Obamacare 2022 Rates for Louisa County

Obamacare > Rates > Virginia > Louisa 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 Louisa County, VA.

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, 69 Plans and 2022 Rates for Louisa County, Virginia

Below, you’ll find a summary of the 69 plans for Louisa County, Virginia 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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Optima Health Plan

Local: 1-866-946-6034 | Toll Free: 1-866-946-6034 | TTY: 1-800-828-1140
Toc - Plan #1 Optima Health Plan
Expanded Bronze

(HMO) OptimaFit Bronze 6250 20% HSA Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341.18
$387.24
$436.03
$609.35
$925.97 		$602.19
$648.25
$697.04
$870.36 		$863.20
$909.26
$958.05
$1,131.37 		$1,124.21
$1,170.27
$1,219.06
$1,392.38 		$261.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.36
$774.48
$872.06
$1,218.70
$1,851.94 		$943.37
$1,035.49
$1,133.07
$1,479.71 		$1,204.38
$1,296.50
$1,394.08
$1,740.72 		$1,465.39
$1,557.51
$1,655.09
$2,001.73 		$261.01
Toc - Plan #2 Optima Health Plan
Catastrophic

(HMO) OptimaFit Catastrophic 8700 M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

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 		$259.75
$294.82
$331.97
$463.92
$704.97 		$458.46
$493.53
$530.68
$662.63 		$657.17
$692.24
$729.39
$861.34 		$855.88
$890.95
$928.10
$1,060.05 		$198.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.50
$589.64
$663.94
$927.84
$1,409.94 		$718.21
$788.35
$862.65
$1,126.55 		$916.92
$987.06
$1,061.36
$1,325.26 		$1,115.63
$1,185.77
$1,260.07
$1,523.97 		$198.71
Toc - Plan #3 Optima Health Plan
Gold

(HMO) OptimaFit Gold 1300 20% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$1,300 $2,600 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 		$410.01
$465.36
$524.00
$732.28
$1,112.78 		$723.67
$779.02
$837.66
$1,045.94 		$1,037.33
$1,092.68
$1,151.32
$1,359.60 		$1,350.99
$1,406.34
$1,464.98
$1,673.26 		$313.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.02
$930.72
$1,048.00
$1,464.56
$2,225.56 		$1,133.68
$1,244.38
$1,361.66
$1,778.22 		$1,447.34
$1,558.04
$1,675.32
$2,091.88 		$1,761.00
$1,871.70
$1,988.98
$2,405.54 		$313.66
Toc - Plan #4 Optima Health Plan
Expanded Bronze

(HMO) OptimaFit Bronze 7200 40% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

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 		$318.44
$361.43
$406.96
$568.73
$864.24 		$562.04
$605.03
$650.56
$812.33 		$805.64
$848.63
$894.16
$1,055.93 		$1,049.24
$1,092.23
$1,137.76
$1,299.53 		$243.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.88
$722.86
$813.92
$1,137.46
$1,728.48 		$880.48
$966.46
$1,057.52
$1,381.06 		$1,124.08
$1,210.06
$1,301.12
$1,624.66 		$1,367.68
$1,453.66
$1,544.72
$1,868.26 		$243.60
Toc - Plan #5 Optima Health Plan
Silver

(HMO) OptimaFit Silver 3000 25% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

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 		$422.30
$479.32
$539.71
$754.24
$1,146.14 		$745.36
$802.38
$862.77
$1,077.30 		$1,068.42
$1,125.44
$1,185.83
$1,400.36 		$1,391.48
$1,448.50
$1,508.89
$1,723.42 		$323.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.60
$958.64
$1,079.42
$1,508.48
$2,292.28 		$1,167.66
$1,281.70
$1,402.48
$1,831.54 		$1,490.72
$1,604.76
$1,725.54
$2,154.60 		$1,813.78
$1,927.82
$2,048.60
$2,477.66 		$323.06
Toc - Plan #6 Optima Health Plan
Silver

(HMO) OptimaFit Silver 6600 30% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$6,600 $13,200 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 		$403.78
$458.29
$516.03
$721.16
$1,095.87 		$712.67
$767.18
$824.92
$1,030.05 		$1,021.56
$1,076.07
$1,133.81
$1,338.94 		$1,330.45
$1,384.96
$1,442.70
$1,647.83 		$308.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.56
$916.58
$1,032.06
$1,442.32
$2,191.74 		$1,116.45
$1,225.47
$1,340.95
$1,751.21 		$1,425.34
$1,534.36
$1,649.84
$2,060.10 		$1,734.23
$1,843.25
$1,958.73
$2,368.99 		$308.89
Toc - Plan #7 Optima Health Plan
Silver

(HMO) OptimaFit Silver 4600 30% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$4,600 $9,200 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 		$410.48
$465.89
$524.59
$733.11
$1,114.04 		$724.50
$779.91
$838.61
$1,047.13 		$1,038.52
$1,093.93
$1,152.63
$1,361.15 		$1,352.54
$1,407.95
$1,466.65
$1,675.17 		$314.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.96
$931.78
$1,049.18
$1,466.22
$2,228.08 		$1,134.98
$1,245.80
$1,363.20
$1,780.24 		$1,449.00
$1,559.82
$1,677.22
$2,094.26 		$1,763.02
$1,873.84
$1,991.24
$2,408.28 		$314.02

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UnitedHealthcare

Local: 1-877-265-9199 | Toll Free: 1-877-265-9199 | TTY: 1-877-265-9199
Toc - Plan #8 UnitedHealthcare
Gold

