Obamacare 2022 Rates for Florence County

Obamacare > Rates > Wisconsin > Florence 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 Florence County, WI.

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, 67 Plans and 2022 Rates for Florence County, Wisconsin

Below, you’ll find a summary of the 67 plans for Florence County, Wisconsin 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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HealthPartners

Local: 1-952-883-5900 | Toll Free: 1-855-813-3887 | TTY: 1-952-883-6060

Toc - Plan #1 HealthPartners
Gold

(PPO) Robin Oak $1,800 w/Copay P-S Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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
$405.89
$460.69
$518.73
$724.92
$1,101.59
$716.40
$771.20
$829.24
$1,035.43
$1,026.91
$1,081.71
$1,139.75
$1,345.94
$1,337.42
$1,392.22
$1,450.26
$1,656.45
$310.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.78
$921.38
$1,037.46
$1,449.84
$2,203.18
$1,122.29
$1,231.89
$1,347.97
$1,760.35
$1,432.80
$1,542.40
$1,658.48
$2,070.86
$1,743.31
$1,852.91
$1,968.99
$2,381.37
$310.51
Toc - Plan #2 HealthPartners
Expanded Bronze

(PPO) Robin Oak $6,250 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$299.25
$339.65
$382.44
$534.46
$812.16
$528.18
$568.58
$611.37
$763.39
$757.11
$797.51
$840.30
$992.32
$986.04
$1,026.44
$1,069.23
$1,221.25
$228.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.50
$679.30
$764.88
$1,068.92
$1,624.32
$827.43
$908.23
$993.81
$1,297.85
$1,056.36
$1,137.16
$1,222.74
$1,526.78
$1,285.29
$1,366.09
$1,451.67
$1,755.71
$228.93
Toc - Plan #3 HealthPartners
Catastrophic

(PPO) Robin Oak $8,700 Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$227.18
$257.85
$290.34
$405.74
$616.57
$400.97
$431.64
$464.13
$579.53
$574.76
$605.43
$637.92
$753.32
$748.55
$779.22
$811.71
$927.11
$173.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$454.36
$515.70
$580.68
$811.48
$1,233.14
$628.15
$689.49
$754.47
$985.27
$801.94
$863.28
$928.26
$1,159.06
$975.73
$1,037.07
$1,102.05
$1,332.85
$173.79
Toc - Plan #4 HealthPartners
Silver

(PPO) Robin Oak $7,500 w/Copay P-S Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$368.89
$418.69
$471.44
$658.84
$1,001.17
$651.09
$700.89
$753.64
$941.04
$933.29
$983.09
$1,035.84
$1,223.24
$1,215.49
$1,265.29
$1,318.04
$1,505.44
$282.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.78
$837.38
$942.88
$1,317.68
$2,002.34
$1,019.98
$1,119.58
$1,225.08
$1,599.88
$1,302.18
$1,401.78
$1,507.28
$1,882.08
$1,584.38
$1,683.98
$1,789.48
$2,164.28
$282.20
Toc - Plan #5 HealthPartners
Silver

(PPO) Robin Oak $4,500 Plus Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$364.82
$414.07
$466.24
$651.57
$990.12
$643.91
$693.16
$745.33
$930.66
$923.00
$972.25
$1,024.42
$1,209.75
$1,202.09
$1,251.34
$1,303.51
$1,488.84
$279.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.64
$828.14
$932.48
$1,303.14
$1,980.24
$1,008.73
$1,107.23
$1,211.57
$1,582.23
$1,287.82
$1,386.32
$1,490.66
$1,861.32
$1,566.91
$1,665.41
$1,769.75
$2,140.41
$279.09
Toc - Plan #6 HealthPartners
Expanded Bronze

(PPO) Robin Oak $7,000 HSA Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

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
$294.86
$334.67
$376.83
$526.62
$800.25
$520.43
$560.24
$602.40
$752.19
$746.00
$785.81
$827.97
$977.76
$971.57
$1,011.38
$1,053.54
$1,203.33
$225.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$589.72
$669.34
$753.66
$1,053.24
$1,600.50
$815.29
$894.91
$979.23
$1,278.81
$1,040.86
$1,120.48
$1,204.80
$1,504.38
$1,266.43
$1,346.05
$1,430.37
$1,729.95
$225.57
Toc - Plan #7 HealthPartners
Expanded Bronze

(PPO) Robin Oak $8,000 Plus Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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
$296.72
$336.78
$379.21
$529.94
$805.30
$523.71
$563.77
$606.20
$756.93
$750.70
$790.76
$833.19
$983.92
$977.69
$1,017.75
$1,060.18
$1,210.91
$226.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$593.44
$673.56
$758.42
$1,059.88
$1,610.60
$820.43
$900.55
$985.41
$1,286.87
$1,047.42
$1,127.54
$1,212.40
$1,513.86
$1,274.41
$1,354.53
$1,439.39
$1,740.85
$226.99
Toc - Plan #8 HealthPartners
Silver

(PPO) Robin Oak $25/$50 P-S Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-813-3887

Annual Out of Pocket Expenses:

