.64 		$546.34
$698.90
$733.72
$987.24 		$701.46
$854.02
$888.84
$1,142.36 		$856.58
$1,009.14
$1,043.96
$1,297.48 		$155.12
Toc - Plan #74 SelectHealth
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze 6800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$219.27
$304.79
$324.30
$466.39
$657.81 		$393.15
$478.67
$498.18
$640.27 		$567.03
$652.55
$672.06
$814.15 		$740.91
$826.43
$845.94
$988.03 		$173.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$438.54
$609.58
$648.60
$932.78
$1,315.62 		$612.42
$783.46
$822.48
$1,106.66 		$786.30
$957.34
$996.36
$1,280.54 		$960.18
$1,131.22
$1,170.24
$1,454.42 		$173.88
Toc - Plan #75 SelectHealth
Expanded Bronze

(HMO) Value Benchmark Expanded Bronze 6800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$194.05
$269.73
$287.00
$412.74
$582.14 		$347.93
$423.61
$440.88
$566.62 		$501.81
$577.49
$594.76
$720.50 		$655.69
$731.37
$748.64
$874.38 		$153.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$388.10
$539.46
$574.00
$825.48
$1,164.28 		$541.98
$693.34
$727.88
$979.36 		$695.86
$847.22
$881.76
$1,133.24 		$849.74
$1,001.10
$1,035.64
$1,287.12 		$153.88
Toc - Plan #76 SelectHealth
Expanded Bronze

(HMO) Value Benchmark Expanded Bronze 3800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$224.95
$312.68
$332.70
$478.46
$674.84 		$403.33
$491.06
$511.08
$656.84 		$581.71
$669.44
$689.46
$835.22 		$760.09
$847.82
$867.84
$1,013.60 		$178.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$449.90
$625.36
$665.40
$956.92
$1,349.68 		$628.28
$803.74
$843.78
$1,135.30 		$806.66
$982.12
$1,022.16
$1,313.68 		$985.04
$1,160.50
$1,200.54
$1,492.06 		$178.38
Toc - Plan #77 SelectHealth
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze 3800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$254.19
$353.32
$375.94
$540.66
$762.56 		$455.76
$554.89
$577.51
$742.23 		$657.33
$756.46
$779.08
$943.80 		$858.90
$958.03
$980.65
$1,145.37 		$201.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508.38
$706.64
$751.88
$1,081.32
$1,525.12 		$709.95
$908.21
$953.45
$1,282.89 		$911.52
$1,109.78
$1,155.02
$1,484.46 		$1,113.09
$1,311.35
$1,356.59
$1,686.03 		$201.57
Toc - Plan #78 SelectHealth
Bronze

(HMO) Value Benchmark Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$187.46
$260.57
$277.26
$398.73
$562.38 		$336.12
$409.23
$425.92
$547.39 		$484.78
$557.89
$574.58
$696.05 		$633.44
$706.55
$723.24
$844.71 		$148.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$374.92
$521.14
$554.52
$797.46
$1,124.76 		$523.58
$669.80
$703.18
$946.12 		$672.24
$818.46
$851.84
$1,094.78 		$820.90
$967.12
$1,000.50
$1,243.44 		$148.66
Toc - Plan #79 SelectHealth
Bronze

(HMO) Med Benchmark Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$211.83
$294.44
$313.30
$450.56
$635.49 		$379.81
$462.42
$481.28
$618.54 		$547.79
$630.40
$649.26
$786.52 		$715.77
$798.38
$817.24
$954.50 		$167.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$423.66
$588.88
$626.60
$901.12
$1,270.98 		$591.64
$756.86
$794.58
$1,069.10 		$759.62
$924.84
$962.56
$1,237.08 		$927.60
$1,092.82
$1,130.54
$1,405.06 		$167.98
Toc - Plan #80 SelectHealth
Silver

(HMO) Value Benchmark Silver 6500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$299.57
$416.41
$443.07
$637.19
$898.71 		$537.13
$653.97
$680.63
$874.75 		$774.69
$891.53
$918.19
$1,112.31 		$1,012.25
$1,129.09
$1,155.75
$1,349.87 		$237.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.14
$832.82
$886.14
$1,274.38
$1,797.42 		$836.70
$1,070.38
$1,123.70
$1,511.94 		$1,074.26
$1,307.94
$1,361.26
$1,749.50 		$1,311.82
$1,545.50
$1,598.82
$1,987.06 		$237.56
Toc - Plan #81 SelectHealth
Silver

