Obamacare 2022 Rates for Ozaukee County

Obamacare > Rates > Wisconsin > Ozaukee 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 Ozaukee 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, 125 Plans and 2022 Rates for Ozaukee County, Wisconsin

Below, you’ll find a summary of the 125 plans for Ozaukee 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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Together with CCHP

Local: 1-844-201-4672 | Toll Free: 1-844-201-4672 | TTY: 1-844-531-4856
Toc - Plan #1 Together with CCHP
Expanded Bronze

(EPO) Together Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$320.11
$363.31
$409.08
$571.69
$868.74 		$564.98
$608.18
$653.95
$816.56 		$809.85
$853.05
$898.82
$1,061.43 		$1,054.72
$1,097.92
$1,143.69
$1,306.30 		$244.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.22
$726.62
$818.16
$1,143.38
$1,737.48 		$885.09
$971.49
$1,063.03
$1,388.25 		$1,129.96
$1,216.36
$1,307.90
$1,633.12 		$1,374.83
$1,461.23
$1,552.77
$1,877.99 		$244.87
Toc - Plan #2 Together with CCHP
Silver

(EPO) Together Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$437.30
$496.32
$558.86
$781.00
$1,186.80 		$771.83
$830.85
$893.39
$1,115.53 		$1,106.36
$1,165.38
$1,227.92
$1,450.06 		$1,440.89
$1,499.91
$1,562.45
$1,784.59 		$334.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.60
$992.64
$1,117.72
$1,562.00
$2,373.60 		$1,209.13
$1,327.17
$1,452.25
$1,896.53 		$1,543.66
$1,661.70
$1,786.78
$2,231.06 		$1,878.19
$1,996.23
$2,121.31
$2,565.59 		$334.53
Toc - Plan #3 Together with CCHP
Silver

(EPO) Together Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$384.39
$436.27
$491.23
$686.50
$1,043.20 		$678.44
$730.32
$785.28
$980.55 		$972.49
$1,024.37
$1,079.33
$1,274.60 		$1,266.54
$1,318.42
$1,373.38
$1,568.65 		$294.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.78
$872.54
$982.46
$1,373.00
$2,086.40 		$1,062.83
$1,166.59
$1,276.51
$1,667.05 		$1,356.88
$1,460.64
$1,570.56
$1,961.10 		$1,650.93
$1,754.69
$1,864.61
$2,255.15 		$294.05
Toc - Plan #4 Together with CCHP
Gold

(EPO) Together Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$450.86
$511.71
$576.18
$805.21
$1,223.59 		$795.76
$856.61
$921.08
$1,150.11 		$1,140.66
$1,201.51
$1,265.98
$1,495.01 		$1,485.56
$1,546.41
$1,610.88
$1,839.91 		$344.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.72
$1,023.42
$1,152.36
$1,610.42
$2,447.18 		$1,246.62
$1,368.32
$1,497.26
$1,955.32 		$1,591.52
$1,713.22
$1,842.16
$2,300.22 		$1,936.42
$2,058.12
$2,187.06
$2,645.12 		$344.90
Toc - Plan #5 Together with CCHP
Expanded Bronze

(EPO) Together Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$352.03
$399.54
$449.88
$628.70
$955.38 		$621.32
$668.83
$719.17
$897.99 		$890.61
$938.12
$988.46
$1,167.28 		$1,159.90
$1,207.41
$1,257.75
$1,436.57 		$269.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.06
$799.08
$899.76
$1,257.40
$1,910.76 		$973.35
$1,068.37
$1,169.05
$1,526.69 		$1,242.64
$1,337.66
$1,438.34
$1,795.98 		$1,511.93
$1,606.95
$1,707.63
$2,065.27 		$269.29
Toc - Plan #6 Together with CCHP
Silver

(EPO) Together Silver Select

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 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 		$421.56
$478.46
$538.74
$752.88
$1,144.08 		$744.04
$800.94
$861.22
$1,075.36 		$1,066.52
$1,123.42
$1,183.70
$1,397.84 		$1,389.00
$1,445.90
$1,506.18
$1,720.32 		$322.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.12
$956.92
$1,077.48
$1,505.76
$2,288.16 		$1,165.60
$1,279.40
$1,399.96
$1,828.24 		$1,488.08
$1,601.88
$1,722.44
$2,150.72 		$1,810.56
$1,924.36
$2,044.92
$2,473.20 		$322.48
Toc - Plan #7 Together with CCHP
Catastrophic

(EPO) Together Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$270.69
$307.22
$345.93
$483.44
$734.63 		$477.76
$514.29
$553.00
$690.51 		$684.83
$721.36
$760.07
$897.58 		$891.90
$928.43
$967.14
$1,104.65 		$207.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.38
$614.44
$691.86
$966.88
$1,469.26 		$748.45
$821.51
$898.93
$1,173.95 		$955.52
$1,028.58
$1,106.00
$1,381.02 		$1,162.59
$1,235.65
$1,313.07
$1,588.09 		$207.07
Toc - Plan #8 Together with CCHP
Expanded Bronze

(EPO) Together Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-201-4672

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 		$352.90
$400.53
$451.00
$630.27
$957.75 		$622.86
$670.49
$720.96
$900.23 		$892.82
$940.45
$990.92
$1,170.19 		$1,162.78
$1,210.41
$1,260.88
$1,440.15 		$269.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.80
$801.06
$902.00
$1,260.54
$1,915.50 		$975.76
$1,071.02
$1,171.96
$1,530.50 		$1,245.72
$1,340.98
$1,441.92
$1,800.46 		$1,515.68
$1,610.94
$1,711.88
$2,070.42 		$269.96

ADVERTISEMENT

Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973
Toc - Plan #9 Quartz
Gold