Individual Family
$0 Not Applicable Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.71
$492.26
$554.28
$774.61
$1,177.09
$765.50
$824.05
$886.07
$1,106.40
$1,097.29
$1,155.84
$1,217.86
$1,438.19
$1,429.08
$1,487.63
$1,549.65
$1,769.98
$331.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.42
$984.52
$1,108.56
$1,549.22
$2,354.18
$1,199.21
$1,316.31
$1,440.35
$1,881.01
$1,531.00
$1,648.10
$1,772.14
$2,212.80
$1,862.79
$1,979.89
$2,103.93
$2,544.59
$331.79

ADVERTISEMENT

Security Health Plan

Local: 1-715-221-9258x19258 | Toll Free: 1-844-293-9624 | TTY: 1-877-727-2232

Toc - Plan #9 Security Health Plan
Gold

(EPO) SimplyOne $3,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.57
$437.61
$492.75
$688.62
$1,046.42
$680.53
$732.57
$787.71
$983.58
$975.49
$1,027.53
$1,082.67
$1,278.54
$1,270.45
$1,322.49
$1,377.63
$1,573.50
$294.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.14
$875.22
$985.50
$1,377.24
$2,092.84
$1,066.10
$1,170.18
$1,280.46
$1,672.20
$1,361.06
$1,465.14
$1,575.42
$1,967.16
$1,656.02
$1,760.10
$1,870.38
$2,262.12
$294.96
Toc - Plan #10 Security Health Plan
Silver

(EPO) SimplyOne $4,800 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$7,900 $15,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.55
$470.51
$529.79
$740.37
$1,125.07
$731.68
$787.64
$846.92
$1,057.50
$1,048.81
$1,104.77
$1,164.05
$1,374.63
$1,365.94
$1,421.90
$1,481.18
$1,691.76
$317.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.10
$941.02
$1,059.58
$1,480.74
$2,250.14
$1,146.23
$1,258.15
$1,376.71
$1,797.87
$1,463.36
$1,575.28
$1,693.84
$2,115.00
$1,780.49
$1,892.41
$2,010.97
$2,432.13
$317.13
Toc - Plan #11 Security Health Plan
Silver

(EPO) SimplyOne $6,950 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,950 $13,900 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
$385.34
$437.34
$492.45
$688.19
$1,045.77
$680.11
$732.11
$787.22
$982.96
$974.88
$1,026.88
$1,081.99
$1,277.73
$1,269.65
$1,321.65
$1,376.76
$1,572.50
$294.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.68
$874.68
$984.90
$1,376.38
$2,091.54
$1,065.45
$1,169.45
$1,279.67
$1,671.15
$1,360.22
$1,464.22
$1,574.44
$1,965.92
$1,654.99
$1,758.99
$1,869.21
$2,260.69
$294.77
Toc - Plan #12 Security Health Plan
Silver

(EPO) SimplyOne $4,500 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$428.04
$485.81
$547.02
$764.45
$1,161.66
$755.48
$813.25
$874.46
$1,091.89
$1,082.92
$1,140.69
$1,201.90
$1,419.33
$1,410.36
$1,468.13
$1,529.34
$1,746.77
$327.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.08
$971.62
$1,094.04
$1,528.90
$2,323.32
$1,183.52
$1,299.06
$1,421.48
$1,856.34
$1,510.96
$1,626.50
$1,748.92
$2,183.78
$1,838.40
$1,953.94
$2,076.36
$2,511.22
$327.44
Toc - Plan #13 Security Health Plan
Expanded Bronze

(EPO) SimplyOne $6,200 HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.87
$358.50
$403.67
$564.12
$857.24
$557.50
$600.13
$645.30
$805.75
$799.13
$841.76
$886.93
$1,047.38
$1,040.76
$1,083.39
$1,128.56
$1,289.01
$241.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.74
$717.00
$807.34
$1,128.24
$1,714.48
$873.37
$958.63
$1,048.97
$1,369.87
$1,115.00
$1,200.26
$1,290.60
$1,611.50
$1,356.63
$1,441.89
$1,532.23
$1,853.13
$241.63
Toc - Plan #14 Security Health Plan
Bronze

(EPO) SimplyOne $7,500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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
$286.77
$325.47
$366.48
$512.15
$778.27
$506.14
$544.84
$585.85
$731.52
$725.51
$764.21
$805.22
$950.89
$944.88
$983.58
$1,024.59
$1,170.26
$219.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$573.54
$650.94
$732.96
$1,024.30
$1,556.54
$792.91
$870.31
$952.33
$1,243.67
$1,012.28
$1,089.68
$1,171.70
$1,463.04
$1,231.65
$1,309.05
$1,391.07
$1,682.41
$219.37
Toc - Plan #15 Security Health Plan
Bronze

(EPO) SimplyOne $8,700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$279.34
$317.04
$356.98
$498.88
$758.09
$493.03
$530.73
$570.67
$712.57
$706.72
$744.42
$784.36
$926.26
$920.41
$958.11
$998.05
$1,139.95
$213.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$558.68
$634.08
$713.96
$997.76
$1,516.18
$772.37
$847.77
$927.65
$1,211.45
$986.06
$1,061.46
$1,141.34
$1,425.14
$1,199.75
$1,275.15
$1,355.03
$1,638.83
$213.69
Toc - Plan #16 Security Health Plan
Catastrophic

