Obamacare 2022 Rates for Jefferson County

Obamacare > Rates > Wisconsin > Jefferson 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 Jefferson 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, 95 Plans and 2022 Rates for Jefferson County, Wisconsin

Below, you’ll find a summary of the 95 plans for Jefferson 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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Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973
Toc - Plan #1 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$405.20
$459.90
$517.84
$723.68
$1,099.70 		$715.17
$769.87
$827.81
$1,033.65 		$1,025.14
$1,079.84
$1,137.78
$1,343.62 		$1,335.11
$1,389.81
$1,447.75
$1,653.59 		$309.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.40
$919.80
$1,035.68
$1,447.36
$2,199.40 		$1,120.37
$1,229.77
$1,345.65
$1,757.33 		$1,430.34
$1,539.74
$1,655.62
$2,067.30 		$1,740.31
$1,849.71
$1,965.59
$2,377.27 		$309.97
Toc - Plan #2 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,250 $8,500 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 		$462.05
$524.42
$590.49
$825.20
$1,253.98 		$815.51
$877.88
$943.95
$1,178.66 		$1,168.97
$1,231.34
$1,297.41
$1,532.12 		$1,522.43
$1,584.80
$1,650.87
$1,885.58 		$353.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.10
$1,048.84
$1,180.98
$1,650.40
$2,507.96 		$1,277.56
$1,402.30
$1,534.44
$2,003.86 		$1,631.02
$1,755.76
$1,887.90
$2,357.32 		$1,984.48
$2,109.22
$2,241.36
$2,710.78 		$353.46
Toc - Plan #3 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$399.86
$453.84
$511.02
$714.15
$1,085.22 		$705.75
$759.73
$816.91
$1,020.04 		$1,011.64
$1,065.62
$1,122.80
$1,325.93 		$1,317.53
$1,371.51
$1,428.69
$1,631.82 		$305.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.72
$907.68
$1,022.04
$1,428.30
$2,170.44 		$1,105.61
$1,213.57
$1,327.93
$1,734.19 		$1,411.50
$1,519.46
$1,633.82
$2,040.08 		$1,717.39
$1,825.35
$1,939.71
$2,345.97 		$305.89
Toc - Plan #4 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.87
$462.93
$521.26
$728.45
$1,106.96 		$719.89
$774.95
$833.28
$1,040.47 		$1,031.91
$1,086.97
$1,145.30
$1,352.49 		$1,343.93
$1,398.99
$1,457.32
$1,664.51 		$312.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.74
$925.86
$1,042.52
$1,456.90
$2,213.92 		$1,127.76
$1,237.88
$1,354.54
$1,768.92 		$1,439.78
$1,549.90
$1,666.56
$2,080.94 		$1,751.80
$1,861.92
$1,978.58
$2,392.96 		$312.02
Toc - Plan #5 Quartz
Silver

(HMO) Tiered Choice Plus Silver I306 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 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 		$400.65
$454.73
$512.03
$715.56
$1,087.36 		$707.14
$761.22
$818.52
$1,022.05 		$1,013.63
$1,067.71
$1,125.01
$1,328.54 		$1,320.12
$1,374.20
$1,431.50
$1,635.03 		$306.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.30
$909.46
$1,024.06
$1,431.12
$2,174.72 		$1,107.79
$1,215.95
$1,330.55
$1,737.61 		$1,414.28
$1,522.44
$1,637.04
$2,044.10 		$1,720.77
$1,828.93
$1,943.53
$2,350.59 		$306.49
Toc - Plan #6 Quartz
Silver

(HMO) Quartz One Silver I303 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$447.91
$508.37
$572.42
$799.95
$1,215.60 		$790.55
$851.01
$915.06
$1,142.59 		$1,133.19
$1,193.65
$1,257.70
$1,485.23 		$1,475.83
$1,536.29
$1,600.34
$1,827.87 		$342.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.82
$1,016.74
$1,144.84
$1,599.90
$2,431.20 		$1,238.46
$1,359.38
$1,487.48
$1,942.54 		$1,581.10
$1,702.02
$1,830.12
$2,285.18 		$1,923.74
$2,044.66
$2,172.76
$2,627.82 		$342.64
Toc - Plan #7 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I201 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$344.40
$390.88
$440.13
$615.08
$934.68 		$607.86
$654.34
$703.59
$878.54 		$871.32
$917.80
$967.05
$1,142.00 		$1,134.78
$1,181.26
$1,230.51
$1,405.46 		$263.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.80
$781.76
$880.26
$1,230.16
$1,869.36 		$952.26
$1,045.22
$1,143.72
$1,493.62 		$1,215.72
$1,308.68
$1,407.18
$1,757.08 		$1,479.18
$1,572.14
$1,670.64
$2,020.54 		$263.46
Toc - Plan #8 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I202 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$340.42
$386.37
$435.05
$607.98
$923.89 		$600.84
$646.79
$695.47
$868.40 		$861.26
$907.21
$955.89
$1,128.82 		$1,121.68
$1,167.63
$1,216.31
$1,389.24 		$260.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.84
$772.74
$870.10
$1,215.96
$1,847.78 		$941.26
$1,033.16
$1,130.52
$1,476.38 		$1,201.68
$1,293.58
$1,390.94
$1,736.80 		$1,462.10
$1,554.00
$1,651.36
$1,997.22 		$260.42
Toc - Plan #9 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I204 with Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,050 $6,100 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 		$360.32
$408.96
$460.49
$643.53
$977.90 		$635.96
$684.60
$736.13
$919.17 		$911.60
$960.24
$1,011.77
$1,194.81 		$1,187.24
$1,235.88
$1,287.41
$1,470.45 		$275.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.64
$817.92
$920.98
$1,287.06
$1,955.80 		$996.28
$1,093.56
$1,196.62
$1,562.70 		$1,271.92
$1,369.20
$1,472.26
$1,838.34 		$1,547.56
$1,644.84
$1,747.90
$2,113.98 		$275.64
Toc - Plan #10 Quartz
Gold

(HMO) Tiered Choice Plus Gold I406

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$388.22
$440.62
$496.13
$693.34
$1,053.60 		$685.20
$737.60
$793.11
$990.32 		$982.18
$1,034.58
$1,090.09
$1,287.30 		$1,279.16
$1,331.56
$1,387.07
$1,584.28 		$296.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.44
$881.24
$992.26
$1,386.68
$2,107.20 		$1,073.42
$1,178.22
$1,289.24
$1,683.66 		$1,370.40
$1,475.20
$1,586.22
$1,980.64 		$1,667.38
$1,772.18
$1,883.20
$2,277.62 		$296.98
Toc - Plan #11 Quartz
Gold

(HMO) Tiered Choice Plus Gold I407 Maintenance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,250 $8,500 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 		$442.68
$502.43
$565.74
$790.61
$1,201.42 		$781.33
$841.08
$904.39
$1,129.26 		$1,119.98
$1,179.73
$1,243.04
$1,467.91 		$1,458.63
$1,518.38
$1,581.69
$1,806.56 		$338.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$885.36
$1,004.86
$1,131.48
$1,581.22
$2,402.84 		$1,224.01
$1,343.51
$1,470.13
$1,919.87 		$1,562.66
$1,682.16
$1,808.78
$2,258.52 		$1,901.31
$2,020.81
$2,147.43
$2,597.17 		$338.65
Toc - Plan #12 Quartz
Gold