(HMO) UHC Value Gold ($3 Walgreens Rx + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$336.26
$381.66
$429.74
$600.56
$912.61 		$593.50
$638.90
$686.98
$857.80 		$850.74
$896.14
$944.22
$1,115.04 		$1,107.98
$1,153.38
$1,201.46
$1,372.28 		$257.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.52
$763.32
$859.48
$1,201.12
$1,825.22 		$929.76
$1,020.56
$1,116.72
$1,458.36 		$1,187.00
$1,277.80
$1,373.96
$1,715.60 		$1,444.24
$1,535.04
$1,631.20
$1,972.84 		$257.24
Toc - Plan #9 UnitedHealthcare
Silver

(HMO) UHC Value Base Silver ($3 Walgreens Rx + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.25
$399.80
$450.18
$629.12
$956.01 		$621.72
$669.27
$719.65
$898.59 		$891.19
$938.74
$989.12
$1,168.06 		$1,160.66
$1,208.21
$1,258.59
$1,437.53 		$269.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.50
$799.60
$900.36
$1,258.24
$1,912.02 		$973.97
$1,069.07
$1,169.83
$1,527.71 		$1,243.44
$1,338.54
$1,439.30
$1,797.18 		$1,512.91
$1,608.01
$1,708.77
$2,066.65 		$269.47
Toc - Plan #10 UnitedHealthcare
Expanded Bronze

(HMO) UHC Value Bronze ($3 Walgreens Rx + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 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 		$270.08
$306.54
$345.16
$482.36
$733.00 		$476.69
$513.15
$551.77
$688.97 		$683.30
$719.76
$758.38
$895.58 		$889.91
$926.37
$964.99
$1,102.19 		$206.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.16
$613.08
$690.32
$964.72
$1,466.00 		$746.77
$819.69
$896.93
$1,171.33 		$953.38
$1,026.30
$1,103.54
$1,377.94 		$1,159.99
$1,232.91
$1,310.15
$1,584.55 		$206.61
Toc - Plan #11 UnitedHealthcare
Expanded Bronze

(HMO) UHC Value Base Bronze ($3 Walgreens Rx + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$269.02
$305.34
$343.81
$480.47
$730.12 		$474.82
$511.14
$549.61
$686.27 		$680.62
$716.94
$755.41
$892.07 		$886.42
$922.74
$961.21
$1,097.87 		$205.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538.04
$610.68
$687.62
$960.94
$1,460.24 		$743.84
$816.48
$893.42
$1,166.74 		$949.64
$1,022.28
$1,099.22
$1,372.54 		$1,155.44
$1,228.08
$1,305.02
$1,578.34 		$205.80
Toc - Plan #12 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First ($3 Walgreens Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261.63
$296.95
$334.36
$467.27
$710.06 		$461.78
$497.10
$534.51
$667.42 		$661.93
$697.25
$734.66
$867.57 		$862.08
$897.40
$934.81
$1,067.72 		$200.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.26
$593.90
$668.72
$934.54
$1,420.12 		$723.41
$794.05
$868.87
$1,134.69 		$923.56
$994.20
$1,069.02
$1,334.84 		$1,123.71
$1,194.35
$1,269.17
$1,534.99 		$200.15
Toc - Plan #13 UnitedHealthcare
Bronze

(HMO) UHC Simple Bronze (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$256.62
$291.26
$327.96
$458.32
$696.47 		$452.93
$487.57
$524.27
$654.63 		$649.24
$683.88
$720.58
$850.94 		$845.55
$880.19
$916.89
$1,047.25 		$196.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$513.24
$582.52
$655.92
$916.64
$1,392.94 		$709.55
$778.83
$852.23
$1,112.95 		$905.86
$975.14
$1,048.54
$1,309.26 		$1,102.17
$1,171.45
$1,244.85
$1,505.57 		$196.31
Toc - Plan #14 UnitedHealthcare
Gold

(HMO) UHC Value Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$1,400 $2,800 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 		$347.56
$394.48
$444.18
$620.74
$943.28 		$613.44
$660.36
$710.06
$886.62 		$879.32
$926.24
$975.94
$1,152.50 		$1,145.20
$1,192.12
$1,241.82
$1,418.38 		$265.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.12
$788.96
$888.36
$1,241.48
$1,886.56 		$961.00
$1,054.84
$1,154.24
$1,507.36 		$1,226.88
$1,320.72
$1,420.12
$1,773.24 		$1,492.76
$1,586.60
$1,686.00
$2,039.12 		$265.88
Toc - Plan #15 UnitedHealthcare
Gold

(HMO) UHC Advantage Plus Gold ($3 Walgreens Rx + Dental + Vision + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$2,250 $4,500 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 		$357.05
$405.25
$456.31
$637.69
$969.03 		$630.19
$678.39
$729.45
$910.83 		$903.33
$951.53
$1,002.59
$1,183.97 		$1,176.47
$1,224.67
$1,275.73
$1,457.11 		$273.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.10
$810.50
$912.62
$1,275.38
$1,938.06 		$987.24
$1,083.64
$1,185.76
$1,548.52 		$1,260.38
$1,356.78
$1,458.90
$1,821.66 		$1,533.52
$1,629.92
$1,732.04
$2,094.80 		$273.14
Toc - Plan #16 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First ($3 Walgreens Rx + Unlimited Free App-based Care) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$337.36
$382.90
$431.15
$602.52
$915.60 		$595.44
$640.98
$689.23
$860.60 		$853.52
$899.06
$947.31
$1,118.68 		$1,111.60
$1,157.14
$1,205.39
$1,376.76 		$258.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.72
$765.80
$862.30
$1,205.04
$1,831.20 		$932.80
$1,023.88
$1,120.38
$1,463.12 		$1,190.88
$1,281.96
$1,378.46
$1,721.20 		$1,448.96
$1,540.04
$1,636.54
$1,979.28 		$258.08
Toc - Plan #17 UnitedHealthcare
Silver