(HMO) Med Benchmark Silver 6500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$338.51
$470.53
$500.66
$720.02
$1,015.53 		$606.95
$738.97
$769.10
$988.46 		$875.39
$1,007.41
$1,037.54
$1,256.90 		$1,143.83
$1,275.85
$1,305.98
$1,525.34 		$268.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.02
$941.06
$1,001.32
$1,440.04
$2,031.06 		$945.46
$1,209.50
$1,269.76
$1,708.48 		$1,213.90
$1,477.94
$1,538.20
$1,976.92 		$1,482.34
$1,746.38
$1,806.64
$2,245.36 		$268.44
Toc - Plan #82 SelectHealth
Expanded Bronze

(HMO) Value Benchmark Expanded Bronze 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$220.70
$306.77
$326.41
$469.42
$662.09 		$395.71
$481.78
$501.42
$644.43 		$570.72
$656.79
$676.43
$819.44 		$745.73
$831.80
$851.44
$994.45 		$175.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$441.40
$613.54
$652.82
$938.84
$1,324.18 		$616.41
$788.55
$827.83
$1,113.85 		$791.42
$963.56
$1,002.84
$1,288.86 		$966.43
$1,138.57
$1,177.85
$1,463.87 		$175.01
Toc - Plan #83 SelectHealth
Expanded Bronze

(HMO) Med Benchmark Expanded Bronze 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$249.39
$346.65
$368.84
$530.44
$748.16 		$447.15
$544.41
$566.60
$728.20 		$644.91
$742.17
$764.36
$925.96 		$842.67
$939.93
$962.12
$1,123.72 		$197.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$498.78
$693.30
$737.68
$1,060.88
$1,496.32 		$696.54
$891.06
$935.44
$1,258.64 		$894.30
$1,088.82
$1,133.20
$1,456.40 		$1,092.06
$1,286.58
$1,330.96
$1,654.16 		$197.76
Toc - Plan #84 SelectHealth
Silver

(HMO) Value Benchmark Silver 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$306.50
$426.04
$453.32
$651.93
$919.50 		$549.56
$669.10
$696.38
$894.99 		$792.62
$912.16
$939.44
$1,138.05 		$1,035.68
$1,155.22
$1,182.50
$1,381.11 		$243.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.00
$852.08
$906.64
$1,303.86
$1,839.00 		$856.06
$1,095.14
$1,149.70
$1,546.92 		$1,099.12
$1,338.20
$1,392.76
$1,789.98 		$1,342.18
$1,581.26
$1,635.82
$2,033.04 		$243.06
Toc - Plan #85 SelectHealth
Silver

(HMO) Med Benchmark Silver 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$346.34
$481.42
$512.24
$736.67
$1,039.02 		$620.99
$756.07
$786.89
$1,011.32 		$895.64
$1,030.72
$1,061.54
$1,285.97 		$1,170.29
$1,305.37
$1,336.19
$1,560.62 		$274.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.68
$962.84
$1,024.48
$1,473.34
$2,078.04 		$967.33
$1,237.49
$1,299.13
$1,747.99 		$1,241.98
$1,512.14
$1,573.78
$2,022.64 		$1,516.63
$1,786.79
$1,848.43
$2,297.29 		$274.65
Toc - Plan #86 SelectHealth
Bronze

(HMO) Signature Benchmark Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$182.81
$254.10
$270.37
$388.83
$548.43 		$327.78
$399.07
$415.34
$533.80 		$472.75
$544.04
$560.31
$678.77 		$617.72
$689.01
$705.28
$823.74 		$144.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$365.62
$508.20
$540.74
$777.66
$1,096.86 		$510.59
$653.17
$685.71
$922.63 		$655.56
$798.14
$830.68
$1,067.60 		$800.53
$943.11
$975.65
$1,212.57 		$144.97
Toc - Plan #87 SelectHealth
Silver

(HMO) Signature Benchmark Silver 6500 - no deductible for office visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$292.14
$406.07
$432.07
$621.37
$876.41 		$523.80
$637.73
$663.73
$853.03 		$755.46
$869.39
$895.39
$1,084.69 		$987.12
$1,101.05
$1,127.05
$1,316.35 		$231.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.28
$812.14
$864.14
$1,242.74
$1,752.82 		$815.94
$1,043.80
$1,095.80
$1,474.40 		$1,047.60
$1,275.46
$1,327.46
$1,706.06 		$1,279.26
$1,507.12
$1,559.12
$1,937.72 		$231.66
Toc - Plan #88 SelectHealth
Expanded Bronze