(HMO) Tiered Choice Plus Gold I409

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$383.10
$434.82
$489.60
$684.21
$1,039.73 		$676.17
$727.89
$782.67
$977.28 		$969.24
$1,020.96
$1,075.74
$1,270.35 		$1,262.31
$1,314.03
$1,368.81
$1,563.42 		$293.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.20
$869.64
$979.20
$1,368.42
$2,079.46 		$1,059.27
$1,162.71
$1,272.27
$1,661.49 		$1,352.34
$1,455.78
$1,565.34
$1,954.56 		$1,645.41
$1,748.85
$1,858.41
$2,247.63 		$293.07
Toc - Plan #13 Quartz
Silver

(HMO) Tiered Choice Plus Silver I305

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$390.78
$443.53
$499.41
$697.92
$1,060.55 		$689.72
$742.47
$798.35
$996.86 		$988.66
$1,041.41
$1,097.29
$1,295.80 		$1,287.60
$1,340.35
$1,396.23
$1,594.74 		$298.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.56
$887.06
$998.82
$1,395.84
$2,121.10 		$1,080.50
$1,186.00
$1,297.76
$1,694.78 		$1,379.44
$1,484.94
$1,596.70
$1,993.72 		$1,678.38
$1,783.88
$1,895.64
$2,292.66 		$298.94
Toc - Plan #14 Quartz
Silver

(HMO) Tiered Choice Plus Silver I306

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$4,250 $8,500 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 		$383.86
$435.67
$490.56
$685.56
$1,041.78 		$677.51
$729.32
$784.21
$979.21 		$971.16
$1,022.97
$1,077.86
$1,272.86 		$1,264.81
$1,316.62
$1,371.51
$1,566.51 		$293.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.72
$871.34
$981.12
$1,371.12
$2,083.56 		$1,061.37
$1,164.99
$1,274.77
$1,664.77 		$1,355.02
$1,458.64
$1,568.42
$1,958.42 		$1,648.67
$1,752.29
$1,862.07
$2,252.07 		$293.65
Toc - Plan #15 Quartz
Silver

(HMO) Quartz One Silver I303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.13
$487.06
$548.42
$766.42
$1,164.65 		$757.41
$815.34
$876.70
$1,094.70 		$1,085.69
$1,143.62
$1,204.98
$1,422.98 		$1,413.97
$1,471.90
$1,533.26
$1,751.26 		$328.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.26
$974.12
$1,096.84
$1,532.84
$2,329.30 		$1,186.54
$1,302.40
$1,425.12
$1,861.12 		$1,514.82
$1,630.68
$1,753.40
$2,189.40 		$1,843.10
$1,958.96
$2,081.68
$2,517.68 		$328.28
Toc - Plan #16 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$329.96
$374.50
$421.68
$589.30
$895.50 		$582.38
$626.92
$674.10
$841.72 		$834.80
$879.34
$926.52
$1,094.14 		$1,087.22
$1,131.76
$1,178.94
$1,346.56 		$252.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.92
$749.00
$843.36
$1,178.60
$1,791.00 		$912.34
$1,001.42
$1,095.78
$1,431.02 		$1,164.76
$1,253.84
$1,348.20
$1,683.44 		$1,417.18
$1,506.26
$1,600.62
$1,935.86 		$252.42
Toc - Plan #17 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$326.15
$370.18
$416.82
$582.50
$885.16 		$575.65
$619.68
$666.32
$832.00 		$825.15
$869.18
$915.82
$1,081.50 		$1,074.65
$1,118.68
$1,165.32
$1,331.00 		$249.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.30
$740.36
$833.64
$1,165.00
$1,770.32 		$901.80
$989.86
$1,083.14
$1,414.50 		$1,151.30
$1,239.36
$1,332.64
$1,664.00 		$1,400.80
$1,488.86
$1,582.14
$1,913.50 		$249.50
Toc - Plan #18 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,050 $6,100 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.22
$391.82
$441.18
$616.55
$936.91 		$609.31
$655.91
$705.27
$880.64 		$873.40
$920.00
$969.36
$1,144.73 		$1,137.49
$1,184.09
$1,233.45
$1,408.82 		$264.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.44
$783.64
$882.36
$1,233.10
$1,873.82 		$954.53
$1,047.73
$1,146.45
$1,497.19 		$1,218.62
$1,311.82
$1,410.54
$1,761.28 		$1,482.71
$1,575.91
$1,674.63
$2,025.37 		$264.09
Toc - Plan #19 Quartz
Gold

(HMO) Tiered Choice Plus Gold I408 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$2,500 $5,000 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 		$414.61
$470.58
$529.87
$740.48
$1,125.24 		$731.78
$787.75
$847.04
$1,057.65 		$1,048.95
$1,104.92
$1,164.21
$1,374.82 		$1,366.12
$1,422.09
$1,481.38
$1,691.99 		$317.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.22
$941.16
$1,059.74
$1,480.96
$2,250.48 		$1,146.39
$1,258.33
$1,376.91
$1,798.13 		$1,463.56
$1,575.50
$1,694.08
$2,115.30 		$1,780.73
$1,892.67
$2,011.25
$2,432.47 		$317.17
Toc - Plan #20 Quartz
Silver

(HMO) Quartz One Silver I304 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$5,250 $10,500 Annual Deductible
$5,250 $10,500 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 		$460.50
$522.66
$588.51
$822.44
$1,249.78 		$812.78
$874.94
$940.79
$1,174.72 		$1,165.06
$1,227.22
$1,293.07
$1,527.00 		$1,517.34
$1,579.50
$1,645.35
$1,879.28 		$352.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.00
$1,045.32
$1,177.02
$1,644.88
$2,499.56 		$1,273.28
$1,397.60
$1,529.30
$1,997.16 		$1,625.56
$1,749.88
$1,881.58
$2,349.44 		$1,977.84
$2,102.16
$2,233.86
$2,701.72 		$352.28
Toc - Plan #21 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I203 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.44
$389.80
$438.91
$613.37
$932.07 		$606.17
$652.53
$701.64
$876.10 		$868.90
$915.26
$964.37
$1,138.83 		$1,131.63
$1,177.99
$1,227.10
$1,401.56 		$262.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.88
$779.60
$877.82
$1,226.74
$1,864.14 		$949.61
$1,042.33
$1,140.55
$1,489.47 		$1,212.34
$1,305.06
$1,403.28
$1,752.20 		$1,475.07
$1,567.79
$1,666.01
$2,014.93 		$262.73
Toc - Plan #22 Quartz
Catastrophic

(HMO) Quartz One Catastrophic I101

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$252.35
$286.41
$322.49
$450.68
$684.86 		$445.39
$479.45
$515.53
$643.72 		$638.43
$672.49
$708.57
$836.76 		$831.47
$865.53
$901.61
$1,029.80 		$193.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.70
$572.82
$644.98
$901.36
$1,369.72 		$697.74
$765.86
$838.02
$1,094.40 		$890.78
$958.90
$1,031.06
$1,287.44 		$1,083.82
$1,151.94
$1,224.10
$1,480.48 		$193.04

ADVERTISEMENT

Dean Health Plan

Local: 1-800-279-1302 | Toll Free: 1-800-279-1302 | TTY: 1-800-279-1302
Toc - Plan #23 Dean Health Plan
Catastrophic

(HMO) Dean Catastrophic Safety Net

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$215.13
$244.17
$274.94
$384.22
$583.87 		$379.71
$408.75
$439.52
$548.80 		$544.29
$573.33
$604.10
$713.38 		$708.87
$737.91
$768.68
$877.96 		$164.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$430.26
$488.34
$549.88
$768.44
$1,167.74 		$594.84
$652.92
$714.46
$933.02 		$759.42
$817.50
$879.04
$1,097.60 		$924.00
$982.08
$1,043.62
$1,262.18 		$164.58
Toc - Plan #24 Dean Health Plan
Silver