(HMO) UHC Value Plus Silver ($3 Walgreens Rx + 3 $0 Primary Care Visits + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$353.79
$401.55
$452.14
$631.87
$960.19 		$624.44
$672.20
$722.79
$902.52 		$895.09
$942.85
$993.44
$1,173.17 		$1,165.74
$1,213.50
$1,264.09
$1,443.82 		$270.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.58
$803.10
$904.28
$1,263.74
$1,920.38 		$978.23
$1,073.75
$1,174.93
$1,534.39 		$1,248.88
$1,344.40
$1,445.58
$1,805.04 		$1,519.53
$1,615.05
$1,716.23
$2,075.69 		$270.65
Toc - Plan #18 UnitedHealthcare
Silver

(HMO) UHC Value Silver ($3 Walgreens Rx + 3 $0 Primary Care Visits + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$357.01
$405.21
$456.26
$637.62
$968.93 		$630.12
$678.32
$729.37
$910.73 		$903.23
$951.43
$1,002.48
$1,183.84 		$1,176.34
$1,224.54
$1,275.59
$1,456.95 		$273.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.02
$810.42
$912.52
$1,275.24
$1,937.86 		$987.13
$1,083.53
$1,185.63
$1,548.35 		$1,260.24
$1,356.64
$1,458.74
$1,821.46 		$1,533.35
$1,629.75
$1,731.85
$2,094.57 		$273.11
Toc - Plan #19 UnitedHealthcare
Expanded Bronze

(HMO) UHC Value Plus Bronze ($3 Walgreens Rx + 3 $0 Primary Care Visits + 6 $0 Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$269.23
$305.58
$344.08
$480.84
$730.69 		$475.19
$511.54
$550.04
$686.80 		$681.15
$717.50
$756.00
$892.76 		$887.11
$923.46
$961.96
$1,098.72 		$205.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538.46
$611.16
$688.16
$961.68
$1,461.38 		$744.42
$817.12
$894.12
$1,167.64 		$950.38
$1,023.08
$1,100.08
$1,373.60 		$1,156.34
$1,229.04
$1,306.04
$1,579.56 		$205.96

ADVERTISEMENT

Bright HealthCare

Local:  | Toll Free: 

Toc - Plan #20 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:

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 		$401.07
$455.21
$512.57
$716.31
$1,088.51 		$707.89
$762.03
$819.39
$1,023.13 		$1,014.71
$1,068.85
$1,126.21
$1,329.95 		$1,321.53
$1,375.67
$1,433.03
$1,636.77 		$306.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.14
$910.42
$1,025.14
$1,432.62
$2,177.02 		$1,108.96
$1,217.24
$1,331.96
$1,739.44 		$1,415.78
$1,524.06
$1,638.78
$2,046.26 		$1,722.60
$1,830.88
$1,945.60
$2,353.08 		$306.82
Toc - Plan #21 Bright HealthCare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$444.63
$504.66
$568.24
$794.12
$1,206.74 		$784.78
$844.81
$908.39
$1,134.27 		$1,124.93
$1,184.96
$1,248.54
$1,474.42 		$1,465.08
$1,525.11
$1,588.69
$1,814.57 		$340.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.26
$1,009.32
$1,136.48
$1,588.24
$2,413.48 		$1,229.41
$1,349.47
$1,476.63
$1,928.39 		$1,569.56
$1,689.62
$1,816.78
$2,268.54 		$1,909.71
$2,029.77
$2,156.93
$2,608.69 		$340.15
Toc - Plan #22 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:

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 		$387.63
$439.95
$495.38
$692.30
$1,052.01 		$684.16
$736.48
$791.91
$988.83 		$980.69
$1,033.01
$1,088.44
$1,285.36 		$1,277.22
$1,329.54
$1,384.97
$1,581.89 		$296.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.26
$879.90
$990.76
$1,384.60
$2,104.02 		$1,071.79
$1,176.43
$1,287.29
$1,681.13 		$1,368.32
$1,472.96
$1,583.82
$1,977.66 		$1,664.85
$1,769.49
$1,880.35
$2,274.19 		$296.53
Toc - Plan #23 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:

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 		$393.39
$446.50
$502.76
$702.60
$1,067.67 		$694.34
$747.45
$803.71
$1,003.55 		$995.29
$1,048.40
$1,104.66
$1,304.50 		$1,296.24
$1,349.35
$1,405.61
$1,605.45 		$300.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.78
$893.00
$1,005.52
$1,405.20
$2,135.34 		$1,087.73
$1,193.95
$1,306.47
$1,706.15 		$1,388.68
$1,494.90
$1,607.42
$2,007.10 		$1,689.63
$1,795.85
$1,908.37
$2,308.05 		$300.95
Toc - Plan #24 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:

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 		$395.11
$448.44
$504.94
$705.66
$1,072.32 		$697.37
$750.70
$807.20
$1,007.92 		$999.63
$1,052.96
$1,109.46
$1,310.18 		$1,301.89
$1,355.22
$1,411.72
$1,612.44 		$302.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.22
$896.88
$1,009.88
$1,411.32
$2,144.64 		$1,092.48
$1,199.14
$1,312.14
$1,713.58 		$1,394.74
$1,501.40
$1,614.40
$2,015.84 		$1,697.00
$1,803.66
$1,916.66
$2,318.10 		$302.26
Toc - Plan #25 Bright HealthCare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$410.08
$465.44
$524.08
$732.39
$1,112.94 		$723.79
$779.15
$837.79
$1,046.10 		$1,037.50
$1,092.86
$1,151.50
$1,359.81 		$1,351.21
$1,406.57
$1,465.21
$1,673.52 		$313.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.16
$930.88
$1,048.16
$1,464.78
$2,225.88 		$1,133.87
$1,244.59
$1,361.87
$1,778.49 		$1,447.58
$1,558.30
$1,675.58
$2,092.20 		$1,761.29
$1,872.01
$1,989.29
$2,405.91 		$313.71
Toc - Plan #26 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:

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 		$430.34
$488.43
$549.97
$768.58
$1,167.93 		$759.55
$817.64
$879.18
$1,097.79 		$1,088.76
$1,146.85
$1,208.39
$1,427.00 		$1,417.97
$1,476.06
$1,537.60
$1,756.21 		$329.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$860.68
$976.86
$1,099.94
$1,537.16
$2,335.86 		$1,189.89
$1,306.07
$1,429.15
$1,866.37 		$1,519.10
$1,635.28
$1,758.36
$2,195.58 		$1,848.31
$1,964.49
$2,087.57
$2,524.79 		$329.21
Toc - Plan #27 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:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$317.91
$360.83
$406.29
$567.79
$862.82 		$561.11
$604.03
$649.49
$810.99 		$804.31
$847.23
$892.69
$1,054.19 		$1,047.51
$1,090.43
$1,135.89
$1,297.39 		$243.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.82
$721.66
$812.58
$1,135.58
$1,725.64 		$879.02
$964.86
$1,055.78
$1,378.78 		$1,122.22
$1,208.06
$1,298.98
$1,621.98 		$1,365.42
$1,451.26
$1,542.18
$1,865.18 		$243.20
Toc - Plan #28 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:

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 		$326.58
$370.67
$417.37
$583.28
$886.35 		$576.42
$620.51
$667.21
$833.12 		$826.26
$870.35
$917.05
$1,082.96 		$1,076.10
$1,120.19
$1,166.89
$1,332.80 		$249.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.16
$741.34
$834.74
$1,166.56
$1,772.70 		$903.00
$991.18
$1,084.58
$1,416.40 		$1,152.84
$1,241.02
$1,334.42
$1,666.24 		$1,402.68
$1,490.86
$1,584.26
$1,916.08 		$249.84
Toc - Plan #29 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:

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 		$341.55
$387.66
$436.50
$610.01
$926.98 		$602.84
$648.95
$697.79
$871.30 		$864.13
$910.24
$959.08
$1,132.59 		$1,125.42
$1,171.53
$1,220.37
$1,393.88 		$261.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.10
$775.32
$873.00
$1,220.02
$1,853.96 		$944.39
$1,036.61
$1,134.29
$1,481.31 		$1,205.68
$1,297.90
$1,395.58
$1,742.60 		$1,466.97
$1,559.19
$1,656.87
$2,003.89 		$261.29
Toc - Plan #30 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:

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 		$360.58
$409.26
$460.83
$644.00
$978.62 		$636.43
$685.11
$736.68
$919.85 		$912.28
$960.96
$1,012.53
$1,195.70 		$1,188.13
$1,236.81
$1,288.38
$1,471.55 		$275.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.16
$818.52
$921.66
$1,288.00
$1,957.24 		$997.01
$1,094.37
$1,197.51
$1,563.85 		$1,272.86
$1,370.22
$1,473.36
$1,839.70 		$1,548.71
$1,646.07
$1,749.21
$2,115.55 		$275.85
Toc - Plan #31 Bright HealthCare
Expanded Bronze

(EPO) Bronze 5300 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$365.37
$414.70
$466.95
$652.56
$991.63 		$644.88
$694.21
$746.46
$932.07 		$924.39
$973.72
$1,025.97
$1,211.58 		$1,203.90
$1,253.23
$1,305.48
$1,491.09 		$279.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.74
$829.40
$933.90
$1,305.12
$1,983.26 		$1,010.25
$1,108.91
$1,213.41
$1,584.63 		$1,289.76
$1,388.42
$1,492.92
$1,864.14 		$1,569.27
$1,667.93
$1,772.43
$2,143.65 		$279.51
Toc - Plan #32 Bright HealthCare
Catastrophic

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$242.40
$275.13
$309.79
$432.93
$657.89 		$427.84
$460.57
$495.23
$618.37 		$613.28
$646.01
$680.67
$803.81 		$798.72
$831.45
$866.11
$989.25 		$185.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$484.80
$550.26
$619.58
$865.86
$1,315.78 		$670.24
$735.70
$805.02
$1,051.30 		$855.68
$921.14
$990.46
$1,236.74 		$1,041.12
$1,106.58
$1,175.90
$1,422.18 		$185.44

ADVERTISEMENT

Cigna Health and Life Insurance Company

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #33 Cigna Health and Life Insurance Company
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 		$274.59
$311.66
$350.92
$490.41
$745.23 		$484.65
$521.72
$560.98
$700.47 		$694.71
$731.78
$771.04
$910.53 		$904.77
$941.84
$981.10
$1,120.59 		$210.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$549.18
$623.32
$701.84
$980.82
$1,490.46 		$759.24
$833.38
$911.90
$1,190.88 		$969.30
$1,043.44
$1,121.96
$1,400.94 		$1,179.36
$1,253.50
$1,332.02
$1,611.00 		$210.06
Toc - Plan #34 Cigna Health and Life Insurance Company
Expanded Bronze