(EPO) SimplyOne Protection

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$191.10
$216.88
$244.21
$341.28
$518.61
$337.28
$363.06
$390.39
$487.46
$483.46
$509.24
$536.57
$633.64
$629.64
$655.42
$682.75
$779.82
$146.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$382.20
$433.76
$488.42
$682.56
$1,037.22
$528.38
$579.94
$634.60
$828.74
$674.56
$726.12
$780.78
$974.92
$820.74
$872.30
$926.96
$1,121.10
$146.18
Toc - Plan #17 Security Health Plan
Gold

(EPO) SimplyOne $1,500 - 30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.65
$472.88
$532.46
$744.12
$1,130.76
$735.38
$791.61
$851.19
$1,062.85
$1,054.11
$1,110.34
$1,169.92
$1,381.58
$1,372.84
$1,429.07
$1,488.65
$1,700.31
$318.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833.30
$945.76
$1,064.92
$1,488.24
$2,261.52
$1,152.03
$1,264.49
$1,383.65
$1,806.97
$1,470.76
$1,583.22
$1,702.38
$2,125.70
$1,789.49
$1,901.95
$2,021.11
$2,444.43
$318.73
Toc - Plan #18 Security Health Plan
Expanded Bronze

(EPO) SimplyOne $8,700 Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-293-9624

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
$292.42
$331.89
$373.71
$522.25
$793.61
$516.12
$555.59
$597.41
$745.95
$739.82
$779.29
$821.11
$969.65
$963.52
$1,002.99
$1,044.81
$1,193.35
$223.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$584.84
$663.78
$747.42
$1,044.50
$1,587.22
$808.54
$887.48
$971.12
$1,268.20
$1,032.24
$1,111.18
$1,194.82
$1,491.90
$1,255.94
$1,334.88
$1,418.52
$1,715.60
$223.70

ADVERTISEMENT

Aspirus Health Plan

Local: 1-866-631-4611 | Toll Free: 1-866-631-4611 | TTY: 1-866-631-8597

Toc - Plan #19 Aspirus Health Plan
Silver

(HMO) HMO Silver 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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
$471.51
$535.16
$602.59
$842.11
$1,279.67
$832.21
$895.86
$963.29
$1,202.81
$1,192.91
$1,256.56
$1,323.99
$1,563.51
$1,553.61
$1,617.26
$1,684.69
$1,924.21
$360.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$943.02
$1,070.32
$1,205.18
$1,684.22
$2,559.34
$1,303.72
$1,431.02
$1,565.88
$2,044.92
$1,664.42
$1,791.72
$1,926.58
$2,405.62
$2,025.12
$2,152.42
$2,287.28
$2,766.32
$360.70
Toc - Plan #20 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$344.06
$390.51
$439.71
$614.50
$933.79
$607.27
$653.72
$702.92
$877.71
$870.48
$916.93
$966.13
$1,140.92
$1,133.69
$1,180.14
$1,229.34
$1,404.13
$263.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.12
$781.02
$879.42
$1,229.00
$1,867.58
$951.33
$1,044.23
$1,142.63
$1,492.21
$1,214.54
$1,307.44
$1,405.84
$1,755.42
$1,477.75
$1,570.65
$1,669.05
$2,018.63
$263.21
Toc - Plan #21 Aspirus Health Plan
Bronze

(HMO) HMO Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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
$320.40
$363.65
$409.47
$572.23
$869.56
$565.51
$608.76
$654.58
$817.34
$810.62
$853.87
$899.69
$1,062.45
$1,055.73
$1,098.98
$1,144.80
$1,307.56
$245.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.80
$727.30
$818.94
$1,144.46
$1,739.12
$885.91
$972.41
$1,064.05
$1,389.57
$1,131.02
$1,217.52
$1,309.16
$1,634.68
$1,376.13
$1,462.63
$1,554.27
$1,879.79
$245.11
Toc - Plan #22 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 6500 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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
$340.43
$386.38
$435.06
$608.00
$923.92
$600.86
$646.81
$695.49
$868.43
$861.29
$907.24
$955.92
$1,128.86
$1,121.72
$1,167.67
$1,216.35
$1,389.29
$260.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.86
$772.76
$870.12
$1,216.00
$1,847.84
$941.29
$1,033.19
$1,130.55
$1,476.43
$1,201.72
$1,293.62
$1,390.98
$1,736.86
$1,462.15
$1,554.05
$1,651.41
$1,997.29
$260.43
Toc - Plan #23 Aspirus Health Plan
Gold

(HMO) HMO Gold 2750

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 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
$427.81
$485.57
$546.75
$764.08
$1,161.09
$755.09
$812.85
$874.03
$1,091.36
$1,082.37
$1,140.13
$1,201.31
$1,418.64
$1,409.65
$1,467.41
$1,528.59
$1,745.92
$327.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$855.62
$971.14
$1,093.50
$1,528.16
$2,322.18
$1,182.90
$1,298.42
$1,420.78
$1,855.44
$1,510.18
$1,625.70
$1,748.06
$2,182.72
$1,837.46
$1,952.98
$2,075.34
$2,510.00
$327.28
Toc - Plan #24 Aspirus Health Plan
Catastrophic