(HMO) Dean Silver Copay Plus 4800X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$406.31
$461.16
$519.26
$725.66
$1,102.71 		$717.13
$771.98
$830.08
$1,036.48 		$1,027.95
$1,082.80
$1,140.90
$1,347.30 		$1,338.77
$1,393.62
$1,451.72
$1,658.12 		$310.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.62
$922.32
$1,038.52
$1,451.32
$2,205.42 		$1,123.44
$1,233.14
$1,349.34
$1,762.14 		$1,434.26
$1,543.96
$1,660.16
$2,072.96 		$1,745.08
$1,854.78
$1,970.98
$2,383.78 		$310.82
Toc - Plan #25 Dean Health Plan
Silver

(HMO) Dean Silver Classic 5000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$395.20
$448.55
$505.06
$705.82
$1,072.56 		$697.53
$750.88
$807.39
$1,008.15 		$999.86
$1,053.21
$1,109.72
$1,310.48 		$1,302.19
$1,355.54
$1,412.05
$1,612.81 		$302.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.40
$897.10
$1,010.12
$1,411.64
$2,145.12 		$1,092.73
$1,199.43
$1,312.45
$1,713.97 		$1,395.06
$1,501.76
$1,614.78
$2,016.30 		$1,697.39
$1,804.09
$1,917.11
$2,318.63 		$302.33
Toc - Plan #26 Dean Health Plan
Silver

(HMO) Dean Silver Value Copay 5000X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$412.47
$468.16
$527.14
$736.68
$1,119.45 		$728.01
$783.70
$842.68
$1,052.22 		$1,043.55
$1,099.24
$1,158.22
$1,367.76 		$1,359.09
$1,414.78
$1,473.76
$1,683.30 		$315.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.94
$936.32
$1,054.28
$1,473.36
$2,238.90 		$1,140.48
$1,251.86
$1,369.82
$1,788.90 		$1,456.02
$1,567.40
$1,685.36
$2,104.44 		$1,771.56
$1,882.94
$2,000.90
$2,419.98 		$315.54
Toc - Plan #27 Dean Health Plan
Gold

(HMO) Dean Gold Value Copay 3700X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 Annual Deductible
$3,700 $7,400 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 		$399.12
$453.00
$510.07
$712.82
$1,083.20 		$704.44
$758.32
$815.39
$1,018.14 		$1,009.76
$1,063.64
$1,120.71
$1,323.46 		$1,315.08
$1,368.96
$1,426.03
$1,628.78 		$305.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.24
$906.00
$1,020.14
$1,425.64
$2,166.40 		$1,103.56
$1,211.32
$1,325.46
$1,730.96 		$1,408.88
$1,516.64
$1,630.78
$2,036.28 		$1,714.20
$1,821.96
$1,936.10
$2,341.60 		$305.32
Toc - Plan #28 Dean Health Plan
Bronze

(HMO) Dean Bronze Value Copay 8650X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$263.86
$299.48
$337.22
$471.26
$716.12 		$465.71
$501.33
$539.07
$673.11 		$667.56
$703.18
$740.92
$874.96 		$869.41
$905.03
$942.77
$1,076.81 		$201.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527.72
$598.96
$674.44
$942.52
$1,432.24 		$729.57
$800.81
$876.29
$1,144.37 		$931.42
$1,002.66
$1,078.14
$1,346.22 		$1,133.27
$1,204.51
$1,279.99
$1,548.07 		$201.85
Toc - Plan #29 Dean Health Plan
Silver

(HMO) Dean Silver HSA-E 4500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$389.37
$441.93
$497.61
$695.41
$1,056.75 		$687.24
$739.80
$795.48
$993.28 		$985.11
$1,037.67
$1,093.35
$1,291.15 		$1,282.98
$1,335.54
$1,391.22
$1,589.02 		$297.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.74
$883.86
$995.22
$1,390.82
$2,113.50 		$1,076.61
$1,181.73
$1,293.09
$1,688.69 		$1,374.48
$1,479.60
$1,590.96
$1,986.56 		$1,672.35
$1,777.47
$1,888.83
$2,284.43 		$297.87
Toc - Plan #30 Dean Health Plan
Gold

(HMO) Dean Gold Copay Plus 1500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,100 $10,200 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 		$405.18
$459.88
$517.82
$723.65
$1,099.66 		$715.14
$769.84
$827.78
$1,033.61 		$1,025.10
$1,079.80
$1,137.74
$1,343.57 		$1,335.06
$1,389.76
$1,447.70
$1,653.53 		$309.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.36
$919.76
$1,035.64
$1,447.30
$2,199.32 		$1,120.32
$1,229.72
$1,345.60
$1,757.26 		$1,430.28
$1,539.68
$1,655.56
$2,067.22 		$1,740.24
$1,849.64
$1,965.52
$2,377.18 		$309.96
Toc - Plan #31 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze HSA-E 6950X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$6,950 $13,900 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 		$278.69
$316.31
$356.16
$497.73
$756.35 		$491.88
$529.50
$569.35
$710.92 		$705.07
$742.69
$782.54
$924.11 		$918.26
$955.88
$995.73
$1,137.30 		$213.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.38
$632.62
$712.32
$995.46
$1,512.70 		$770.57
$845.81
$925.51
$1,208.65 		$983.76
$1,059.00
$1,138.70
$1,421.84 		$1,196.95
$1,272.19
$1,351.89
$1,635.03 		$213.19
Toc - Plan #32 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay Plus 8650X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$273.03
$309.89
$348.93
$487.63
$741.00 		$481.90
$518.76
$557.80
$696.50 		$690.77
$727.63
$766.67
$905.37 		$899.64
$936.50
$975.54
$1,114.24 		$208.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.06
$619.78
$697.86
$975.26
$1,482.00 		$754.93
$828.65
$906.73
$1,184.13 		$963.80
$1,037.52
$1,115.60
$1,393.00 		$1,172.67
$1,246.39
$1,324.47
$1,601.87 		$208.87
Toc - Plan #33 Dean Health Plan
Gold

(HMO) Dean Gold Copay Elite 1500X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,100 $10,200 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 		$389.06
$441.59
$497.22
$694.87
$1,055.92 		$686.69
$739.22
$794.85
$992.50 		$984.32
$1,036.85
$1,092.48
$1,290.13 		$1,281.95
$1,334.48
$1,390.11
$1,587.76 		$297.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.12
$883.18
$994.44
$1,389.74
$2,111.84 		$1,075.75
$1,180.81
$1,292.07
$1,687.37 		$1,373.38
$1,478.44
$1,589.70
$1,985.00 		$1,671.01
$1,776.07
$1,887.33
$2,282.63 		$297.63
Toc - Plan #34 Dean Health Plan
Silver

(HMO) Dean Silver Copay Elite 4800X

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$381.91
$433.46
$488.08
$682.08
$1,036.49 		$674.07
$725.62
$780.24
$974.24 		$966.23
$1,017.78
$1,072.40
$1,266.40 		$1,258.39
$1,309.94
$1,364.56
$1,558.56 		$292.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.82
$866.92
$976.16
$1,364.16
$2,072.98 		$1,055.98
$1,159.08
$1,268.32
$1,656.32 		$1,348.14
$1,451.24
$1,560.48
$1,948.48 		$1,640.30
$1,743.40
$1,852.64
$2,240.64 		$292.16