(HMO) Quartz One With Aurora Health Care Gold I401 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
$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 		$403.28
$457.72
$515.39
$720.25
$1,094.49 		$711.79
$766.23
$823.90
$1,028.76 		$1,020.30
$1,074.74
$1,132.41
$1,337.27 		$1,328.81
$1,383.25
$1,440.92
$1,645.78 		$308.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.56
$915.44
$1,030.78
$1,440.50
$2,188.98 		$1,115.07
$1,223.95
$1,339.29
$1,749.01 		$1,423.58
$1,532.46
$1,647.80
$2,057.52 		$1,732.09
$1,840.97
$1,956.31
$2,366.03 		$308.51
Toc - Plan #10 Quartz
Gold

(HMO) Quartz One With Aurora Health Care Gold I402 Maintenance with Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$400.42
$454.47
$511.73
$715.14
$1,086.72 		$706.74
$760.79
$818.05
$1,021.46 		$1,013.06
$1,067.11
$1,124.37
$1,327.78 		$1,319.38
$1,373.43
$1,430.69
$1,634.10 		$306.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.84
$908.94
$1,023.46
$1,430.28
$2,173.44 		$1,107.16
$1,215.26
$1,329.78
$1,736.60 		$1,413.48
$1,521.58
$1,636.10
$2,042.92 		$1,719.80
$1,827.90
$1,942.42
$2,349.24 		$306.32
Toc - Plan #11 Quartz
Gold

(HMO) Quartz One With Aurora Health Care Gold I405 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
$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 		$398.65
$452.46
$509.47
$711.98
$1,081.93 		$703.62
$757.43
$814.44
$1,016.95 		$1,008.59
$1,062.40
$1,119.41
$1,321.92 		$1,313.56
$1,367.37
$1,424.38
$1,626.89 		$304.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.30
$904.92
$1,018.94
$1,423.96
$2,163.86 		$1,102.27
$1,209.89
$1,323.91
$1,728.93 		$1,407.24
$1,514.86
$1,628.88
$2,033.90 		$1,712.21
$1,819.83
$1,933.85
$2,338.87 		$304.97
Toc - Plan #12 Quartz
Silver

(HMO) Quartz One With Aurora Health Care Silver I301 with Dental

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

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 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 		$402.57
$456.91
$514.48
$718.99
$1,092.57 		$710.53
$764.87
$822.44
$1,026.95 		$1,018.49
$1,072.83
$1,130.40
$1,334.91 		$1,326.45
$1,380.79
$1,438.36
$1,642.87 		$307.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.14
$913.82
$1,028.96
$1,437.98
$2,185.14 		$1,113.10
$1,221.78
$1,336.92
$1,745.94 		$1,421.06
$1,529.74
$1,644.88
$2,053.90 		$1,729.02
$1,837.70
$1,952.84
$2,361.86 		$307.96
Toc - Plan #13 Quartz
Silver

(HMO) Quartz One With Aurora Health Care Silver I302 with Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$404.01
$458.55
$516.32
$721.55
$1,096.47 		$713.07
$767.61
$825.38
$1,030.61 		$1,022.13
$1,076.67
$1,134.44
$1,339.67 		$1,331.19
$1,385.73
$1,443.50
$1,648.73 		$309.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.02
$917.10
$1,032.64
$1,443.10
$2,192.94 		$1,117.08
$1,226.16
$1,341.70
$1,752.16 		$1,426.14
$1,535.22
$1,650.76
$2,061.22 		$1,735.20
$1,844.28
$1,959.82
$2,370.28 		$309.06
Toc - Plan #14 Quartz
Silver

(HMO) Quartz One With Aurora Health Care 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 		$395.03
$448.36
$504.84
$705.52
$1,072.10 		$697.23
$750.56
$807.04
$1,007.72 		$999.43
$1,052.76
$1,109.24
$1,309.92 		$1,301.63
$1,354.96
$1,411.44
$1,612.12 		$302.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.06
$896.72
$1,009.68
$1,411.04
$2,144.20 		$1,092.26
$1,198.92
$1,311.88
$1,713.24 		$1,394.46
$1,501.12
$1,614.08
$2,015.44 		$1,696.66
$1,803.32
$1,916.28
$2,317.64 		$302.20
Toc - Plan #15 Quartz
Expanded Bronze

(HMO) Quartz One With Aurora Health Care 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 		$303.74
$344.74
$388.18
$542.47
$824.34 		$536.10
$577.10
$620.54
$774.83 		$768.46
$809.46
$852.90
$1,007.19 		$1,000.82
$1,041.82
$1,085.26
$1,239.55 		$232.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.48
$689.48
$776.36
$1,084.94
$1,648.68 		$839.84
$921.84
$1,008.72
$1,317.30 		$1,072.20
$1,154.20
$1,241.08
$1,549.66 		$1,304.56
$1,386.56
$1,473.44
$1,782.02 		$232.36
Toc - Plan #16 Quartz
Expanded Bronze

(HMO) Quartz One With Aurora Health Care 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 		$300.24
$340.76
$383.70
$536.21
$814.83 		$529.92
$570.44
$613.38
$765.89 		$759.60
$800.12
$843.06
$995.57 		$989.28
$1,029.80
$1,072.74
$1,225.25 		$229.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.48
$681.52
$767.40
$1,072.42
$1,629.66 		$830.16
$911.20
$997.08
$1,302.10 		$1,059.84
$1,140.88
$1,226.76
$1,531.78 		$1,289.52
$1,370.56
$1,456.44
$1,761.46 		$229.68
Toc - Plan #17 Quartz
Expanded Bronze