(HMO) HMO Catastrophic 8700 with 3 Free PCP visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$233.02
$264.48
$297.80
$416.18
$632.42
$411.28
$442.74
$476.06
$594.44
$589.54
$621.00
$654.32
$772.70
$767.80
$799.26
$832.58
$950.96
$178.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$466.04
$528.96
$595.60
$832.36
$1,264.84
$644.30
$707.22
$773.86
$1,010.62
$822.56
$885.48
$952.12
$1,188.88
$1,000.82
$1,063.74
$1,130.38
$1,367.14
$178.26
Toc - Plan #25 Aspirus Health Plan
Expanded Bronze

(HMO) HMO HDHP Bronze 6900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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
$342.70
$388.96
$437.97
$612.06
$930.09
$604.86
$651.12
$700.13
$874.22
$867.02
$913.28
$962.29
$1,136.38
$1,129.18
$1,175.44
$1,224.45
$1,398.54
$262.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.40
$777.92
$875.94
$1,224.12
$1,860.18
$947.56
$1,040.08
$1,138.10
$1,486.28
$1,209.72
$1,302.24
$1,400.26
$1,748.44
$1,471.88
$1,564.40
$1,662.42
$2,010.60
$262.16
Toc - Plan #26 Aspirus Health Plan
Expanded Bronze

(HMO) HMO Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

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
$329.05
$373.47
$420.53
$587.69
$893.05
$580.77
$625.19
$672.25
$839.41
$832.49
$876.91
$923.97
$1,091.13
$1,084.21
$1,128.63
$1,175.69
$1,342.85
$251.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$658.10
$746.94
$841.06
$1,175.38
$1,786.10
$909.82
$998.66
$1,092.78
$1,427.10
$1,161.54
$1,250.38
$1,344.50
$1,678.82
$1,413.26
$1,502.10
$1,596.22
$1,930.54
$251.72
Toc - Plan #27 Aspirus Health Plan
Silver

(HMO) HMO Silver 4800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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
$483.34
$548.59
$617.71
$863.25
$1,311.79
$853.10
$918.35
$987.47
$1,233.01
$1,222.86
$1,288.11
$1,357.23
$1,602.77
$1,592.62
$1,657.87
$1,726.99
$1,972.53
$369.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$966.68
$1,097.18
$1,235.42
$1,726.50
$2,623.58
$1,336.44
$1,466.94
$1,605.18
$2,096.26
$1,706.20
$1,836.70
$1,974.94
$2,466.02
$2,075.96
$2,206.46
$2,344.70
$2,835.78
$369.76
Toc - Plan #28 Aspirus Health Plan
Silver

(HMO) HMO HDHP Silver 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$5,900 $11,800 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
$462.85
$525.34
$591.53
$826.66
$1,256.19
$816.93
$879.42
$945.61
$1,180.74
$1,171.01
$1,233.50
$1,299.69
$1,534.82
$1,525.09
$1,587.58
$1,653.77
$1,888.90
$354.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$925.70
$1,050.68
$1,183.06
$1,653.32
$2,512.38
$1,279.78
$1,404.76
$1,537.14
$2,007.40
$1,633.86
$1,758.84
$1,891.22
$2,361.48
$1,987.94
$2,112.92
$2,245.30
$2,715.56
$354.08
Toc - Plan #29 Aspirus Health Plan
Silver

(POS) POS Silver 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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
$538.41
$611.09
$688.09
$961.60
$1,461.24
$950.29
$1,022.97
$1,099.97
$1,373.48
$1,362.17
$1,434.85
$1,511.85
$1,785.36
$1,774.05
$1,846.73
$1,923.73
$2,197.24
$411.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,076.82
$1,222.18
$1,376.18
$1,923.20
$2,922.48
$1,488.70
$1,634.06
$1,788.06
$2,335.08
$1,900.58
$2,045.94
$2,199.94
$2,746.96
$2,312.46
$2,457.82
$2,611.82
$3,158.84
$411.88
Toc - Plan #30 Aspirus Health Plan
Expanded Bronze

(POS) POS HDHP Bronze 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-631-4611

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$378.66
$429.78
$483.92
$676.28
$1,027.67
$668.33
$719.45
$773.59
$965.95
$958.00
$1,009.12
$1,063.26
$1,255.62
$1,247.67
$1,298.79
$1,352.93
$1,545.29
$289.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.32
$859.56
$967.84
$1,352.56
$2,055.34
$1,046.99
$1,149.23
$1,257.51
$1,642.23
$1,336.66
$1,438.90
$1,547.18
$1,931.90
$1,626.33
$1,728.57
$1,836.85
$2,221.57
$289.67