ADVERTISEMENT

Molina Healthcare

Local: 1-888-560-2043 | Toll Free: 1-888-560-2043

Toc - Plan #35 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.94
$524.31
$590.36
$825.03
$1,253.72 		$815.33
$877.70
$943.75
$1,178.42 		$1,168.72
$1,231.09
$1,297.14
$1,531.81 		$1,522.11
$1,584.48
$1,650.53
$1,885.20 		$353.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$923.88
$1,048.62
$1,180.72
$1,650.06
$2,507.44 		$1,277.27
$1,402.01
$1,534.11
$2,003.45 		$1,630.66
$1,755.40
$1,887.50
$2,356.84 		$1,984.05
$2,108.79
$2,240.89
$2,710.23 		$353.39
Toc - Plan #36 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$414.14
$470.05
$529.28
$739.66
$1,123.98 		$730.96
$786.87
$846.10
$1,056.48 		$1,047.78
$1,103.69
$1,162.92
$1,373.30 		$1,364.60
$1,420.51
$1,479.74
$1,690.12 		$316.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.28
$940.10
$1,058.56
$1,479.32
$2,247.96 		$1,145.10
$1,256.92
$1,375.38
$1,796.14 		$1,461.92
$1,573.74
$1,692.20
$2,112.96 		$1,778.74
$1,890.56
$2,009.02
$2,429.78 		$316.82
Toc - Plan #37 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.12
$465.49
$524.14
$732.48
$1,113.07 		$723.86
$779.23
$837.88
$1,046.22 		$1,037.60
$1,092.97
$1,151.62
$1,359.96 		$1,351.34
$1,406.71
$1,465.36
$1,673.70 		$313.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.24
$930.98
$1,048.28
$1,464.96
$2,226.14 		$1,133.98
$1,244.72
$1,362.02
$1,778.70 		$1,447.72
$1,558.46
$1,675.76
$2,092.44 		$1,761.46
$1,872.20
$1,989.50
$2,406.18 		$313.74
Toc - Plan #38 Molina Healthcare
Silver

(HMO) Constant Care Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$402.66
$457.02
$514.60
$719.16
$1,092.83 		$710.70
$765.06
$822.64
$1,027.20 		$1,018.74
$1,073.10
$1,130.68
$1,335.24 		$1,326.78
$1,381.14
$1,438.72
$1,643.28 		$308.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.32
$914.04
$1,029.20
$1,438.32
$2,185.66 		$1,113.36
$1,222.08
$1,337.24
$1,746.36 		$1,421.40
$1,530.12
$1,645.28
$2,054.40 		$1,729.44
$1,838.16
$1,953.32
$2,362.44 		$308.04
Toc - Plan #39 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$455.76
$517.29
$582.46
$813.99
$1,236.94 		$804.42
$865.95
$931.12
$1,162.65 		$1,153.08
$1,214.61
$1,279.78
$1,511.31 		$1,501.74
$1,563.27
$1,628.44
$1,859.97 		$348.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.52
$1,034.58
$1,164.92
$1,627.98
$2,473.88 		$1,260.18
$1,383.24
$1,513.58
$1,976.64 		$1,608.84
$1,731.90
$1,862.24
$2,325.30 		$1,957.50
$2,080.56
$2,210.90
$2,673.96 		$348.66
Toc - Plan #40 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.97
$466.45
$525.22
$733.99
$1,115.37 		$725.36
$780.84
$839.61
$1,048.38 		$1,039.75
$1,095.23
$1,154.00
$1,362.77 		$1,354.14
$1,409.62
$1,468.39
$1,677.16 		$314.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.94
$932.90
$1,050.44
$1,467.98
$2,230.74 		$1,136.33
$1,247.29
$1,364.83
$1,782.37 		$1,450.72
$1,561.68
$1,679.22
$2,096.76 		$1,765.11
$1,876.07
$1,993.61
$2,411.15 		$314.39
Toc - Plan #41 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-560-2043

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.19
$468.98
$528.06
$737.96
$1,121.41 		$729.28
$785.07
$844.15
$1,054.05 		$1,045.37
$1,101.16
$1,160.24
$1,370.14 		$1,361.46
$1,417.25
$1,476.33
$1,686.23 		$316.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.38
$937.96
$1,056.12
$1,475.92
$2,242.82 		$1,142.47
$1,254.05
$1,372.21
$1,792.01 		$1,458.56
$1,570.14
$1,688.30
$2,108.10 		$1,774.65
$1,886.23
$2,004.39
$2,424.19 		$316.09