(HMO) Quartz One With Aurora Health Care 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 		$317.79
$360.68
$406.13
$567.56
$862.46 		$560.89
$603.78
$649.23
$810.66 		$803.99
$846.88
$892.33
$1,053.76 		$1,047.09
$1,089.98
$1,135.43
$1,296.86 		$243.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.58
$721.36
$812.26
$1,135.12
$1,724.92 		$878.68
$964.46
$1,055.36
$1,378.22 		$1,121.78
$1,207.56
$1,298.46
$1,621.32 		$1,364.88
$1,450.66
$1,541.56
$1,864.42 		$243.10
Toc - Plan #18 Quartz
Gold

(HMO) Quartz One With Aurora Health Care Gold I401

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
$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 		$386.38
$438.53
$493.78
$690.06
$1,048.61 		$681.95
$734.10
$789.35
$985.63 		$977.52
$1,029.67
$1,084.92
$1,281.20 		$1,273.09
$1,325.24
$1,380.49
$1,576.77 		$295.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.76
$877.06
$987.56
$1,380.12
$2,097.22 		$1,068.33
$1,172.63
$1,283.13
$1,675.69 		$1,363.90
$1,468.20
$1,578.70
$1,971.26 		$1,659.47
$1,763.77
$1,874.27
$2,266.83 		$295.57
Toc - Plan #19 Quartz
Gold

(HMO) Quartz One With Aurora Health Care Gold I402 Maintenance

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$383.63
$435.42
$490.28
$685.16
$1,041.17 		$677.11
$728.90
$783.76
$978.64 		$970.59
$1,022.38
$1,077.24
$1,272.12 		$1,264.07
$1,315.86
$1,370.72
$1,565.60 		$293.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.26
$870.84
$980.56
$1,370.32
$2,082.34 		$1,060.74
$1,164.32
$1,274.04
$1,663.80 		$1,354.22
$1,457.80
$1,567.52
$1,957.28 		$1,647.70
$1,751.28
$1,861.00
$2,250.76 		$293.48
Toc - Plan #20 Quartz
Gold

(HMO) Quartz One With Aurora Health Care Gold I405

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
$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 		$381.94
$433.50
$488.12
$682.14
$1,036.58 		$674.12
$725.68
$780.30
$974.32 		$966.30
$1,017.86
$1,072.48
$1,266.50 		$1,258.48
$1,310.04
$1,364.66
$1,558.68 		$292.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.88
$867.00
$976.24
$1,364.28
$2,073.16 		$1,056.06
$1,159.18
$1,268.42
$1,656.46 		$1,348.24
$1,451.36
$1,560.60
$1,948.64 		$1,640.42
$1,743.54
$1,852.78
$2,240.82 		$292.18
Toc - Plan #21 Quartz
Silver

(HMO) Quartz One With Aurora Health Care Silver I301

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

Annual Out of Pocket Expenses:

Individual Family
$4,400 $8,800 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 		$385.70
$437.76
$492.92
$688.85
$1,046.77 		$680.76
$732.82
$787.98
$983.91 		$975.82
$1,027.88
$1,083.04
$1,278.97 		$1,270.88
$1,322.94
$1,378.10
$1,574.03 		$295.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.40
$875.52
$985.84
$1,377.70
$2,093.54 		$1,066.46
$1,170.58
$1,280.90
$1,672.76 		$1,361.52
$1,465.64
$1,575.96
$1,967.82 		$1,656.58
$1,760.70
$1,871.02
$2,262.88 		$295.06
Toc - Plan #22 Quartz
Silver

(HMO) Quartz One With Aurora Health Care Silver I302

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$387.08
$439.33
$494.68
$691.31
$1,050.51 		$683.19
$735.44
$790.79
$987.42 		$979.30
$1,031.55
$1,086.90
$1,283.53 		$1,275.41
$1,327.66
$1,383.01
$1,579.64 		$296.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.16
$878.66
$989.36
$1,382.62
$2,101.02 		$1,070.27
$1,174.77
$1,285.47
$1,678.73 		$1,366.38
$1,470.88
$1,581.58
$1,974.84 		$1,662.49
$1,766.99
$1,877.69
$2,270.95 		$296.11
Toc - Plan #23 Quartz
Silver

(HMO) Quartz One With Aurora Health Care 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 		$378.47
$429.56
$483.68
$675.95
$1,027.16 		$668.00
$719.09
$773.21
$965.48 		$957.53
$1,008.62
$1,062.74
$1,255.01 		$1,247.06
$1,298.15
$1,352.27
$1,544.54 		$289.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.94
$859.12
$967.36
$1,351.90
$2,054.32 		$1,046.47
$1,148.65
$1,256.89
$1,641.43 		$1,336.00
$1,438.18
$1,546.42
$1,930.96 		$1,625.53
$1,727.71
$1,835.95
$2,220.49 		$289.53
Toc - Plan #24 Quartz
Expanded Bronze

(HMO) Quartz One With Aurora Health Care 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 		$291.01
$330.29
$371.90
$519.73
$789.79 		$513.63
$552.91
$594.52
$742.35 		$736.25
$775.53
$817.14
$964.97 		$958.87
$998.15
$1,039.76
$1,187.59 		$222.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.02
$660.58
$743.80
$1,039.46
$1,579.58 		$804.64
$883.20
$966.42
$1,262.08 		$1,027.26
$1,105.82
$1,189.04
$1,484.70 		$1,249.88
$1,328.44
$1,411.66
$1,707.32 		$222.62
Toc - Plan #25 Quartz
Expanded Bronze

(HMO) Quartz One With Aurora Health Care 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 		$287.65
$326.48
$367.61
$513.74
$780.67 		$507.70
$546.53
$587.66
$733.79 		$727.75
$766.58
$807.71
$953.84 		$947.80
$986.63
$1,027.76
$1,173.89 		$220.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.30
$652.96
$735.22
$1,027.48
$1,561.34 		$795.35
$873.01
$955.27
$1,247.53 		$1,015.40
$1,093.06
$1,175.32
$1,467.58 		$1,235.45
$1,313.11
$1,395.37
$1,687.63 		$220.05
Toc - Plan #26 Quartz
Expanded Bronze