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442

Toc - Plan #31 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Solutions Bronze $0 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$268.59
$304.84
$343.24
$479.68
$728.92
$474.05
$510.30
$548.70
$685.14
$679.51
$715.76
$754.16
$890.60
$884.97
$921.22
$959.62
$1,096.06
$205.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.18
$609.68
$686.48
$959.36
$1,457.84
$742.64
$815.14
$891.94
$1,164.82
$948.10
$1,020.60
$1,097.40
$1,370.28
$1,153.56
$1,226.06
$1,302.86
$1,575.74
$205.46
Toc - Plan #32 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Solutions Silver $0 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$385.40
$437.41
$492.52
$688.30
$1,045.93
$680.22
$732.23
$787.34
$983.12
$975.04
$1,027.05
$1,082.16
$1,277.94
$1,269.86
$1,321.87
$1,376.98
$1,572.76
$294.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.80
$874.82
$985.04
$1,376.60
$2,091.86
$1,065.62
$1,169.64
$1,279.86
$1,671.42
$1,360.44
$1,464.46
$1,574.68
$1,966.24
$1,655.26
$1,759.28
$1,869.50
$2,261.06
$294.82
Toc - Plan #33 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Solutions Gold $0 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.21
$464.44
$522.96
$730.83
$1,110.57
$722.25
$777.48
$836.00
$1,043.87
$1,035.29
$1,090.52
$1,149.04
$1,356.91
$1,348.33
$1,403.56
$1,462.08
$1,669.95
$313.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.42
$928.88
$1,045.92
$1,461.66
$2,221.14
$1,131.46
$1,241.92
$1,358.96
$1,774.70
$1,444.50
$1,554.96
$1,672.00
$2,087.74
$1,757.54
$1,868.00
$1,985.04
$2,400.78
$313.04
Toc - Plan #34 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value 2 Gold $3000 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.55
$406.95
$458.22
$640.36
$973.09
$632.84
$681.24
$732.51
$914.65
$907.13
$955.53
$1,006.80
$1,188.94
$1,181.42
$1,229.82
$1,281.09
$1,463.23
$274.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.10
$813.90
$916.44
$1,280.72
$1,946.18
$991.39
$1,088.19
$1,190.73
$1,555.01
$1,265.68
$1,362.48
$1,465.02
$1,829.30
$1,539.97
$1,636.77
$1,739.31
$2,103.59
$274.29
Toc - Plan #35 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value 1 Gold $3600 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 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
$348.14
$395.12
$444.90
$621.75
$944.81
$614.46
$661.44
$711.22
$888.07
$880.78
$927.76
$977.54
$1,154.39
$1,147.10
$1,194.08
$1,243.86
$1,420.71
$266.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.28
$790.24
$889.80
$1,243.50
$1,889.62
$962.60
$1,056.56
$1,156.12
$1,509.82
$1,228.92
$1,322.88
$1,422.44
$1,776.14
$1,495.24
$1,589.20
$1,688.76
$2,042.46
$266.32
Toc - Plan #36 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value Premier Gold $1800 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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
$387.09
$439.34
$494.69
$691.33
$1,050.54
$683.21
$735.46
$790.81
$987.45
$979.33
$1,031.58
$1,086.93
$1,283.57
$1,275.45
$1,327.70
$1,383.05
$1,579.69
$296.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.18
$878.68
$989.38
$1,382.66
$2,101.08
$1,070.30
$1,174.80
$1,285.50
$1,678.78
$1,366.42
$1,470.92
$1,581.62
$1,974.90
$1,662.54
$1,767.04
$1,877.74
$2,271.02
$296.12
Toc - Plan #37 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value Plus Gold $2000 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$360.84
$409.54
$461.14
$644.44
$979.28
$636.87
$685.57
$737.17
$920.47
$912.90
$961.60
$1,013.20
$1,196.50
$1,188.93
$1,237.63
$1,289.23
$1,472.53
$276.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.68
$819.08
$922.28
$1,288.88
$1,958.56
$997.71
$1,095.11
$1,198.31
$1,564.91
$1,273.74
$1,371.14
$1,474.34
$1,840.94
$1,549.77
$1,647.17
$1,750.37
$2,116.97
$276.03
Toc - Plan #38 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value Plus Silver $4000 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$347.43
$394.32
$444.00
$620.49
$942.90
$613.21
$660.10
$709.78
$886.27
$878.99
$925.88
$975.56
$1,152.05
$1,144.77
$1,191.66
$1,241.34
$1,417.83
$265.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$694.86
$788.64
$888.00
$1,240.98
$1,885.80
$960.64
$1,054.42
$1,153.78
$1,506.76
$1,226.42
$1,320.20
$1,419.56
$1,772.54
$1,492.20
$1,585.98
$1,685.34
$2,038.32
$265.78
Toc - Plan #39 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value Premier Silver $3000 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$361.87
$410.71
$462.45
$646.27
$982.08
$638.69
$687.53
$739.27
$923.09
$915.51
$964.35
$1,016.09
$1,199.91
$1,192.33
$1,241.17
$1,292.91
$1,476.73
$276.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.74
$821.42
$924.90
$1,292.54
$1,964.16
$1,000.56
$1,098.24
$1,201.72
$1,569.36
$1,277.38
$1,375.06
$1,478.54
$1,846.18
$1,554.20
$1,651.88
$1,755.36
$2,123.00
$276.82
Toc - Plan #40 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value 2 Silver $6500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$295.56
$335.45
$377.71
$527.85
$802.12
$521.65
$561.54
$603.80
$753.94
$747.74
$787.63
$829.89
$980.03
$973.83
$1,013.72
$1,055.98
$1,206.12
$226.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.12
$670.90
$755.42
$1,055.70
$1,604.24
$817.21
$896.99
$981.51
$1,281.79
$1,043.30
$1,123.08
$1,207.60
$1,507.88
$1,269.39
$1,349.17
$1,433.69
$1,733.97
$226.09
Toc - Plan #41 Common Ground Healthcare Cooperative
Catastrophic