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442
Toc - Plan #42 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 		$291.61
$330.97
$372.66
$520.80
$791.40 		$514.68
$554.04
$595.73
$743.87 		$737.75
$777.11
$818.80
$966.94 		$960.82
$1,000.18
$1,041.87
$1,190.01 		$223.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.22
$661.94
$745.32
$1,041.60
$1,582.80 		$806.29
$885.01
$968.39
$1,264.67 		$1,029.36
$1,108.08
$1,191.46
$1,487.74 		$1,252.43
$1,331.15
$1,414.53
$1,710.81 		$223.07
Toc - Plan #43 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 		$418.43
$474.90
$534.74
$747.29
$1,135.59 		$738.52
$794.99
$854.83
$1,067.38 		$1,058.61
$1,115.08
$1,174.92
$1,387.47 		$1,378.70
$1,435.17
$1,495.01
$1,707.56 		$320.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.86
$949.80
$1,069.48
$1,494.58
$2,271.18 		$1,156.95
$1,269.89
$1,389.57
$1,814.67 		$1,477.04
$1,589.98
$1,709.66
$2,134.76 		$1,797.13
$1,910.07
$2,029.75
$2,454.85 		$320.09
Toc - Plan #44 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 		$444.28
$504.25
$567.78
$793.47
$1,205.76 		$784.15
$844.12
$907.65
$1,133.34 		$1,124.02
$1,183.99
$1,247.52
$1,473.21 		$1,463.89
$1,523.86
$1,587.39
$1,813.08 		$339.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.56
$1,008.50
$1,135.56
$1,586.94
$2,411.52 		$1,228.43
$1,348.37
$1,475.43
$1,926.81 		$1,568.30
$1,688.24
$1,815.30
$2,266.68 		$1,908.17
$2,028.11
$2,155.17
$2,606.55 		$339.87
Toc - Plan #45 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 		$389.29
$441.83
$497.49
$695.25
$1,056.49 		$687.09
$739.63
$795.29
$993.05 		$984.89
$1,037.43
$1,093.09
$1,290.85 		$1,282.69
$1,335.23
$1,390.89
$1,588.65 		$297.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.58
$883.66
$994.98
$1,390.50
$2,112.98 		$1,076.38
$1,181.46
$1,292.78
$1,688.30 		$1,374.18
$1,479.26
$1,590.58
$1,986.10 		$1,671.98
$1,777.06
$1,888.38
$2,283.90 		$297.80
Toc - Plan #46 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 		$377.97
$428.99
$483.04
$675.04
$1,025.80 		$667.11
$718.13
$772.18
$964.18 		$956.25
$1,007.27
$1,061.32
$1,253.32 		$1,245.39
$1,296.41
$1,350.46
$1,542.46 		$289.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.94
$857.98
$966.08
$1,350.08
$2,051.60 		$1,045.08
$1,147.12
$1,255.22
$1,639.22 		$1,334.22
$1,436.26
$1,544.36
$1,928.36 		$1,623.36
$1,725.40
$1,833.50
$2,217.50 		$289.14
Toc - Plan #47 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 		$420.27
$476.99
$537.09
$750.58
$1,140.58 		$741.77
$798.49
$858.59
$1,072.08 		$1,063.27
$1,119.99
$1,180.09
$1,393.58 		$1,384.77
$1,441.49
$1,501.59
$1,715.08 		$321.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$840.54
$953.98
$1,074.18
$1,501.16
$2,281.16 		$1,162.04
$1,275.48
$1,395.68
$1,822.66 		$1,483.54
$1,596.98
$1,717.18
$2,144.16 		$1,805.04
$1,918.48
$2,038.68
$2,465.66 		$321.50
Toc - Plan #48 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 		$391.76
$444.64
$500.66
$699.67
$1,063.22 		$691.45
$744.33
$800.35
$999.36 		$991.14
$1,044.02
$1,100.04
$1,299.05 		$1,290.83
$1,343.71
$1,399.73
$1,598.74 		$299.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.52
$889.28
$1,001.32
$1,399.34
$2,126.44 		$1,083.21
$1,188.97
$1,301.01
$1,699.03 		$1,382.90
$1,488.66
$1,600.70
$1,998.72 		$1,682.59
$1,788.35
$1,900.39
$2,298.41 		$299.69
Toc - Plan #49 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 		$377.21
$428.12
$482.06
$673.68
$1,023.72 		$665.77
$716.68
$770.62
$962.24 		$954.33
$1,005.24
$1,059.18
$1,250.80 		$1,242.89
$1,293.80
$1,347.74
$1,539.36 		$288.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.42
$856.24
$964.12
$1,347.36
$2,047.44 		$1,042.98
$1,144.80
$1,252.68
$1,635.92 		$1,331.54
$1,433.36
$1,541.24
$1,924.48 		$1,620.10
$1,721.92
$1,829.80
$2,213.04 		$288.56
Toc - Plan #50 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 		$392.88
$445.91
$502.09
$701.67
$1,066.25 		$693.43
$746.46
$802.64
$1,002.22 		$993.98
$1,047.01
$1,103.19
$1,302.77 		$1,294.53
$1,347.56
$1,403.74
$1,603.32 		$300.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.76
$891.82
$1,004.18
$1,403.34
$2,132.50 		$1,086.31
$1,192.37
$1,304.73
$1,703.89 		$1,386.86
$1,492.92
$1,605.28
$2,004.44 		$1,687.41
$1,793.47
$1,905.83
$2,304.99 		$300.55
Toc - Plan #51 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 		$320.89
$364.20
$410.09
$573.09
$870.87 		$566.36
$609.67
$655.56
$818.56 		$811.83
$855.14
$901.03
$1,064.03 		$1,057.30
$1,100.61
$1,146.50
$1,309.50 		$245.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.78
$728.40
$820.18
$1,146.18
$1,741.74 		$887.25
$973.87
$1,065.65
$1,391.65 		$1,132.72
$1,219.34
$1,311.12
$1,637.12 		$1,378.19
$1,464.81
$1,556.59
$1,882.59 		$245.47
Toc - Plan #52 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 		$199.06
$225.93
$254.39
$355.51
$540.23 		$351.34
$378.21
$406.67
$507.79 		$503.62
$530.49
$558.95
$660.07 		$655.90
$682.77
$711.23
$812.35 		$152.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$398.12
$451.86
$508.78
$711.02
$1,080.46 		$550.40
$604.14
$661.06
$863.30 		$702.68
$756.42
$813.34
$1,015.58 		$854.96
$908.70
$965.62
$1,167.86 		$152.28
Toc - Plan #53 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 		$275.27
$312.42
$351.78
$491.61
$747.05 		$485.84
$522.99
$562.35
$702.18 		$696.41
$733.56
$772.92
$912.75 		$906.98
$944.13
$983.49
$1,123.32 		$210.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.54
$624.84
$703.56
$983.22
$1,494.10 		$761.11
$835.41
$914.13
$1,193.79 		$971.68
$1,045.98
$1,124.70
$1,404.36 		$1,182.25
$1,256.55
$1,335.27
$1,614.93 		$210.57
Toc - Plan #54 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 		$283.93
$322.25
$362.85
$507.08
$770.55 		$501.13
$539.45
$580.05
$724.28 		$718.33
$756.65
$797.25
$941.48 		$935.53
$973.85
$1,014.45
$1,158.68 		$217.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.86
$644.50
$725.70
$1,014.16
$1,541.10 		$785.06
$861.70
$942.90
$1,231.36 		$1,002.26
$1,078.90
$1,160.10
$1,448.56 		$1,219.46
$1,296.10
$1,377.30
$1,665.76 		$217.20
Toc - Plan #55 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 		$285.84
$324.42
$365.29
$510.50
$775.75 		$504.50
$543.08
$583.95
$729.16 		$723.16
$761.74
$802.61
$947.82 		$941.82
$980.40
$1,021.27
$1,166.48 		$218.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.68
$648.84
$730.58
$1,021.00
$1,551.50 		$790.34
$867.50
$949.24
$1,239.66 		$1,009.00
$1,086.16
$1,167.90
$1,458.32 		$1,227.66
$1,304.82
$1,386.56
$1,676.98 		$218.66
Toc - Plan #56 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 		$446.21
$506.44
$570.24
$796.91
$1,210.98 		$787.55
$847.78
$911.58
$1,138.25 		$1,128.89
$1,189.12
$1,252.92
$1,479.59 		$1,470.23
$1,530.46
$1,594.26
$1,820.93 		$341.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.42
$1,012.88
$1,140.48
$1,593.82
$2,421.96 		$1,233.76
$1,354.22
$1,481.82
$1,935.16 		$1,575.10
$1,695.56
$1,823.16
$2,276.50 		$1,916.44
$2,036.90
$2,164.50
$2,617.84 		$341.34
Toc - Plan #57 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 		$434.04
$492.62
$554.69
$775.17
$1,177.95 		$766.07
$824.65
$886.72
$1,107.20 		$1,098.10
$1,156.68
$1,218.75
$1,439.23 		$1,430.13
$1,488.71
$1,550.78
$1,771.26 		$332.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.08
$985.24
$1,109.38
$1,550.34
$2,355.90 		$1,200.11
$1,317.27
$1,441.41
$1,882.37 		$1,532.14
$1,649.30
$1,773.44
$2,214.40 		$1,864.17
$1,981.33
$2,105.47
$2,546.43 		$332.03
Toc - Plan #58 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 		$273.44
$310.34
$349.44
$488.34
$742.08 		$482.61
$519.51
$558.61
$697.51 		$691.78
$728.68
$767.78
$906.68 		$900.95
$937.85
$976.95
$1,115.85 		$209.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.88
$620.68
$698.88
$976.68
$1,484.16 		$756.05
$829.85
$908.05
$1,185.85 		$965.22
$1,039.02
$1,117.22
$1,395.02 		$1,174.39
$1,248.19
$1,326.39
$1,604.19 		$209.17
Toc - Plan #59 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 		$281.40
$319.37
$359.61
$502.55
$763.68 		$496.66
$534.63
$574.87
$717.81 		$711.92
$749.89
$790.13
$933.07 		$927.18
$965.15
$1,005.39
$1,148.33 		$215.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.80
$638.74
$719.22
$1,005.10
$1,527.36 		$778.06
$854.00
$934.48
$1,220.36 		$993.32
$1,069.26
$1,149.74
$1,435.62 		$1,208.58
$1,284.52
$1,365.00
$1,650.88 		$215.26
Toc - Plan #60 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 		$320.83
$364.13
$410.00
$572.98
$870.70 		$566.26
$609.56
$655.43
$818.41 		$811.69
$854.99
$900.86
$1,063.84 		$1,057.12
$1,100.42
$1,146.29