(EPO) Cigna Connect 6750 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$6,750 $13,500 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 		$289.65
$328.75
$370.17
$517.32
$786.11 		$511.23
$550.33
$591.75
$738.90 		$732.81
$771.91
$813.33
$960.48 		$954.39
$993.49
$1,034.91
$1,182.06 		$221.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.30
$657.50
$740.34
$1,034.64
$1,572.22 		$800.88
$879.08
$961.92
$1,256.22 		$1,022.46
$1,100.66
$1,183.50
$1,477.80 		$1,244.04
$1,322.24
$1,405.08
$1,699.38 		$221.58
Toc - Plan #35 Cigna Health and Life Insurance Company
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 		$371.42
$421.56
$474.67
$663.35
$1,008.03 		$655.56
$705.70
$758.81
$947.49 		$939.70
$989.84
$1,042.95
$1,231.63 		$1,223.84
$1,273.98
$1,327.09
$1,515.77 		$284.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.84
$843.12
$949.34
$1,326.70
$2,016.06 		$1,026.98
$1,127.26
$1,233.48
$1,610.84 		$1,311.12
$1,411.40
$1,517.62
$1,894.98 		$1,595.26
$1,695.54
$1,801.76
$2,179.12 		$284.14
Toc - Plan #36 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 1600 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 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 		$342.98
$389.28
$438.33
$612.56
$930.85 		$605.36
$651.66
$700.71
$874.94 		$867.74
$914.04
$963.09
$1,137.32 		$1,130.12
$1,176.42
$1,225.47
$1,399.70 		$262.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.96
$778.56
$876.66
$1,225.12
$1,861.70 		$948.34
$1,040.94
$1,139.04
$1,487.50 		$1,210.72
$1,303.32
$1,401.42
$1,749.88 		$1,473.10
$1,565.70
$1,663.80
$2,012.26 		$262.38
Toc - Plan #37 Cigna Health and Life Insurance Company
Silver

(EPO) Cigna Connect 6500 ($0 Telehealth)

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

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 		$366.83
$416.35
$468.80
$655.15
$995.57 		$647.45
$696.97
$749.42
$935.77 		$928.07
$977.59
$1,030.04
$1,216.39 		$1,208.69
$1,258.21
$1,310.66
$1,497.01 		$280.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.66
$832.70
$937.60
$1,310.30
$1,991.14 		$1,014.28
$1,113.32
$1,218.22
$1,590.92 		$1,294.90
$1,393.94
$1,498.84
$1,871.54 		$1,575.52
$1,674.56
$1,779.46
$2,152.16 		$280.62
Toc - Plan #38 Cigna Health and Life Insurance Company
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 		$287.23
$326.01
$367.09
$513.00
$779.55 		$506.96
$545.74
$586.82
$732.73 		$726.69
$765.47
$806.55
$952.46 		$946.42
$985.20
$1,026.28
$1,172.19 		$219.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.46
$652.02
$734.18
$1,026.00
$1,559.10 		$794.19
$871.75
$953.91
$1,245.73 		$1,013.92
$1,091.48
$1,173.64
$1,465.46 		$1,233.65
$1,311.21
$1,393.37
$1,685.19 		$219.73
Toc - Plan #39 Cigna Health and Life Insurance Company
Silver

(EPO) Cigna Connect 4000 ($0 Telehealth)

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

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 		$376.29
$427.09
$480.90
$672.06
$1,021.26 		$664.15
$714.95
$768.76
$959.92 		$952.01
$1,002.81
$1,056.62
$1,247.78 		$1,239.87
$1,290.67
$1,344.48
$1,535.64 		$287.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.58
$854.18
$961.80
$1,344.12
$2,042.52 		$1,040.44
$1,142.04
$1,249.66
$1,631.98 		$1,328.30
$1,429.90
$1,537.52
$1,919.84 		$1,616.16
$1,717.76
$1,825.38
$2,207.70 		$287.86
Toc - Plan #40 Cigna Health and Life Insurance Company
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 		$375.41
$426.09
$479.77
$670.48
$1,018.85 		$662.60
$713.28
$766.96
$957.67 		$949.79
$1,000.47
$1,054.15
$1,244.86 		$1,236.98
$1,287.66
$1,341.34
$1,532.05 		$287.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.82
$852.18
$959.54
$1,340.96
$2,037.70 		$1,038.01
$1,139.37
$1,246.73
$1,628.15 		$1,325.20
$1,426.56
$1,533.92
$1,915.34 		$1,612.39
$1,713.75
$1,821.11
$2,202.53 		$287.19
Toc - Plan #41 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 2000 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,500 $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 		$343.34
$389.70
$438.79
$613.21
$931.84 		$606.00
$652.36
$701.45
$875.87 		$868.66
$915.02
$964.11
$1,138.53 		$1,131.32
$1,177.68
$1,226.77
$1,401.19 		$262.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.68
$779.40
$877.58
$1,226.42
$1,863.68 		$949.34
$1,042.06
$1,140.24
$1,489.08 		$1,212.00
$1,304.72
$1,402.90
$1,751.74 		$1,474.66
$1,567.38
$1,665.56
$2,014.40 		$262.66
Toc - Plan #42 Cigna Health and Life Insurance Company
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 		$286.31
$324.96
$365.90
$511.35
$777.04 		$505.34
$543.99
$584.93
$730.38 		$724.37
$763.02
$803.96
$949.41 		$943.40
$982.05
$1,022.99
$1,168.44 		$219.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.62
$649.92
$731.80
$1,022.70
$1,554.08 		$791.65
$868.95
$950.83
$1,241.73 		$1,010.68
$1,087.98
$1,169.86
$1,460.76 		$1,229.71
$1,307.01
$1,388.89
$1,679.79 		$219.03
Toc - Plan #43 Cigna Health and Life Insurance Company
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 		$287.03
$325.78
$366.83
$512.64
$779.01 		$506.61
$545.36
$586.41
$732.22 		$726.19
$764.94
$805.99
$951.80 		$945.77
$984.52
$1,025.57
$1,171.38 		$219.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.06
$651.56
$733.66
$1,025.28
$1,558.02 		$793.64
$871.14
$953.24
$1,244.86 		$1,013.22
$1,090.72
$1,172.82
$1,464.44 		$1,232.80
$1,310.30
$1,392.40
$1,684.02 		$219.58
Toc - Plan #44 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 1250 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
$1,250 $2,500 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 		$357.28
$405.51
$456.60
$638.10
$969.66 		$630.60
$678.83
$729.92
$911.42 		$903.92
$952.15
$1,003.24
$1,184.74 		$1,177.24
$1,225.47
$1,276.56
$1,458.06 		$273.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.56
$811.02
$913.20
$1,276.20
$1,939.32 		$987.88
$1,084.34
$1,186.52
$1,549.52 		$1,261.20
$1,357.66
$1,459.84
$1,822.84 		$1,534.52
$1,630.98
$1,733.16
$2,096.16 		$273.32
Toc - Plan #45 Cigna Health and Life Insurance Company
Silver