(EPO) CGHC Catastrophic $8700 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$183.35
$208.09
$234.31
$327.44
$497.58
$323.60
$348.34
$374.56
$467.69
$463.85
$488.59
$514.81
$607.94
$604.10
$628.84
$655.06
$748.19
$140.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$366.70
$416.18
$468.62
$654.88
$995.16
$506.95
$556.43
$608.87
$795.13
$647.20
$696.68
$749.12
$935.38
$787.45
$836.93
$889.37
$1,075.63
$140.25
Toc - Plan #42 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value Plus Bronze $8700 Deductible ($35 PCP Copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$253.54
$287.75
$324.01
$452.80
$688.07
$447.49
$481.70
$517.96
$646.75
$641.44
$675.65
$711.91
$840.70
$835.39
$869.60
$905.86
$1,034.65
$193.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$507.08
$575.50
$648.02
$905.60
$1,376.14
$701.03
$769.45
$841.97
$1,099.55
$894.98
$963.40
$1,035.92
$1,293.50
$1,088.93
$1,157.35
$1,229.87
$1,487.45
$193.95
Toc - Plan #43 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value Premier Bronze $8150 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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
$261.51
$296.81
$334.20
$467.04
$709.72
$461.56
$496.86
$534.25
$667.09
$661.61
$696.91
$734.30
$867.14
$861.66
$896.96
$934.35
$1,067.19
$200.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$523.02
$593.62
$668.40
$934.08
$1,419.44
$723.07
$793.67
$868.45
$1,134.13
$923.12
$993.72
$1,068.50
$1,334.18
$1,123.17
$1,193.77
$1,268.55
$1,534.23
$200.05
Toc - Plan #44 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7000 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$263.28
$298.81
$336.46
$470.20
$714.51
$464.68
$500.21
$537.86
$671.60
$666.08
$701.61
$739.26
$873.00
$867.48
$903.01
$940.66
$1,074.40
$201.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$526.56
$597.62
$672.92
$940.40
$1,429.02
$727.96
$799.02
$874.32
$1,141.80
$929.36
$1,000.42
$1,075.72
$1,343.20
$1,130.76
$1,201.82
$1,277.12
$1,544.60
$201.40
Toc - Plan #45 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $2800 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$5,600 $11,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$410.98
$466.45
$525.22
$734.00
$1,115.38
$725.37
$780.84
$839.61
$1,048.39
$1,039.76
$1,095.23
$1,154.00
$1,362.78
$1,354.15
$1,409.62
$1,468.39
$1,677.17
$314.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$821.96
$932.90
$1,050.44
$1,468.00
$2,230.76
$1,136.35
$1,247.29
$1,364.83
$1,782.39
$1,450.74
$1,561.68
$1,679.22
$2,096.78
$1,765.13
$1,876.07
$1,993.61
$2,411.17
$314.39
Toc - Plan #46 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3000 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$399.77
$453.73
$510.90
$713.97
$1,084.95
$705.59
$759.55
$816.72
$1,019.79
$1,011.41
$1,065.37
$1,122.54
$1,325.61
$1,317.23
$1,371.19
$1,428.36
$1,631.43
$305.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.54
$907.46
$1,021.80
$1,427.94
$2,169.90
$1,105.36
$1,213.28
$1,327.62
$1,733.76
$1,411.18
$1,519.10
$1,633.44
$2,039.58
$1,717.00
$1,824.92
$1,939.26
$2,345.40
$305.82
Toc - Plan #47 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Value 1 Bronze $8700 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$251.85
$285.84
$321.85
$449.79
$683.49
$444.51
$478.50
$514.51
$642.45
$637.17
$671.16
$707.17
$835.11
$829.83
$863.82
$899.83
$1,027.77
$192.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$503.70
$571.68
$643.70
$899.58
$1,366.98
$696.36
$764.34
$836.36
$1,092.24
$889.02
$957.00
$1,029.02
$1,284.90
$1,081.68
$1,149.66
$1,221.68
$1,477.56
$192.66
Toc - Plan #48 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value 2 Bronze $6000 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$259.18
$294.16
$331.22
$462.88
$703.39
$457.45
$492.43
$529.49
$661.15
$655.72
$690.70
$727.76
$859.42
$853.99
$888.97
$926.03
$1,057.69
$198.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$518.36
$588.32
$662.44
$925.76
$1,406.78
$716.63
$786.59
$860.71
$1,124.03
$914.90
$984.86
$1,058.98
$1,322.30
$1,113.17
$1,183.13
$1,257.25
$1,520.57
$198.27
Toc - Plan #49 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value 1 Silver $7500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$295.50
$335.38
$377.64
$527.74
$801.96
$521.55
$561.43
$603.69
$753.79
$747.60
$787.48
$829.74
$979.84
$973.65
$1,013.53
$1,055.79
$1,205.89
$226.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$591.00
$670.76
$755.28
$1,055.48
$1,603.92
$817.05
$896.81
$981.33
$1,281.53
$1,043.10
$1,122.86
$1,207.38
$1,507.58
$1,269.15
$1,348.91
$1,433.43
$1,733.63
$226.05
Toc - Plan #50 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value Premier Gold $1800 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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
$390.02
$442.66
$498.43
$696.56
$1,058.49
$688.38
$741.02
$796.79
$994.92
$986.74
$1,039.38
$1,095.15
$1,293.28
$1,285.10
$1,337.74
$1,393.51
$1,591.64
$298.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.04
$885.32
$996.86
$1,393.12
$2,116.98
$1,078.40
$1,183.68
$1,295.22
$1,691.48
$1,376.76
$1,482.04
$1,593.58
$1,989.84
$1,675.12
$1,780.40
$1,891.94
$2,288.20
$298.36
Toc - Plan #51 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value Plus Gold $2000 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$363.75
$412.84
$464.86
$649.63
$987.18
$642.01
$691.10
$743.12
$927.89
$920.27
$969.36
$1,021.38
$1,206.15
$1,198.53
$1,247.62
$1,299.64
$1,484.41
$278.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.50
$825.68
$929.72
$1,299.26
$1,974.36
$1,005.76
$1,103.94
$1,207.98
$1,577.52
$1,284.02
$1,382.20
$1,486.24
$1,855.78
$1,562.28
$1,660.46
$1,764.50
$2,134.04
$278.26
Toc - Plan #52 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value 2 Gold $3000 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.46
$410.25
$461.94
$645.56
$980.98
$637.97
$686.76
$738.45
$922.07
$914.48
$963.27
$1,014.96
$1,198.58
$1,190.99
$1,239.78
$1,291.47
$1,475.09
$276.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.92
$820.50
$923.88
$1,291.12
$1,961.96
$999.43
$1,097.01
$1,200.39
$1,567.63
$1,275.94
$1,373.52
$1,476.90
$1,844.14
$1,552.45
$1,650.03
$1,753.41
$2,120.65
$276.51
Toc - Plan #53 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value 1 Gold $3600 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 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