$1,309.27 		$245.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.66
$728.26
$820.00
$1,145.96
$1,741.40 		$887.09
$973.69
$1,065.43
$1,391.39 		$1,132.52
$1,219.12
$1,310.86
$1,636.82 		$1,377.95
$1,464.55
$1,556.29
$1,882.25 		$245.43
Toc - Plan #61 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 		$423.45
$480.60
$541.16
$756.26
$1,149.22 		$747.38
$804.53
$865.09
$1,080.19 		$1,071.31
$1,128.46
$1,189.02
$1,404.12 		$1,395.24
$1,452.39
$1,512.95
$1,728.05 		$323.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.90
$961.20
$1,082.32
$1,512.52
$2,298.44 		$1,170.83
$1,285.13
$1,406.25
$1,836.45 		$1,494.76
$1,609.06
$1,730.18
$2,160.38 		$1,818.69
$1,932.99
$2,054.11
$2,484.31 		$323.93
Toc - Plan #62 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 		$394.92
$448.23
$504.70
$705.32
$1,071.80 		$697.03
$750.34
$806.81
$1,007.43 		$999.14
$1,052.45
$1,108.92
$1,309.54 		$1,301.25
$1,354.56
$1,411.03
$1,611.65 		$302.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.84
$896.46
$1,009.40
$1,410.64
$2,143.60 		$1,091.95
$1,198.57
$1,311.51
$1,712.75 		$1,394.06
$1,500.68
$1,613.62
$2,014.86 		$1,696.17
$1,802.79
$1,915.73
$2,316.97 		$302.11
Toc - Plan #63 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 		$392.45
$445.41
$501.53
$700.89
$1,065.07 		$692.66
$745.62
$801.74
$1,001.10 		$992.87
$1,045.83
$1,101.95
$1,301.31 		$1,293.08
$1,346.04
$1,402.16
$1,601.52 		$300.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.90
$890.82
$1,003.06
$1,401.78
$2,130.14 		$1,085.11
$1,191.03
$1,303.27
$1,701.99 		$1,385.32
$1,491.24
$1,603.48
$2,002.20 		$1,685.53
$1,791.45
$1,903.69
$2,302.41 		$300.21
Toc - Plan #64 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 		$381.12
$432.56
$487.06
$680.67
$1,034.34 		$672.67
$724.11
$778.61
$972.22 		$964.22
$1,015.66
$1,070.16
$1,263.77 		$1,255.77
$1,307.21
$1,361.71
$1,555.32 		$291.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.24
$865.12
$974.12
$1,361.34
$2,068.68 		$1,053.79
$1,156.67
$1,265.67
$1,652.89 		$1,345.34
$1,448.22
$1,557.22
$1,944.44 		$1,636.89
$1,739.77
$1,848.77
$2,235.99 		$291.55
Toc - Plan #65 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 		$380.36
$431.70
$486.08
$679.30
$1,032.26 		$671.33
$722.67
$777.05
$970.27 		$962.30
$1,013.64
$1,068.02
$1,261.24 		$1,253.27
$1,304.61
$1,358.99
$1,552.21 		$290.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.72
$863.40
$972.16
$1,358.60
$2,064.52 		$1,051.69
$1,154.37
$1,263.13
$1,649.57 		$1,342.66
$1,445.34
$1,554.10
$1,940.54 		$1,633.63
$1,736.31
$1,845.07
$2,231.51 		$290.97
Toc - Plan #66 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 		$396.04
$449.50
$506.13
$707.31
$1,074.83 		$699.00
$752.46
$809.09
$1,010.27 		$1,001.96
$1,055.42
$1,112.05
$1,313.23 		$1,304.92
$1,358.38
$1,415.01
$1,616.19 		$302.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.08
$899.00
$1,012.26
$1,414.62
$2,149.66 		$1,095.04
$1,201.96
$1,315.22
$1,717.58 		$1,398.00
$1,504.92
$1,618.18
$2,020.54 		$1,700.96
$1,807.88
$1,921.14
$2,323.50 		$302.96
Toc - Plan #67 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 		$323.93
$367.65
$413.98
$578.53
$879.13 		$571.73
$615.45
$661.78
$826.33 		$819.53
$863.25
$909.58
$1,074.13 		$1,067.33
$1,111.05
$1,157.38
$1,321.93 		$247.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.86
$735.30
$827.96
$1,157.06
$1,758.26 		$895.66
$983.10
$1,075.76
$1,404.86 		$1,143.46
$1,230.90
$1,323.56
$1,652.66 		$1,391.26
$1,478.70
$1,571.36
$1,900.46 		$247.80
Toc - Plan #68 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 		$324.01
$367.74
$414.07
$578.66
$879.33 		$571.87
$615.60
$661.93
$826.52 		$819.73
$863.46
$909.79
$1,074.38 		$1,067.59
$1,111.32
$1,157.65
$1,322.24 		$247.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.02
$735.48
$828.14
$1,157.32
$1,758.66 		$895.88
$983.34
$1,076.00
$1,405.18 		$1,143.74
$1,231.20
$1,323.86
$1,653.04 		$1,391.60
$1,479.06
$1,571.72
$1,900.90 		$247.86
Toc - Plan #69 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 		$276.52
$313.84
$353.38
$493.85
$750.45 		$488.05
$525.37
$564.91
$705.38 		$699.58
$736.90
$776.44
$916.91 		$911.11
$948.43
$987.97
$1,128.44 		$211.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.04
$627.68
$706.76
$987.70
$1,500.90 		$764.57
$839.21
$918.29
$1,199.23 		$976.10
$1,050.74
$1,129.82
$1,410.76 		$1,187.63
$1,262.27
$1,341.35
$1,622.29 		$211.53
Toc - Plan #70 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 		$278.35
$315.92
$355.72
$497.12
$755.42 		$491.28
$528.85
$568.65
$710.05 		$704.21
$741.78
$781.58
$922.98 		$917.14
$954.71
$994.51
$1,135.91 		$212.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.70
$631.84
$711.44
$994.24
$1,510.84 		$769.63
$844.77
$924.37
$1,207.17 		$982.56
$1,057.70
$1,137.30
$1,420.10 		$1,195.49
$1,270.63
$1,350.23
$1,633.03 		$212.93
Toc - Plan #71 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 		$287.02
$325.76
$366.80
$512.61
$778.96 		$506.59
$545.33
$586.37
$732.18 		$726.16
$764.90
$805.94
$951.75 		$945.73
$984.47
$1,025.51
$1,171.32 		$219.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.04
$651.52
$733.60
$1,025.22
$1,557.92 		$793.61
$871.09
$953.17
$1,244.79 		$1,013.18
$1,090.66
$1,172.74
$1,464.36 		$1,232.75
$1,310.23
$1,392.31
$1,683.93 		$219.57
Toc - Plan #72 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 		$284.48
$322.87
$363.55
$508.07
$772.05 		$502.10
$540.49
$581.17
$725.69 		$719.72
$758.11
$798.79
$943.31 		$937.34
$975.73
$1,016.41
$1,160.93 		$217.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568.96
$645.74
$727.10
$1,016.14
$1,544.10 		$786.58
$863.36
$944.72
$1,233.76 		$1,004.20
$1,080.98
$1,162.34
$1,451.38 		$1,221.82
$1,298.60
$1,379.96
$1,669.00 		$217.62
Toc - Plan #73 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 		$288.94
$327.93
$369.25
$516.03
$784.15 		$509.97
$548.96
$590.28
$737.06 		$731.00
$769.99
$811.31
$958.09 		$952.03
$991.02
$1,032.34
$1,179.12 		$221.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.88
$655.86
$738.50
$1,032.06
$1,568.30 		$798.91
$876.89
$959.53
$1,253.09 		$1,019.94
$1,097.92
$1,180.56
$1,474.12 		$1,240.97
$1,318.95
$1,401.59
$1,695.15 		$221.03
Toc - Plan #74 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 		$437.23
$496.24
$558.77
$780.87
$1,186.61 		$771.70
$830.71
$893.24
$1,115.34 		$1,106.17
$1,165.18
$1,227.71
$1,449.81 		$1,440.64
$1,499.65
$1,562.18
$1,784.28 		$334.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.46
$992.48
$1,117.54
$1,561.74
$2,373.22 		$1,208.93
$1,326.95
$1,452.01
$1,896.21 		$1,543.40
$1,661.42
$1,786.48
$2,230.68 		$1,877.87
$1,995.89
$2,120.95
$2,565.15 		$334.47
Toc - Plan #75 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 		$449.41
$510.07
$574.34
$802.63
$1,219.68 		$793.20
$853.86
$918.13
$1,146.42 		$1,136.99
$1,197.65
$1,261.92
$1,490.21 		$1,480.78
$1,541.44
$1,605.71
$1,834.00 		$343.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.82
$1,020.14
$1,148.68
$1,605.26
$2,439.36 		$1,242.61
$1,363.93
$1,492.47
$1,949.05 		$1,586.40
$1,707.72
$1,836.26
$2,292.84 		$1,930.19
$2,051.51
$2,180.05
$2,636.63 		$343.79
Toc - Plan #76 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 		$294.71
$334.48
$376.62
$526.33
$799.81 		$520.15
$559.92
$602.06
$751.77 		$745.59
$785.36
$827.50
$977.21 		$971.03
$1,010.80
$1,052.94
$1,202.65 		$225.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.42
$668.96
$753.24
$1,052.66
$1,599.62 		$814.86
$894.40
$978.68
$1,278.10 		$1,040.30
$1,119.84
$1,204.12
$1,503.54 		$1,265.74
$1,345.28
$1,429.56
$1,728.98 		$225.44
Toc - Plan #77 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 		$421.61
$478.52
$538.80
$752.98
$1,144.22 		$744.13
$801.04
$861.32
$1,075.50 		$1,066.65
$1,123.56
$1,183.84
$1,398.02 		$1,389.17
$1,446.08
$1,506.36
$1,720.54 		$322.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.22
$957.04
$1,077.60
$1,505.96
$2,288.44 		$1,165.74
$1,279.56
$1,400.12
$1,828.48 		$1,488.26
$1,602.08
$1,722.64
$2,151.00 		$1,810.78
$1,924.60
$2,045.16
$2,473.52 		$322.52
Toc - Plan #78 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 		$447.48
$507.87
$571.86
$799.17
$1,214.42 		$789.79
$850.18
$914.17
$1,141.48 		$1,132.10
$1,192.49
$1,256.48
$1,483.79 		$1,474.41
$1,534.80
$1,598.79
$1,826.10 		$342.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.96
$1,015.74
$1,143.72
$1,598.34
$2,428.84 		$1,237.27
$1,358.05
$1,486.03
$1,940.65 		$1,579.58
$1,700.36
$1,828.34
$2,282.96 		$1,921.89
$2,042.67
$2,170.65
$2,625.27 		$342.31