(HMO) Quartz One With Aurora Health Care 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 		$304.47
$345.56
$389.10
$543.77
$826.31 		$537.38
$578.47
$622.01
$776.68 		$770.29
$811.38
$854.92
$1,009.59 		$1,003.20
$1,044.29
$1,087.83
$1,242.50 		$232.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.94
$691.12
$778.20
$1,087.54
$1,652.62 		$841.85
$924.03
$1,011.11
$1,320.45 		$1,074.76
$1,156.94
$1,244.02
$1,553.36 		$1,307.67
$1,389.85
$1,476.93
$1,786.27 		$232.91
Toc - Plan #27 Quartz
Gold

(HMO) Quartz One With Aurora Health Care Gold I403 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$3,000 $6,000 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 		$416.40
$472.61
$532.15
$743.68
$1,130.09 		$734.94
$791.15
$850.69
$1,062.22 		$1,053.48
$1,109.69
$1,169.23
$1,380.76 		$1,372.02
$1,428.23
$1,487.77
$1,699.30 		$318.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.80
$945.22
$1,064.30
$1,487.36
$2,260.18 		$1,151.34
$1,263.76
$1,382.84
$1,805.90 		$1,469.88
$1,582.30
$1,701.38
$2,124.44 		$1,788.42
$1,900.84
$2,019.92
$2,442.98 		$318.54
Toc - Plan #28 Quartz
Silver

(HMO) Quartz One With Aurora Health Care 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 		$406.14
$460.96
$519.04
$725.35
$1,102.25 		$716.83
$771.65
$829.73
$1,036.04 		$1,027.52
$1,082.34
$1,140.42
$1,346.73 		$1,338.21
$1,393.03
$1,451.11
$1,657.42 		$310.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.28
$921.92
$1,038.08
$1,450.70
$2,204.50 		$1,122.97
$1,232.61
$1,348.77
$1,761.39 		$1,433.66
$1,543.30
$1,659.46
$2,072.08 		$1,744.35
$1,853.99
$1,970.15
$2,382.77 		$310.69
Toc - Plan #29 Quartz
Expanded Bronze

(HMO) Quartz One With Aurora Health Care 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 		$302.90
$343.78
$387.09
$540.96
$822.05 		$534.61
$575.49
$618.80
$772.67 		$766.32
$807.20
$850.51
$1,004.38 		$998.03
$1,038.91
$1,082.22
$1,236.09 		$231.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.80
$687.56
$774.18
$1,081.92
$1,644.10 		$837.51
$919.27
$1,005.89
$1,313.63 		$1,069.22
$1,150.98
$1,237.60
$1,545.34 		$1,300.93
$1,382.69
$1,469.31
$1,777.05 		$231.71
Toc - Plan #30 Quartz
Catastrophic

(HMO) Quartz One With Aurora Health Care 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 		$222.56
$252.60
$284.42
$397.48
$604.01 		$392.81
$422.85
$454.67
$567.73 		$563.06
$593.10
$624.92
$737.98 		$733.31
$763.35
$795.17
$908.23 		$170.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$445.12
$505.20
$568.84
$794.96
$1,208.02 		$615.37
$675.45
$739.09
$965.21 		$785.62
$845.70
$909.34
$1,135.46 		$955.87
$1,015.95
$1,079.59
$1,305.71 		$170.25

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #31 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 		$436.97
$495.97
$558.45
$780.44
$1,185.95 		$771.26
$830.26
$892.74
$1,114.73 		$1,105.55
$1,164.55
$1,227.03
$1,449.02 		$1,439.84
$1,498.84
$1,561.32
$1,783.31 		$334.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.94
$991.94
$1,116.90
$1,560.88
$2,371.90 		$1,208.23
$1,326.23
$1,451.19
$1,895.17 		$1,542.52
$1,660.52
$1,785.48
$2,229.46 		$1,876.81
$1,994.81
$2,119.77
$2,563.75 		$334.29
Toc - Plan #32 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 		$391.76
$444.64
$500.67
$699.68
$1,063.23 		$691.45
$744.33
$800.36
$999.37 		$991.14
$1,044.02
$1,100.05
$1,299.06 		$1,290.83
$1,343.71
$1,399.74
$1,598.75 		$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
$1,001.34
$1,399.36
$2,126.46 		$1,083.21
$1,188.97
$1,301.03
$1,699.05 		$1,382.90
$1,488.66
$1,600.72
$1,998.74 		$1,682.59
$1,788.35
$1,900.41
$2,298.43 		$299.69
Toc - Plan #33 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 		$387.95
$440.33
$495.80
$692.88
$1,052.90 		$684.73
$737.11
$792.58
$989.66 		$981.51
$1,033.89
$1,089.36
$1,286.44 		$1,278.29
$1,330.67
$1,386.14
$1,583.22 		$296.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.90
$880.66
$991.60
$1,385.76
$2,105.80 		$1,072.68
$1,177.44
$1,288.38
$1,682.54 		$1,369.46
$1,474.22
$1,585.16
$1,979.32 		$1,666.24
$1,771.00
$1,881.94
$2,276.10 		$296.78
Toc - Plan #34 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 		$380.90
$432.32
$486.79
$680.28
$1,033.75 		$672.29
$723.71
$778.18
$971.67 		$963.68
$1,015.10
$1,069.57
$1,263.06 		$1,255.07
$1,306.49
$1,360.96
$1,554.45 		$291.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.80
$864.64
$973.58
$1,360.56
$2,067.50 		$1,053.19
$1,156.03
$1,264.97
$1,651.95 		$1,344.58
$1,447.42
$1,556.36
$1,943.34 		$1,635.97
$1,738.81
$1,847.75
$2,234.73 		$291.39
Toc - Plan #35 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 		$431.13
$489.33
$550.98
$769.99
$1,170.08 		$760.94
$819.14
$880.79
$1,099.80 		$1,090.75
$1,148.95
$1,210.60
$1,429.61 		$1,420.56
$1,478.76
$1,540.41
$1,759.42 		$329.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.26
$978.66
$1,101.96
$1,539.98
$2,340.16 		$1,192.07
$1,308.47
$1,431.77
$1,869.79 		$1,521.88
$1,638.28
$1,761.58
$2,199.60 		$1,851.69
$1,968.09
$2,091.39
$2,529.41 		$329.81
Toc - Plan #36 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 		$388.76
$441.24
$496.83
$694.32
$1,055.08 		$686.16
$738.64
$794.23
$991.72 		$983.56
$1,036.04
$1,091.63
$1,289.12 		$1,280.96
$1,333.44
$1,389.03
$1,586.52 		$297.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.52
$882.48
$993.66
$1,388.64
$2,110.16 		$1,074.92
$1,179.88
$1,291.06
$1,686.04 		$1,372.32
$1,477.28
$1,588.46
$1,983.44 		$1,669.72
$1,774.68
$1,885.86
$2,280.84 		$297.40
Toc - Plan #37 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 		$390.86
$443.63
$499.52
$698.07
$1,060.79 		$689.87
$742.64
$798.53
$997.08 		$988.88
$1,041.65
$1,097.54
$1,296.09 		$1,287.89
$1,340.66
$1,396.55
$1,595.10 		$299.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.72
$887.26
$999.04
$1,396.14
$2,121.58 		$1,080.73
$1,186.27
$1,298.05
$1,695.15 		$1,379.74
$1,485.28
$1,597.06
$1,994.16 		$1,678.75
$1,784.29
$1,896.07
$2,293.17 		$299.01