(HMO) Signature Benchmark Expanded Bronze 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$215.22
$299.15
$318.31
$457.77
$645.66 		$385.89
$469.82
$488.98
$628.44 		$556.56
$640.49
$659.65
$799.11 		$727.23
$811.16
$830.32
$969.78 		$170.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$430.44
$598.30
$636.62
$915.54
$1,291.32 		$601.11
$768.97
$807.29
$1,086.21 		$771.78
$939.64
$977.96
$1,256.88 		$942.45
$1,110.31
$1,148.63
$1,427.55 		$170.67
Toc - Plan #89 SelectHealth
Silver

(HMO) Signature Benchmark Silver 0 Copay Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-5038

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 		$298.89
$415.46
$442.06
$635.75
$896.67 		$535.91
$652.48
$679.08
$872.77 		$772.93
$889.50
$916.10
$1,109.79 		$1,009.95
$1,126.52
$1,153.12
$1,346.81 		$237.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.78
$830.92
$884.12
$1,271.50
$1,793.34 		$834.80
$1,067.94
$1,121.14
$1,508.52 		$1,071.82
$1,304.96
$1,358.16
$1,745.54 		$1,308.84
$1,541.98
$1,595.18
$1,982.56 		$237.02

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #90 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 3400 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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 		$262.03
$364.22
$387.55
$557.34
$786.09 		$469.82
$572.01
$595.34
$765.13 		$677.61
$779.80
$803.13
$972.92 		$885.40
$987.59
$1,010.92
$1,180.71 		$207.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.06
$728.44
$775.10
$1,114.68
$1,572.18 		$731.85
$936.23
$982.89
$1,322.47 		$939.64
$1,144.02
$1,190.68
$1,530.26 		$1,147.43
$1,351.81
$1,398.47
$1,738.05 		$207.79
Toc - Plan #91 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7800 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$264.09
$367.09
$390.59
$561.72
$792.27 		$473.51
$576.51
$600.01
$771.14 		$682.93
$785.93
$809.43
$980.56 		$892.35
$995.35
$1,018.85
$1,189.98 		$209.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528.18
$734.18
$781.18
$1,123.44
$1,584.54 		$737.60
$943.60
$990.60
$1,332.86 		$947.02
$1,153.02
$1,200.02
$1,542.28 		$1,156.44
$1,362.44
$1,409.44
$1,751.70 		$209.42
Toc - Plan #92 Cigna Healthcare
Silver

(EPO) Cigna Connect 1900 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 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 		$337.11
$468.58
$498.58
$717.03
$1,011.32 		$604.44
$735.91
$765.91
$984.36 		$871.77
$1,003.24
$1,033.24
$1,251.69 		$1,139.10
$1,270.57
$1,300.57
$1,519.02 		$267.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.22
$937.16
$997.16
$1,434.06
$2,022.64 		$941.55
$1,204.49
$1,264.49
$1,701.39 		$1,208.88
$1,471.82
$1,531.82
$1,968.72 		$1,476.21
$1,739.15
$1,799.15
$2,236.05 		$267.33
Toc - Plan #93 Cigna Healthcare
Silver

(EPO) Cigna Connect 2200 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 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 		$339.62
$472.07
$502.29
$722.36
$1,018.85 		$608.94
$741.39
$771.61
$991.68 		$878.26
$1,010.71
$1,040.93
$1,261.00 		$1,147.58
$1,280.03
$1,310.25
$1,530.32 		$269.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.24
$944.14
$1,004.58
$1,444.72
$2,037.70 		$948.56
$1,213.46
$1,273.90
$1,714.04 		$1,217.88
$1,482.78
$1,543.22
$1,983.36 		$1,487.20
$1,752.10
$1,812.54
$2,252.68 		$269.32
Toc - Plan #94 Cigna Healthcare
Gold