(EPO) Cigna Connect 2900 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$2,900 $5,800 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 		$359.50
$408.03
$459.44
$642.06
$975.67 		$634.51
$683.04
$734.45
$917.07 		$909.52
$958.05
$1,009.46
$1,192.08 		$1,184.53
$1,233.06
$1,284.47
$1,467.09 		$275.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.00
$816.06
$918.88
$1,284.12
$1,951.34 		$994.01
$1,091.07
$1,193.89
$1,559.13 		$1,269.02
$1,366.08
$1,468.90
$1,834.14 		$1,544.03
$1,641.09
$1,743.91
$2,109.15 		$275.01
Toc - Plan #46 Cigna Health and Life Insurance Company
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 		$367.27
$416.85
$469.37
$655.94
$996.77 		$648.23
$697.81
$750.33
$936.90 		$929.19
$978.77
$1,031.29
$1,217.86 		$1,210.15
$1,259.73
$1,312.25
$1,498.82 		$280.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.54
$833.70
$938.74
$1,311.88
$1,993.54 		$1,015.50
$1,114.66
$1,219.70
$1,592.84 		$1,296.46
$1,395.62
$1,500.66
$1,873.80 		$1,577.42
$1,676.58
$1,781.62
$2,154.76 		$280.96

ADVERTISEMENT

HealthKeepers, Inc.

Local: 1-855-748-1810 | Toll Free: 1-855-748-1810

Toc - Plan #47 HealthKeepers, Inc.
Catastrophic

(HMO) Anthem HealthKeepers Catastrophic X 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$213.31
$242.11
$272.61
$380.97
$578.92 		$376.49
$405.29
$435.79
$544.15 		$539.67
$568.47
$598.97
$707.33 		$702.85
$731.65
$762.15
$870.51 		$163.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$426.62
$484.22
$545.22
$761.94
$1,157.84 		$589.80
$647.40
$708.40
$925.12 		$752.98
$810.58
$871.58
$1,088.30 		$916.16
$973.76
$1,034.76
$1,251.48 		$163.18
Toc - Plan #48 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$275.44
$312.62
$352.01
$491.94
$747.54 		$486.15
$523.33
$562.72
$702.65 		$696.86
$734.04
$773.43
$913.36 		$907.57
$944.75
$984.14
$1,124.07 		$210.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.88
$625.24
$704.02
$983.88
$1,495.08 		$761.59
$835.95
$914.73
$1,194.59 		$972.30
$1,046.66
$1,125.44
$1,405.30 		$1,183.01
$1,257.37
$1,336.15
$1,616.01 		$210.71
Toc - Plan #49 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 5900 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$280.00
$317.80
$357.84
$500.08
$759.92 		$494.20
$532.00
$572.04
$714.28 		$708.40
$746.20
$786.24
$928.48 		$922.60
$960.40
$1,000.44
$1,142.68 		$214.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.00
$635.60
$715.68
$1,000.16
$1,519.84 		$774.20
$849.80
$929.88
$1,214.36 		$988.40
$1,064.00
$1,144.08
$1,428.56 		$1,202.60
$1,278.20
$1,358.28
$1,642.76 		$214.20
Toc - Plan #50 HealthKeepers, Inc.
Bronze

(HMO) Anthem HealthKeepers Bronze X 8200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$265.40
$301.23
$339.18
$474.00
$720.30 		$468.43
$504.26
$542.21
$677.03 		$671.46
$707.29
$745.24
$880.06 		$874.49
$910.32
$948.27
$1,083.09 		$203.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.80
$602.46
$678.36
$948.00
$1,440.60 		$733.83
$805.49
$881.39
$1,151.03 		$936.86
$1,008.52
$1,084.42
$1,354.06 		$1,139.89
$1,211.55
$1,287.45
$1,557.09 		$203.03
Toc - Plan #51 HealthKeepers, Inc.
Gold

(HMO) Anthem HealthKeepers Gold X 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$2,000 $6,000 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 		$339.04
$384.81
$433.29
$605.53
$920.15 		$598.41
$644.18
$692.66
$864.90 		$857.78
$903.55
$952.03
$1,124.27 		$1,117.15
$1,162.92
$1,211.40
$1,383.64 		$259.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.08
$769.62
$866.58
$1,211.06
$1,840.30 		$937.45
$1,028.99
$1,125.95
$1,470.43 		$1,196.82
$1,288.36
$1,385.32
$1,729.80 		$1,456.19
$1,547.73
$1,644.69
$1,989.17 		$259.37
Toc - Plan #52 HealthKeepers, Inc.
Silver

(HMO) Anthem HealthKeepers Silver X 2200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$354.39
$402.23
$452.91
$632.94
$961.81 		$625.50
$673.34
$724.02
$904.05 		$896.61
$944.45
$995.13
$1,175.16 		$1,167.72
$1,215.56
$1,266.24
$1,446.27 		$271.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.78
$804.46
$905.82
$1,265.88
$1,923.62 		$979.89
$1,075.57
$1,176.93
$1,536.99 		$1,251.00
$1,346.68
$1,448.04
$1,808.10 		$1,522.11
$1,617.79
$1,719.15
$2,079.21 		$271.11
Toc - Plan #53 HealthKeepers, Inc.
Silver