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1813 | Toll Free: 1-855-748-1813

Toc - Plan #38 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X 0 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$293.80
$333.46
$375.48
$524.73
$797.37 		$518.56
$558.22
$600.24
$749.49 		$743.32
$782.98
$825.00
$974.25 		$968.08
$1,007.74
$1,049.76
$1,199.01 		$224.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.60
$666.92
$750.96
$1,049.46
$1,594.74 		$812.36
$891.68
$975.72
$1,274.22 		$1,037.12
$1,116.44
$1,200.48
$1,498.98 		$1,261.88
$1,341.20
$1,425.24
$1,723.74 		$224.76
Toc - Plan #39 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$290.53
$329.75
$371.30
$518.89
$788.50 		$512.79
$552.01
$593.56
$741.15 		$735.05
$774.27
$815.82
$963.41 		$957.31
$996.53
$1,038.08
$1,185.67 		$222.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.06
$659.50
$742.60
$1,037.78
$1,577.00 		$803.32
$881.76
$964.86
$1,260.04 		$1,025.58
$1,104.02
$1,187.12
$1,482.30 		$1,247.84
$1,326.28
$1,409.38
$1,704.56 		$222.26
Toc - Plan #40 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X 6550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$6,550 $13,100 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 		$281.71
$319.74
$360.03
$503.13
$764.56 		$497.22
$535.25
$575.54
$718.64 		$712.73
$750.76
$791.05
$934.15 		$928.24
$966.27
$1,006.56
$1,149.66 		$215.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.42
$639.48
$720.06
$1,006.26
$1,529.12 		$778.93
$854.99
$935.57
$1,221.77 		$994.44
$1,070.50
$1,151.08
$1,437.28 		$1,209.95
$1,286.01
$1,366.59
$1,652.79 		$215.51
Toc - Plan #41 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$278.72
$316.35
$356.20
$497.79
$756.45 		$491.94
$529.57
$569.42
$711.01 		$705.16
$742.79
$782.64
$924.23 		$918.38
$956.01
$995.86
$1,137.45 		$213.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.44
$632.70
$712.40
$995.58
$1,512.90 		$770.66
$845.92
$925.62
$1,208.80 		$983.88
$1,059.14
$1,138.84
$1,422.02 		$1,197.10
$1,272.36
$1,352.06
$1,635.24 		$213.22
Toc - Plan #42 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$346.60
$393.39
$442.95
$619.03
$940.67 		$611.75
$658.54
$708.10
$884.18 		$876.90
$923.69
$973.25
$1,149.33 		$1,142.05
$1,188.84
$1,238.40
$1,414.48 		$265.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$693.20
$786.78
$885.90
$1,238.06
$1,881.34 		$958.35
$1,051.93
$1,151.05
$1,503.21 		$1,223.50
$1,317.08
$1,416.20
$1,768.36 		$1,488.65
$1,582.23
$1,681.35
$2,033.51 		$265.15
Toc - Plan #43 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338.95
$384.71
$433.18
$605.36
$919.91 		$598.25
$644.01
$692.48
$864.66 		$857.55
$903.31
$951.78
$1,123.96 		$1,116.85
$1,162.61
$1,211.08
$1,383.26 		$259.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.90
$769.42
$866.36
$1,210.72
$1,839.82 		$937.20
$1,028.72
$1,125.66
$1,470.02 		$1,196.50
$1,288.02
$1,384.96
$1,729.32 		$1,455.80
$1,547.32
$1,644.26
$1,988.62 		$259.30
Toc - Plan #44 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X 6550