$351.04
$398.41
$448.61
$626.93
$952.69
$619.58
$666.95
$717.15
$895.47
$888.12
$935.49
$985.69
$1,164.01
$1,156.66
$1,204.03
$1,254.23
$1,432.55
$268.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.08
$796.82
$897.22
$1,253.86
$1,905.38
$970.62
$1,065.36
$1,165.76
$1,522.40
$1,239.16
$1,333.90
$1,434.30
$1,790.94
$1,507.70
$1,602.44
$1,702.84
$2,059.48
$268.54
Toc - Plan #54 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value Plus Silver $4000 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$350.33
$397.61
$447.71
$625.67
$950.77
$618.33
$665.61
$715.71
$893.67
$886.33
$933.61
$983.71
$1,161.67
$1,154.33
$1,201.61
$1,251.71
$1,429.67
$268.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$700.66
$795.22
$895.42
$1,251.34
$1,901.54
$968.66
$1,063.22
$1,163.42
$1,519.34
$1,236.66
$1,331.22
$1,431.42
$1,787.34
$1,504.66
$1,599.22
$1,699.42
$2,055.34
$268.00
Toc - Plan #55 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value Premier Silver $3000 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$364.78
$414.01
$466.17
$651.47
$989.97
$643.83
$693.06
$745.22
$930.52
$922.88
$972.11
$1,024.27
$1,209.57
$1,201.93
$1,251.16
$1,303.32
$1,488.62
$279.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$729.56
$828.02
$932.34
$1,302.94
$1,979.94
$1,008.61
$1,107.07
$1,211.39
$1,581.99
$1,287.66
$1,386.12
$1,490.44
$1,861.04
$1,566.71
$1,665.17
$1,769.49
$2,140.09
$279.05
Toc - Plan #56 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value 1 Silver $7500 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$298.36
$338.63
$381.29
$532.86
$809.73
$526.60
$566.87
$609.53
$761.10
$754.84
$795.11
$837.77
$989.34
$983.08
$1,023.35
$1,066.01
$1,217.58
$228.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.72
$677.26
$762.58
$1,065.72
$1,619.46
$824.96
$905.50
$990.82
$1,293.96
$1,053.20
$1,133.74
$1,219.06
$1,522.20
$1,281.44
$1,361.98
$1,447.30
$1,750.44
$228.24
Toc - Plan #57 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value 2 Silver $6500 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$298.43
$338.71
$381.38
$532.98
$809.91
$526.72
$567.00
$609.67
$761.27
$755.01
$795.29
$837.96
$989.56
$983.30
$1,023.58
$1,066.25
$1,217.85
$228.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.86
$677.42
$762.76
$1,065.96
$1,619.82
$825.15
$905.71
$991.05
$1,294.25
$1,053.44
$1,134.00
$1,219.34
$1,522.54
$1,281.73
$1,362.29
$1,447.63
$1,750.83
$228.29
Toc - Plan #58 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Value 1 Bronze $8700 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$254.69
$289.06
$325.48
$454.86
$691.21
$449.52
$483.89
$520.31
$649.69
$644.35
$678.72
$715.14
$844.52
$839.18
$873.55
$909.97
$1,039.35
$194.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509.38
$578.12
$650.96
$909.72
$1,382.42
$704.21
$772.95
$845.79
$1,104.55
$899.04
$967.78
$1,040.62
$1,299.38
$1,093.87
$1,162.61
$1,235.45
$1,494.21
$194.83
Toc - Plan #59 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value Plus Bronze $8700 Deductible ($35 PCP Copay+ Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$256.38
$290.98
$327.64
$457.87
$695.78
$452.50
$487.10
$523.76
$653.99
$648.62
$683.22
$719.88
$850.11
$844.74
$879.34
$916.00
$1,046.23
$196.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$512.76
$581.96
$655.28
$915.74
$1,391.56
$708.88
$778.08
$851.40
$1,111.86
$905.00
$974.20
$1,047.52
$1,307.98
$1,101.12
$1,170.32
$1,243.64
$1,504.10
$196.12
Toc - Plan #60 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value Premier Bronze $8150 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$8,150 $16,300 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
$264.37
$300.04
$337.85
$472.14
$717.46
$466.60
$502.27
$540.08
$674.37
$668.83
$704.50
$742.31
$876.60
$871.06
$906.73
$944.54
$1,078.83
$202.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$528.74
$600.08
$675.70
$944.28
$1,434.92
$730.97
$802.31
$877.93
$1,146.51
$933.20
$1,004.54
$1,080.16
$1,348.74
$1,135.43
$1,206.77
$1,282.39
$1,550.97
$202.23
Toc - Plan #61 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value 2 Bronze $6000 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$262.02
$297.38
$334.85
$467.95
$711.10
$462.46
$497.82
$535.29
$668.39
$662.90
$698.26
$735.73
$868.83
$863.34
$898.70
$936.17
$1,069.27
$200.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$524.04
$594.76
$669.70
$935.90
$1,422.20
$724.48
$795.20
$870.14
$1,136.34
$924.92
$995.64
$1,070.58
$1,336.78
$1,125.36
$1,196.08
$1,271.02
$1,537.22
$200.44
Toc - Plan #62 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7000 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$266.13
$302.05
$340.10
$475.29
$722.25
$469.71
$505.63
$543.68
$678.87
$673.29
$709.21
$747.26
$882.45
$876.87
$912.79
$950.84
$1,086.03
$203.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$532.26
$604.10
$680.20
$950.58
$1,444.50
$735.84
$807.68
$883.78
$1,154.16
$939.42
$1,011.26
$1,087.36
$1,357.74
$1,143.00
$1,214.84
$1,290.94
$1,561.32
$203.58
Toc - Plan #63 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3000 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$402.71
$457.07
$514.65
$719.23
$1,092.93
$710.78
$765.14
$822.72
$1,027.30
$1,018.85
$1,073.21
$1,130.79
$1,335.37
$1,326.92
$1,381.28
$1,438.86
$1,643.44
$308.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.42
$914.14
$1,029.30
$1,438.46
$2,185.86
$1,113.49
$1,222.21
$1,337.37
$1,746.53
$1,421.56
$1,530.28
$1,645.44
$2,054.60
$1,729.63
$1,838.35
$1,953.51
$2,362.67
$308.07
Toc - Plan #64 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $2800 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$5,600 $11,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.93
$469.80
$528.99
$739.27
$1,123.39
$730.58
$786.45
$845.64
$1,055.92
$1,047.23
$1,103.10
$1,162.29
$1,372.57
$1,363.88
$1,419.75
$1,478.94
$1,689.22
$316.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$827.86
$939.60
$1,057.98
$1,478.54
$2,246.78
$1,144.51
$1,256.25
$1,374.63
$1,795.19
$1,461.16
$1,572.90
$1,691.28
$2,111.84
$1,777.81
$1,889.55
$2,007.93
$2,428.49
$316.65
Toc - Plan #65 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Solutions Bronze $0 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