ADVERTISEMENT

Group Health Cooperative-SCW

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729 | TTY: 1-608-828-4815
Toc - Plan #79 Group Health Cooperative-SCW
Platinum

(HMO) Platinum 500 Ded/1500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$1,500 $3,000 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 		$405.66
$460.43
$518.44
$724.51
$1,100.96 		$715.99
$770.76
$828.77
$1,034.84 		$1,026.32
$1,081.09
$1,139.10
$1,345.17 		$1,336.65
$1,391.42
$1,449.43
$1,655.50 		$310.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.32
$920.86
$1,036.88
$1,449.02
$2,201.92 		$1,121.65
$1,231.19
$1,347.21
$1,759.35 		$1,431.98
$1,541.52
$1,657.54
$2,069.68 		$1,742.31
$1,851.85
$1,967.87
$2,380.01 		$310.33
Toc - Plan #80 Group Health Cooperative-SCW
Gold

(HMO) Gold 2500 Ded/2500 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$2,500 $5,000 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 		$345.90
$392.59
$442.05
$617.77
$938.75 		$610.51
$657.20
$706.66
$882.38 		$875.12
$921.81
$971.27
$1,146.99 		$1,139.73
$1,186.42
$1,235.88
$1,411.60 		$264.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.80
$785.18
$884.10
$1,235.54
$1,877.50 		$956.41
$1,049.79
$1,148.71
$1,500.15 		$1,221.02
$1,314.40
$1,413.32
$1,764.76 		$1,485.63
$1,579.01
$1,677.93
$2,029.37 		$264.61
Toc - Plan #81 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 4000 Ded/8500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$285.09
$323.58
$364.34
$509.17
$773.72 		$503.18
$541.67
$582.43
$727.26 		$721.27
$759.76
$800.52
$945.35 		$939.36
$977.85
$1,018.61
$1,163.44 		$218.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.18
$647.16
$728.68
$1,018.34
$1,547.44 		$788.27
$865.25
$946.77
$1,236.43 		$1,006.36
$1,083.34
$1,164.86
$1,454.52 		$1,224.45
$1,301.43
$1,382.95
$1,672.61 		$218.09
Toc - Plan #82 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 7050 Ded/7050 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 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 		$282.75
$320.92
$361.36
$504.99
$767.38 		$499.06
$537.23
$577.67
$721.30 		$715.37
$753.54
$793.98
$937.61 		$931.68
$969.85
$1,010.29
$1,153.92 		$216.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.50
$641.84
$722.72
$1,009.98
$1,534.76 		$781.81
$858.15
$939.03
$1,226.29 		$998.12
$1,074.46
$1,155.34
$1,442.60 		$1,214.43
$1,290.77
$1,371.65
$1,658.91 		$216.31
Toc - Plan #83 Group Health Cooperative-SCW
Gold

(HMO) Gold 2500 Ded/6500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$343.92
$390.35
$439.53
$614.24
$933.39 		$607.02
$653.45
$702.63
$877.34 		$870.12
$916.55
$965.73
$1,140.44 		$1,133.22
$1,179.65
$1,228.83
$1,403.54 		$263.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.84
$780.70
$879.06
$1,228.48
$1,866.78 		$950.94
$1,043.80
$1,142.16
$1,491.58 		$1,214.04
$1,306.90
$1,405.26
$1,754.68 		$1,477.14
$1,570.00
$1,668.36
$2,017.78 		$263.10
Toc - Plan #84 Group Health Cooperative-SCW
Gold

(HMO) Gold 1600 Ded/5400 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$5,400 $10,800 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 		$351.38
$398.82
$449.06
$627.56
$953.64 		$620.19
$667.63
$717.87
$896.37 		$889.00
$936.44
$986.68
$1,165.18 		$1,157.81
$1,205.25
$1,255.49
$1,433.99 		$268.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.76
$797.64
$898.12
$1,255.12
$1,907.28 		$971.57
$1,066.45
$1,166.93
$1,523.93 		$1,240.38
$1,335.26
$1,435.74
$1,792.74 		$1,509.19
$1,604.07
$1,704.55
$2,061.55 		$268.81
Toc - Plan #85 Group Health Cooperative-SCW
Silver