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$6,550 $13,100 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 		$337.24
$382.77
$430.99
$602.31
$915.27 		$595.23
$640.76
$688.98
$860.30 		$853.22
$898.75
$946.97
$1,118.29 		$1,111.21
$1,156.74
$1,204.96
$1,376.28 		$257.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.48
$765.54
$861.98
$1,204.62
$1,830.54 		$932.47
$1,023.53
$1,119.97
$1,462.61 		$1,190.46
$1,281.52
$1,377.96
$1,720.60 		$1,448.45
$1,539.51
$1,635.95
$1,978.59 		$257.99
Toc - Plan #45 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X 2700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$5,350 $10,700 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 		$364.41
$413.61
$465.72
$650.84
$989.01 		$643.18
$692.38
$744.49
$929.61 		$921.95
$971.15
$1,023.26
$1,208.38 		$1,200.72
$1,249.92
$1,302.03
$1,487.15 		$278.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.82
$827.22
$931.44
$1,301.68
$1,978.02 		$1,007.59
$1,105.99
$1,210.21
$1,580.45 		$1,286.36
$1,384.76
$1,488.98
$1,859.22 		$1,565.13
$1,663.53
$1,767.75
$2,137.99 		$278.77

ADVERTISEMENT

Network Health

Local: 1-920-720-1400x1400 | Toll Free: 1-855-275-1400 | TTY: 1-800-947-3529
Toc - Plan #46 Network Health
Expanded Bronze

(HMO) Prestige Bronze 20 HDHP + Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.11
$416.67
$469.16
$655.65
$996.32 		$647.95
$697.51
$750.00
$936.49 		$928.79
$978.35
$1,030.84
$1,217.33 		$1,209.63
$1,259.19
$1,311.68
$1,498.17 		$280.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.22
$833.34
$938.32
$1,311.30
$1,992.64 		$1,015.06
$1,114.18
$1,219.16
$1,592.14 		$1,295.90
$1,395.02
$1,500.00
$1,872.98 		$1,576.74
$1,675.86
$1,780.84
$2,153.82 		$280.84
Toc - Plan #47 Network Health
Silver

(HMO) Prestige Silver 20 HDHP + Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$562.83
$638.81
$719.29
$1,005.21
$1,527.51 		$993.40
$1,069.38
$1,149.86
$1,435.78 		$1,423.97
$1,499.95
$1,580.43
$1,866.35 		$1,854.54
$1,930.52
$2,011.00
$2,296.92 		$430.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,125.66
$1,277.62
$1,438.58
$2,010.42
$3,055.02 		$1,556.23
$1,708.19
$1,869.15
$2,440.99 		$1,986.80
$2,138.76
$2,299.72
$2,871.56 		$2,417.37
$2,569.33
$2,730.29
$3,302.13 		$430.57
Toc - Plan #48 Network Health
Expanded Bronze

(HMO) Prestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 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 		$355.81
$403.85
$454.73
$635.48
$965.67 		$628.01
$676.05
$726.93
$907.68 		$900.21
$948.25
$999.13
$1,179.88 		$1,172.41
$1,220.45
$1,271.33
$1,452.08 		$272.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.62
$807.70
$909.46
$1,270.96
$1,931.34 		$983.82
$1,079.90
$1,181.66
$1,543.16 		$1,256.02
$1,352.10
$1,453.86
$1,815.36 		$1,528.22
$1,624.30
$1,726.06
$2,087.56 		$272.20
Toc - Plan #49 Network Health
Silver

(HMO) Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

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 		$547.40
$621.30
$699.58
$977.65
$1,485.63 		$966.16
$1,040.06
$1,118.34
$1,396.41 		$1,384.92
$1,458.82
$1,537.10
$1,815.17 		$1,803.68
$1,877.58
$1,955.86
$2,233.93 		$418.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,094.80
$1,242.60
$1,399.16
$1,955.30
$2,971.26 		$1,513.56
$1,661.36
$1,817.92
$2,374.06 		$1,932.32
$2,080.12
$2,236.68
$2,792.82 		$2,351.08
$2,498.88
$2,655.44
$3,211.58 		$418.76
Toc - Plan #50 Network Health
Gold

(HMO) Prestige Gold Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 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 		$507.52
$576.04
$648.61
$906.43
$1,377.40 		$895.77
$964.29
$1,036.86
$1,294.68 		$1,284.02
$1,352.54
$1,425.11
$1,682.93 		$1,672.27
$1,740.79
$1,813.36
$2,071.18 		$388.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,015.04
$1,152.08
$1,297.22
$1,812.86
$2,754.80 		$1,403.29
$1,540.33
$1,685.47
$2,201.11 		$1,791.54
$1,928.58
$2,073.72
$2,589.36 		$2,179.79
$2,316.83
$2,461.97
$2,977.61 		$388.25
Toc - Plan #51 Network Health
Expanded Bronze

(HMO) Prestige Bronze 0 + Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

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 		$325.78
$369.76
$416.35
$581.85
$884.17 		$575.01
$618.99
$665.58
$831.08 		$824.24
$868.22
$914.81
$1,080.31 		$1,073.47
$1,117.45
$1,164.04
$1,329.54 		$249.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.56
$739.52
$832.70
$1,163.70
$1,768.34 		$900.79
$988.75
$1,081.93
$1,412.93 		$1,150.02
$1,237.98
$1,331.16
$1,662.16 		$1,399.25
$1,487.21
$1,580.39
$1,911.39 		$249.23
Toc - Plan #52 Network Health
Gold

(HMO) Prestige Gold 50 + Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,300 $8,600 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 		$518.59
$588.59
$662.75
$926.19
$1,407.43 		$915.31
$985.31
$1,059.47
$1,322.91 		$1,312.03
$1,382.03
$1,456.19
$1,719.63 		$1,708.75
$1,778.75
$1,852.91
$2,116.35 		$396.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,037.18
$1,177.18
$1,325.50
$1,852.38
$2,814.86 		$1,433.90
$1,573.90
$1,722.22
$2,249.10 		$1,830.62
$1,970.62
$2,118.94
$2,645.82 		$2,227.34
$2,367.34
$2,515.66
$3,042.54 		$396.72
Toc - Plan #53 Network Health
Gold