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
$271.44
$308.07
$346.89
$484.78
$736.66
$479.08
$515.71
$554.53
$692.42
$686.72
$723.35
$762.17
$900.06
$894.36
$930.99
$969.81
$1,107.70
$207.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$542.88
$616.14
$693.78
$969.56
$1,473.32
$750.52
$823.78
$901.42
$1,177.20
$958.16
$1,031.42
$1,109.06
$1,384.84
$1,165.80
$1,239.06
$1,316.70
$1,592.48
$207.64
Toc - Plan #66 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Solutions Silver $0 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.33
$440.74
$496.27
$693.53
$1,053.89
$685.39
$737.80
$793.33
$990.59
$982.45
$1,034.86
$1,090.39
$1,287.65
$1,279.51
$1,331.92
$1,387.45
$1,584.71
$297.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.66
$881.48
$992.54
$1,387.06
$2,107.78
$1,073.72
$1,178.54
$1,289.60
$1,684.12
$1,370.78
$1,475.60
$1,586.66
$1,981.18
$1,667.84
$1,772.66
$1,883.72
$2,278.24
$297.06
Toc - Plan #67 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Solutions Gold $0 Deductible (Allergy Testing+ Vision Exam)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-514-2442

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.15
$467.78
$526.71
$736.08
$1,118.55
$727.44
$783.07
$842.00
$1,051.37
$1,042.73
$1,098.36
$1,157.29
$1,366.66
$1,358.02
$1,413.65
$1,472.58
$1,681.95
$315.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824.30
$935.56
$1,053.42
$1,472.16
$2,237.10
$1,139.59
$1,250.85
$1,368.71
$1,787.45
$1,454.88
$1,566.14
$1,684.00
$2,102.74
$1,770.17
$1,881.43
$1,999.29
$2,418.03
$315.29

‡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 Florence County here.

Florence County is in “Rating Area 13” of Wisconsin.

Currently, there are 67 plans offered in Rating Area 13.

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2022 Obamacare Plans for Florence County, WI

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