(HMO) Anthem HealthKeepers Silver X 6250

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 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 		$337.47
$383.03
$431.29
$602.72
$915.89 		$595.63
$641.19
$689.45
$860.88 		$853.79
$899.35
$947.61
$1,119.04 		$1,111.95
$1,157.51
$1,205.77
$1,377.20 		$258.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.94
$766.06
$862.58
$1,205.44
$1,831.78 		$933.10
$1,024.22
$1,120.74
$1,463.60 		$1,191.26
$1,282.38
$1,378.90
$1,721.76 		$1,449.42
$1,540.54
$1,637.06
$1,979.92 		$258.16
Toc - Plan #54 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$282.94
$321.14
$361.60
$505.33
$767.90 		$499.39
$537.59
$578.05
$721.78 		$715.84
$754.04
$794.50
$938.23 		$932.29
$970.49
$1,010.95
$1,154.68 		$216.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.88
$642.28
$723.20
$1,010.66
$1,535.80 		$782.33
$858.73
$939.65
$1,227.11 		$998.78
$1,075.18
$1,156.10
$1,443.56 		$1,215.23
$1,291.63
$1,372.55
$1,660.01 		$216.45
Toc - Plan #55 HealthKeepers, Inc.
Silver

(HMO) Anthem HealthKeepers Silver X 5300

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$341.76
$387.90
$436.77
$610.38
$927.54 		$603.21
$649.35
$698.22
$871.83 		$864.66
$910.80
$959.67
$1,133.28 		$1,126.11
$1,172.25
$1,221.12
$1,394.73 		$261.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.52
$775.80
$873.54
$1,220.76
$1,855.08 		$944.97
$1,037.25
$1,134.99
$1,482.21 		$1,206.42
$1,298.70
$1,396.44
$1,743.66 		$1,467.87
$1,560.15
$1,657.89
$2,005.11 		$261.45
Toc - Plan #56 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 7000 0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$282.28
$320.39
$360.75
$504.15
$766.11 		$498.22
$536.33
$576.69
$720.09 		$714.16
$752.27
$792.63
$936.03 		$930.10
$968.21
$1,008.57
$1,151.97 		$215.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.56
$640.78
$721.50
$1,008.30
$1,532.22 		$780.50
$856.72
$937.44
$1,224.24 		$996.44
$1,072.66
$1,153.38
$1,440.18 		$1,212.38
$1,288.60
$1,369.32
$1,656.12 		$215.94

ADVERTISEMENT

Kaiser Permanente

Local: 1-800-807-1140 | Toll Free: 1-800-807-1140 | TTY: 1-703-359-7616
Toc - Plan #57 Kaiser Permanente
Gold

(HMO) KP VA Gold 0/20/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,950 $13,900 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 		$364.18
$413.35
$465.43
$650.43
$988.39 		$642.78
$691.95
$744.03
$929.03 		$921.38
$970.55
$1,022.63
$1,207.63 		$1,199.98
$1,249.15
$1,301.23
$1,486.23 		$278.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.36
$826.70
$930.86
$1,300.86
$1,976.78 		$1,006.96
$1,105.30
$1,209.46
$1,579.46 		$1,285.56
$1,383.90
$1,488.06
$1,858.06 		$1,564.16
$1,662.50
$1,766.66
$2,136.66 		$278.60
Toc - Plan #58 Kaiser Permanente
Silver

(HMO) KP VA Silver 2500/35/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$386.24
$438.38
$493.62
$689.83
$1,048.26 		$681.71
$733.85
$789.09
$985.30 		$977.18
$1,029.32
$1,084.56
$1,280.77 		$1,272.65
$1,324.79
$1,380.03
$1,576.24 		$295.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.48
$876.76
$987.24
$1,379.66
$2,096.52 		$1,067.95
$1,172.23
$1,282.71
$1,675.13 		$1,363.42
$1,467.70
$1,578.18
$1,970.60 		$1,658.89
$1,763.17
$1,873.65
$2,266.07 		$295.47
Toc - Plan #59 Kaiser Permanente
Expanded Bronze

(HMO) KP VA Bronze 6000/55/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.14
$323.64
$364.41
$509.26
$773.88 		$503.27
$541.77
$582.54
$727.39 		$721.40
$759.90
$800.67
$945.52 		$939.53
$978.03
$1,018.80
$1,163.65 		$218.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.28
$647.28
$728.82
$1,018.52
$1,547.76 		$788.41
$865.41
$946.95
$1,236.65 		$1,006.54
$1,083.54
$1,165.08
$1,454.78 		$1,224.67
$1,301.67
$1,383.21
$1,672.91 		$218.13
Toc - Plan #60 Kaiser Permanente
Catastrophic

(HMO) KP VA Catastrophic 8700/0/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$189.00
$214.52
$241.54
$337.56
$512.95 		$333.59
$359.11
$386.13
$482.15 		$478.18
$503.70
$530.72
$626.74 		$622.77
$648.29
$675.31
$771.33 		$144.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$378.00
$429.04
$483.08
$675.12
$1,025.90 		$522.59
$573.63
$627.67
$819.71 		$667.18
$718.22
$772.26
$964.30 		$811.77
$862.81
$916.85
$1,108.89 		$144.59
Toc - Plan #61 Kaiser Permanente
Platinum

(HMO) KP VA Platinum 0/15/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$4,000 $8,000 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 		$409.17
$464.41
$522.92
$730.78
$1,110.49 		$722.19
$777.43
$835.94
$1,043.80 		$1,035.21
$1,090.45
$1,148.96
$1,356.82 		$1,348.23
$1,403.47
$1,461.98
$1,669.84 		$313.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.34
$928.82
$1,045.84
$1,461.56
$2,220.98 		$1,131.36
$1,241.84
$1,358.86
$1,774.58 		$1,444.38
$1,554.86
$1,671.88
$2,087.60 		$1,757.40
$1,867.88
$1,984.90
$2,400.62 		$313.02
Toc - Plan #62 Kaiser Permanente
Silver