(HMO) Prestige Gold 0 HDHP + Dental + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$523.14
$593.77
$668.58
$934.33
$1,419.81 		$923.35
$993.98
$1,068.79
$1,334.54 		$1,323.56
$1,394.19
$1,469.00
$1,734.75 		$1,723.77
$1,794.40
$1,869.21
$2,134.96 		$400.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,046.28
$1,187.54
$1,337.16
$1,868.66
$2,839.62 		$1,446.49
$1,587.75
$1,737.37
$2,268.87 		$1,846.70
$1,987.96
$2,137.58
$2,669.08 		$2,246.91
$2,388.17
$2,537.79
$3,069.29 		$400.21
Toc - Plan #54 Network Health
Expanded Bronze

(HMO) Signature Prestige Bronze Copay + Dental + Vision + Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-275-1400

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 		$359.87
$408.45
$459.91
$642.72
$976.68 		$635.17
$683.75
$735.21
$918.02 		$910.47
$959.05
$1,010.51
$1,193.32 		$1,185.77
$1,234.35
$1,285.81
$1,468.62 		$275.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.74
$816.90
$919.82
$1,285.44
$1,953.36 		$995.04
$1,092.20
$1,195.12
$1,560.74 		$1,270.34
$1,367.50
$1,470.42
$1,836.04 		$1,545.64
$1,642.80
$1,745.72
$2,111.34 		$275.30

ADVERTISEMENT

WPS Health Plan

Local: 1-920-490-6900 | Toll Free: 1-800-332-6249 | TTY: 1-888-332-0144
Toc - Plan #55 WPS Health Plan
Bronze

(HMO) WPS HMO Bronze $8,700 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$308.44
$350.08
$394.19
$550.87
$837.11 		$544.40
$586.04
$630.15
$786.83 		$780.36
$822.00
$866.11
$1,022.79 		$1,016.32
$1,057.96
$1,102.07
$1,258.75 		$235.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.88
$700.16
$788.38
$1,101.74
$1,674.22 		$852.84
$936.12
$1,024.34
$1,337.70 		$1,088.80
$1,172.08
$1,260.30
$1,573.66 		$1,324.76
$1,408.04
$1,496.26
$1,809.62 		$235.96
Toc - Plan #56 WPS Health Plan
Expanded Bronze

(HMO) WPS HMO Bronze $6,500 with 3 Free PCP Visits | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$320.63
$363.92
$409.77
$572.65
$870.19 		$565.91
$609.20
$655.05
$817.93 		$811.19
$854.48
$900.33
$1,063.21 		$1,056.47
$1,099.76
$1,145.61
$1,308.49 		$245.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.26
$727.84
$819.54
$1,145.30
$1,740.38 		$886.54
$973.12
$1,064.82
$1,390.58 		$1,131.82
$1,218.40
$1,310.10
$1,635.86 		$1,377.10
$1,463.68
$1,555.38
$1,881.14 		$245.28
Toc - Plan #57 WPS Health Plan
Expanded Bronze

(HMO) WPS HMO Bronze $7,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$309.24
$350.99
$395.21
$552.30
$839.28 		$545.81
$587.56
$631.78
$788.87 		$782.38
$824.13
$868.35
$1,025.44 		$1,018.95
$1,060.70
$1,104.92
$1,262.01 		$236.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.48
$701.98
$790.42
$1,104.60
$1,678.56 		$855.05
$938.55
$1,026.99
$1,341.17 		$1,091.62
$1,175.12
$1,263.56
$1,577.74 		$1,328.19
$1,411.69
$1,500.13
$1,814.31 		$236.57
Toc - Plan #58 WPS Health Plan
Silver

(HMO) WPS HMO Silver $7,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$403.66
$458.15
$515.88
$720.94
$1,095.53 		$712.46
$766.95
$824.68
$1,029.74 		$1,021.26
$1,075.75
$1,133.48
$1,338.54 		$1,330.06
$1,384.55
$1,442.28
$1,647.34 		$308.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.32
$916.30
$1,031.76
$1,441.88
$2,191.06 		$1,116.12
$1,225.10
$1,340.56
$1,750.68 		$1,424.92
$1,533.90
$1,649.36
$2,059.48 		$1,733.72
$1,842.70
$1,958.16
$2,368.28 		$308.80
Toc - Plan #59 WPS Health Plan
Silver

(HMO) WPS HMO Silver $4,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$407.23
$462.21
$520.44
$727.31
$1,105.22 		$718.76
$773.74
$831.97
$1,038.84 		$1,030.29
$1,085.27
$1,143.50
$1,350.37 		$1,341.82
$1,396.80
$1,455.03
$1,661.90 		$311.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.46
$924.42
$1,040.88
$1,454.62
$2,210.44 		$1,125.99
$1,235.95
$1,352.41
$1,766.15 		$1,437.52
$1,547.48
$1,663.94
$2,077.68 		$1,749.05
$1,859.01
$1,975.47
$2,389.21 		$311.53
Toc - Plan #60 WPS Health Plan
Silver

(HMO) WPS HMO Silver $5,000 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$422.00
$478.97
$539.32
$753.69
$1,145.31 		$744.83
$801.80
$862.15
$1,076.52 		$1,067.66
$1,124.63
$1,184.98
$1,399.35 		$1,390.49
$1,447.46
$1,507.81
$1,722.18 		$322.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.00
$957.94
$1,078.64
$1,507.38
$2,290.62 		$1,166.83
$1,280.77
$1,401.47
$1,830.21 		$1,489.66
$1,603.60
$1,724.30
$2,153.04 		$1,812.49
$1,926.43
$2,047.13
$2,475.87 		$322.83
Toc - Plan #61 WPS Health Plan
Gold