(HMO) Silver 4550X Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$398.93
$452.78
$509.83
$712.48
$1,082.69 		$704.11
$757.96
$815.01
$1,017.66 		$1,009.29
$1,063.14
$1,120.19
$1,322.84 		$1,314.47
$1,368.32
$1,425.37
$1,628.02 		$305.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.86
$905.56
$1,019.66
$1,424.96
$2,165.38 		$1,103.04
$1,210.74
$1,324.84
$1,730.14 		$1,408.22
$1,515.92
$1,630.02
$2,035.32 		$1,713.40
$1,821.10
$1,935.20
$2,340.50 		$305.18
Toc - Plan #86 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 6850 Ded/8200 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$8,200 $16,400 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 		$290.89
$330.16
$371.76
$519.53
$789.47 		$513.42
$552.69
$594.29
$742.06 		$735.95
$775.22
$816.82
$964.59 		$958.48
$997.75
$1,039.35
$1,187.12 		$222.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.78
$660.32
$743.52
$1,039.06
$1,578.94 		$804.31
$882.85
$966.05
$1,261.59 		$1,026.84
$1,105.38
$1,188.58
$1,484.12 		$1,249.37
$1,327.91
$1,411.11
$1,706.65 		$222.53
Toc - Plan #87 Group Health Cooperative-SCW
Platinum

(HMO) Platinum No Ded/2000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,000 $4,000 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 		$407.12
$462.08
$520.30
$727.11
$1,104.92 		$718.57
$773.53
$831.75
$1,038.56 		$1,030.02
$1,084.98
$1,143.20
$1,350.01 		$1,341.47
$1,396.43
$1,454.65
$1,661.46 		$311.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.24
$924.16
$1,040.60
$1,454.22
$2,209.84 		$1,125.69
$1,235.61
$1,352.05
$1,765.67 		$1,437.14
$1,547.06
$1,663.50
$2,077.12 		$1,748.59
$1,858.51
$1,974.95
$2,388.57 		$311.45
Toc - Plan #88 Group Health Cooperative-SCW
Bronze

(HMO) Bronze 8700 Ded/8700 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$278.50
$316.09
$355.92
$497.39
$755.83 		$491.55
$529.14
$568.97
$710.44 		$704.60
$742.19
$782.02
$923.49 		$917.65
$955.24
$995.07
$1,136.54 		$213.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.00
$632.18
$711.84
$994.78
$1,511.66 		$770.05
$845.23
$924.89
$1,207.83 		$983.10
$1,058.28
$1,137.94
$1,420.88 		$1,196.15
$1,271.33
$1,350.99
$1,633.93 		$213.05
Toc - Plan #89 Group Health Cooperative-SCW
Silver

(HMO) Silver 4900 Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 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 		$413.90
$469.78
$528.97
$739.23
$1,123.33 		$730.54
$786.42
$845.61
$1,055.87 		$1,047.18
$1,103.06
$1,162.25
$1,372.51 		$1,363.82
$1,419.70
$1,478.89
$1,689.15 		$316.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.80
$939.56
$1,057.94
$1,478.46
$2,246.66 		$1,144.44
$1,256.20
$1,374.58
$1,795.10 		$1,461.08
$1,572.84
$1,691.22
$2,111.74 		$1,777.72
$1,889.48
$2,007.86
$2,428.38 		$316.64
Toc - Plan #90 Group Health Cooperative-SCW
Gold

(HMO) Gold 1500 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$334.58
$379.74
$427.59
$597.55
$908.03 		$590.53
$635.69
$683.54
$853.50 		$846.48
$891.64
$939.49
$1,109.45 		$1,102.43
$1,147.59
$1,195.44
$1,365.40 		$255.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.16
$759.48
$855.18
$1,195.10
$1,816.06 		$925.11
$1,015.43
$1,111.13
$1,451.05 		$1,181.06
$1,271.38
$1,367.08
$1,707.00 		$1,437.01
$1,527.33
$1,623.03
$1,962.95 		$255.95
Toc - Plan #91 Group Health Cooperative-SCW
Silver

(HMO) Silver 8100X Ded/8150 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$7,400 $14,800 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.09
$459.78
$517.71
$723.49
$1,099.41 		$714.99
$769.68
$827.61
$1,033.39 		$1,024.89
$1,079.58
$1,137.51
$1,343.29 		$1,334.79
$1,389.48
$1,447.41
$1,653.19 		$309.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.18
$919.56
$1,035.42
$1,446.98
$2,198.82 		$1,120.08
$1,229.46
$1,345.32
$1,756.88 		$1,429.98
$1,539.36
$1,655.22
$2,066.78 		$1,739.88
$1,849.26
$1,965.12
$2,376.68 		$309.90
Toc - Plan #92 Group Health Cooperative-SCW
Catastrophic

(HMO) Catastrophic 8700 Ded/8700 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$235.72
$267.55
$301.25
$421.00
$639.75 		$416.05
$447.88
$481.58
$601.33 		$596.38
$628.21
$661.91
$781.66 		$776.71
$808.54
$842.24
$961.99 		$180.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$471.44
$535.10
$602.50
$842.00
$1,279.50 		$651.77
$715.43
$782.83
$1,022.33 		$832.10
$895.76
$963.16
$1,202.66 		$1,012.43
$1,076.09
$1,143.49
$1,382.99 		$180.33
Toc - Plan #93 Group Health Cooperative-SCW
Platinum

(HMO) Platinum 1000 Ded/4400 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,400 $8,800 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 		$376.98
$427.87
$481.78
$673.28
$1,023.12 		$665.37
$716.26
$770.17
$961.67 		$953.76
$1,004.65
$1,058.56
$1,250.06 		$1,242.15
$1,293.04
$1,346.95
$1,538.45 		$288.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.96
$855.74
$963.56
$1,346.56
$2,046.24 		$1,042.35
$1,144.13
$1,251.95
$1,634.95 		$1,330.74
$1,432.52
$1,540.34
$1,923.34 		$1,619.13
$1,720.91
$1,828.73
$2,211.73 		$288.39
Toc - Plan #94 Group Health Cooperative-SCW
Gold

(HMO) Gold 4500 Ded/8500 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$325.28
$369.19
$415.70
$580.94
$882.79 		$574.12
$618.03
$664.54
$829.78 		$822.96
$866.87
$913.38
$1,078.62 		$1,071.80
$1,115.71
$1,162.22
$1,327.46 		$248.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.56
$738.38
$831.40
$1,161.88
$1,765.58 		$899.40
$987.22
$1,080.24
$1,410.72 		$1,148.24
$1,236.06
$1,329.08
$1,659.56 		$1,397.08
$1,484.90
$1,577.92
$1,908.40 		$248.84
Toc - Plan #95 Group Health Cooperative-SCW
Silver

(HMO) Silver 8500 Ded/8500 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$412.64
$468.35
$527.36
$736.98
$1,119.91 		$728.31
$784.02
$843.03
$1,052.65 		$1,043.98
$1,099.69
$1,158.70
$1,368.32 		$1,359.65
$1,415.36
$1,474.37
$1,683.99 		$315.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.28
$936.70
$1,054.72
$1,473.96
$2,239.82 		$1,140.95
$1,252.37
$1,370.39
$1,789.63 		$1,456.62
$1,568.04
$1,686.06
$2,105.30 		$1,772.29
$1,883.71
$2,001.73
$2,420.97 		$315.67

‡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 Jefferson County here.

Jefferson County is in “Rating Area 14” of Wisconsin.

Currently, there are 95 plans offered in Rating Area 14.

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