(EPO) Cigna Connect 1800 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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 		$405.44
$563.56
$599.65
$862.37
$1,216.32 		$726.96
$885.08
$921.17
$1,183.89 		$1,048.48
$1,206.60
$1,242.69
$1,505.41 		$1,370.00
$1,528.12
$1,564.21
$1,826.93 		$321.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.88
$1,127.12
$1,199.30
$1,724.74
$2,432.64 		$1,132.40
$1,448.64
$1,520.82
$2,046.26 		$1,453.92
$1,770.16
$1,842.34
$2,367.78 		$1,775.44
$2,091.68
$2,163.86
$2,689.30 		$321.52
Toc - Plan #95 Cigna Healthcare
Silver

(EPO) Cigna Connect 3500 Enhanced Diabetes Care ($0 Preferred Insulin)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338.87
$471.02
$501.18
$720.77
$1,016.60 		$607.59
$739.74
$769.90
$989.49 		$876.31
$1,008.46
$1,038.62
$1,258.21 		$1,145.03
$1,277.18
$1,307.34
$1,526.93 		$268.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.74
$942.04
$1,002.36
$1,441.54
$2,033.20 		$946.46
$1,210.76
$1,271.08
$1,710.26 		$1,215.18
$1,479.48
$1,539.80
$1,978.98 		$1,483.90
$1,748.20
$1,808.52
$2,247.70 		$268.72
Toc - Plan #96 Cigna Healthcare
Silver

(EPO) Cigna Connect 5500 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335.20
$465.92
$495.76
$712.96
$1,005.59 		$601.01
$731.73
$761.57
$978.77 		$866.82
$997.54
$1,027.38
$1,244.58 		$1,132.63
$1,263.35
$1,293.19
$1,510.39 		$265.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.40
$931.84
$991.52
$1,425.92
$2,011.18 		$936.21
$1,197.65
$1,257.33
$1,691.73 		$1,202.02
$1,463.46
$1,523.14
$1,957.54 		$1,467.83
$1,729.27
$1,788.95
$2,223.35 		$265.81
Toc - Plan #97 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care ($0 Preferred Insulin)

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$262.26
$364.54
$387.88
$557.82
$786.77 		$470.23
$572.51
$595.85
$765.79 		$678.20
$780.48
$803.82
$973.76 		$886.17
$988.45
$1,011.79
$1,181.73 		$207.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.52
$729.08
$775.76
$1,115.64
$1,573.54 		$732.49
$937.05
$983.73
$1,323.61 		$940.46
$1,145.02
$1,191.70
$1,531.58 		$1,148.43
$1,352.99
$1,399.67
$1,739.55 		$207.97
Toc - Plan #98 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect HSA 7000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$263.19
$365.84
$389.26
$559.81
$789.57 		$471.90
$574.55
$597.97
$768.52 		$680.61
$783.26
$806.68
$977.23 		$889.32
$991.97
$1,015.39
$1,185.94 		$208.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.38
$731.68
$778.52
$1,119.62
$1,579.14 		$735.09
$940.39
$987.23
$1,328.33 		$943.80
$1,149.10
$1,195.94
$1,537.04 		$1,152.51
$1,357.81
$1,404.65
$1,745.75 		$208.71
Toc - Plan #99 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$337.29
$468.84
$498.86
$717.42
$1,011.87 		$604.76
$736.31
$766.33
$984.89 		$872.23
$1,003.78
$1,033.80
$1,252.36 		$1,139.70
$1,271.25
$1,301.27
$1,519.83 		$267.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.58
$937.68
$997.72
$1,434.84
$2,023.74 		$942.05
$1,205.15
$1,265.19
$1,702.31 		$1,209.52
$1,472.62
$1,532.66
$1,969.78 		$1,476.99
$1,740.09
$1,800.13
$2,237.25 		$267.47
Toc - Plan #100 Cigna Healthcare
Silver

(EPO) Cigna Connect 5000 + Acupuncture ($0 Telehealth)

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

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 		$339.51
$471.92
$502.13
$722.13
$1,018.52 		$608.74
$741.15
$771.36
$991.36 		$877.97
$1,010.38
$1,040.59
$1,260.59 		$1,147.20
$1,279.61
$1,309.82
$1,529.82 		$269.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.02
$943.84
$1,004.26
$1,444.26
$2,037.04 		$948.25
$1,213.07
$1,273.49
$1,713.49 		$1,217.48
$1,482.30
$1,542.72
$1,982.72 		$1,486.71
$1,751.53
$1,811.95
$2,251.95 		$269.23

‡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 Davis County here.

Davis County is in “Rating Area 3” of Utah.

Currently, there are 100 plans offered in Rating Area 3.

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2022 Obamacare Plans for Davis County, UT

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