(HMO) KP VA Silver 5000/40/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$367.62
$417.25
$469.82
$656.57
$997.73 		$648.85
$698.48
$751.05
$937.80 		$930.08
$979.71
$1,032.28
$1,219.03 		$1,211.31
$1,260.94
$1,313.51
$1,500.26 		$281.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.24
$834.50
$939.64
$1,313.14
$1,995.46 		$1,016.47
$1,115.73
$1,220.87
$1,594.37 		$1,297.70
$1,396.96
$1,502.10
$1,875.60 		$1,578.93
$1,678.19
$1,783.33
$2,156.83 		$281.23
Toc - Plan #63 Kaiser Permanente
Gold

(HMO) KP VA Gold 1250/20/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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 		$353.10
$400.77
$451.27
$630.65
$958.33 		$623.23
$670.90
$721.40
$900.78 		$893.36
$941.03
$991.53
$1,170.91 		$1,163.49
$1,211.16
$1,261.66
$1,441.04 		$270.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.20
$801.54
$902.54
$1,261.30
$1,916.66 		$976.33
$1,071.67
$1,172.67
$1,531.43 		$1,246.46
$1,341.80
$1,442.80
$1,801.56 		$1,516.59
$1,611.93
$1,712.93
$2,071.69 		$270.13
Toc - Plan #64 Kaiser Permanente
Gold

(HMO) KP VA Gold 1700/25/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 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 		$337.99
$383.62
$431.96
$603.66
$917.31 		$596.55
$642.18
$690.52
$862.22 		$855.11
$900.74
$949.08
$1,120.78 		$1,113.67
$1,159.30
$1,207.64
$1,379.34 		$258.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.98
$767.24
$863.92
$1,207.32
$1,834.62 		$934.54
$1,025.80
$1,122.48
$1,465.88 		$1,193.10
$1,284.36
$1,381.04
$1,724.44 		$1,451.66
$1,542.92
$1,639.60
$1,983.00 		$258.56
Toc - Plan #65 Kaiser Permanente
Silver

(HMO) KP VA Silver 6500/40/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$352.66
$400.27
$450.70
$629.86
$957.13 		$622.45
$670.06
$720.49
$899.65 		$892.24
$939.85
$990.28
$1,169.44 		$1,162.03
$1,209.64
$1,260.07
$1,439.23 		$269.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.32
$800.54
$901.40
$1,259.72
$1,914.26 		$975.11
$1,070.33
$1,171.19
$1,529.51 		$1,244.90
$1,340.12
$1,440.98
$1,799.30 		$1,514.69
$1,609.91
$1,710.77
$2,069.09 		$269.79
Toc - Plan #66 Kaiser Permanente
Bronze

(HMO) KP VA Bronze 7500/40%/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$262.38
$297.80
$335.32
$468.61
$712.10 		$463.10
$498.52
$536.04
$669.33 		$663.82
$699.24
$736.76
$870.05 		$864.54
$899.96
$937.48
$1,070.77 		$200.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.76
$595.60
$670.64
$937.22
$1,424.20 		$725.48
$796.32
$871.36
$1,137.94 		$926.20
$997.04
$1,072.08
$1,338.66 		$1,126.92
$1,197.76
$1,272.80
$1,539.38 		$200.72
Toc - Plan #67 Kaiser Permanente
Expanded Bronze

(HMO) KP VA Bronze 6900/0%/HSA/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$277.74
$315.24
$354.95
$496.04
$753.79 		$490.21
$527.71
$567.42
$708.51 		$702.68
$740.18
$779.89
$920.98 		$915.15
$952.65
$992.36
$1,133.45 		$212.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.48
$630.48
$709.90
$992.08
$1,507.58 		$767.95
$842.95
$922.37
$1,204.55 		$980.42
$1,055.42
$1,134.84
$1,417.02 		$1,192.89
$1,267.89
$1,347.31
$1,629.49 		$212.47
Toc - Plan #68 Kaiser Permanente
Gold

(HMO) KP VA Gold Virtual 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.16
$369.06
$415.56
$580.74
$882.49 		$573.91
$617.81
$664.31
$829.49 		$822.66
$866.56
$913.06
$1,078.24 		$1,071.41
$1,115.31
$1,161.81
$1,326.99 		$248.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.32
$738.12
$831.12
$1,161.48
$1,764.98 		$899.07
$986.87
$1,079.87
$1,410.23 		$1,147.82
$1,235.62
$1,328.62
$1,658.98 		$1,396.57
$1,484.37
$1,577.37
$1,907.73 		$248.75
Toc - Plan #69 Kaiser Permanente
Silver

(HMO) KP VA Silver Virtual Forward 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$341.43
$387.53
$436.35
$609.80
$926.65 		$602.63
$648.73
$697.55
$871.00 		$863.83
$909.93
$958.75
$1,132.20 		$1,125.03
$1,171.13
$1,219.95
$1,393.40 		$261.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.86
$775.06
$872.70
$1,219.60
$1,853.30 		$944.06
$1,036.26
$1,133.90
$1,480.80 		$1,205.26
$1,297.46
$1,395.10
$1,742.00 		$1,466.46
$1,558.66
$1,656.30
$2,003.20 		$261.20

‡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 Louisa County here.

Louisa County is in “Rating Area 2” of Virginia.

Currently, there are 69 plans offered in Rating Area 2.

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2022 Obamacare Plans for Louisa County, VA

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