(HMO) WPS HMO Gold $3,000 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$552.08
$626.61
$705.56
$986.01
$1,498.35 		$974.42
$1,048.95
$1,127.90
$1,408.35 		$1,396.76
$1,471.29
$1,550.24
$1,830.69 		$1,819.10
$1,893.63
$1,972.58
$2,253.03 		$422.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,104.16
$1,253.22
$1,411.12
$1,972.02
$2,996.70 		$1,526.50
$1,675.56
$1,833.46
$2,394.36 		$1,948.84
$2,097.90
$2,255.80
$2,816.70 		$2,371.18
$2,520.24
$2,678.14
$3,239.04 		$422.34
Toc - Plan #62 WPS Health Plan
Catastrophic

(HMO) WPS HMO Catastrophic $8,700 with 3 Free PCP Visits | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$268.15
$304.35
$342.70
$478.92
$727.76 		$473.28
$509.48
$547.83
$684.05 		$678.41
$714.61
$752.96
$889.18 		$883.54
$919.74
$958.09
$1,094.31 		$205.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.30
$608.70
$685.40
$957.84
$1,455.52 		$741.43
$813.83
$890.53
$1,162.97 		$946.56
$1,018.96
$1,095.66
$1,368.10 		$1,151.69
$1,224.09
$1,300.79
$1,573.23 		$205.13
Toc - Plan #63 WPS Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $7,050 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$321.29
$364.66
$410.61
$573.82
$871.98 		$567.08
$610.45
$656.40
$819.61 		$812.87
$856.24
$902.19
$1,065.40 		$1,058.66
$1,102.03
$1,147.98
$1,311.19 		$245.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.58
$729.32
$821.22
$1,147.64
$1,743.96 		$888.37
$975.11
$1,067.01
$1,393.43 		$1,134.16
$1,220.90
$1,312.80
$1,639.22 		$1,379.95
$1,466.69
$1,558.59
$1,885.01 		$245.79
Toc - Plan #64 WPS Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $6,830 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$6,830 $13,660 Annual Deductible
$6,830 $13,660 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.25
$372.56
$419.50
$586.25
$890.87 		$579.36
$623.67
$670.61
$837.36 		$830.47
$874.78
$921.72
$1,088.47 		$1,081.58
$1,125.89
$1,172.83
$1,339.58 		$251.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.50
$745.12
$839.00
$1,172.50
$1,781.74 		$907.61
$996.23
$1,090.11
$1,423.61 		$1,158.72
$1,247.34
$1,341.22
$1,674.72 		$1,409.83
$1,498.45
$1,592.33
$1,925.83 		$251.11
Toc - Plan #65 WPS Health Plan
Expanded Bronze

(HMO) WPS HMO HDHP Bronze $6,000 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$322.02
$365.49
$411.54
$575.13
$873.96 		$568.37
$611.84
$657.89
$821.48 		$814.72
$858.19
$904.24
$1,067.83 		$1,061.07
$1,104.54
$1,150.59
$1,314.18 		$246.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.04
$730.98
$823.08
$1,150.26
$1,747.92 		$890.39
$977.33
$1,069.43
$1,396.61 		$1,136.74
$1,223.68
$1,315.78
$1,642.96 		$1,383.09
$1,470.03
$1,562.13
$1,889.31 		$246.35
Toc - Plan #66 WPS Health Plan
Silver

(HMO) WPS HMO HDHP Silver $4,500 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.14
$465.51
$524.16
$732.51
$1,113.12 		$723.90
$779.27
$837.92
$1,046.27 		$1,037.66
$1,093.03
$1,151.68
$1,360.03 		$1,351.42
$1,406.79
$1,465.44
$1,673.79 		$313.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.28
$931.02
$1,048.32
$1,465.02
$2,226.24 		$1,134.04
$1,244.78
$1,362.08
$1,778.78 		$1,447.80
$1,558.54
$1,675.84
$2,092.54 		$1,761.56
$1,872.30
$1,989.60
$2,406.30 		$313.76
Toc - Plan #67 WPS Health Plan
Silver

(HMO) WPS HMO HDHP Silver $5,250 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$413.00
$468.76
$527.81
$737.62
$1,120.88 		$728.95
$784.71
$843.76
$1,053.57 		$1,044.90
$1,100.66
$1,159.71
$1,369.52 		$1,360.85
$1,416.61
$1,475.66
$1,685.47 		$315.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.00
$937.52
$1,055.62
$1,475.24
$2,241.76 		$1,141.95
$1,253.47
$1,371.57
$1,791.19 		$1,457.90
$1,569.42
$1,687.52
$2,107.14 		$1,773.85
$1,885.37
$2,003.47
$2,423.09 		$315.95
Toc - Plan #68 WPS Health Plan
Silver

(HMO) WPS HMO HDHP Silver $6,125 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$6,125 $12,250 Annual Deductible
$6,125 $12,250 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.98
$447.17
$503.51
$703.65
$1,069.26 		$695.37
$748.56
$804.90
$1,005.04 		$996.76
$1,049.95
$1,106.29
$1,306.43 		$1,298.15
$1,351.34
$1,407.68
$1,607.82 		$301.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.96
$894.34
$1,007.02
$1,407.30
$2,138.52 		$1,089.35
$1,195.73
$1,308.41
$1,708.69 		$1,390.74
$1,497.12
$1,609.80
$2,010.08 		$1,692.13
$1,798.51
$1,911.19
$2,311.47 		$301.39
Toc - Plan #69 WPS Health Plan
Bronze

(POS) WPS POS Bronze $8,700 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

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 		$329.91
$374.45
$421.62
$589.22
$895.38 		$582.29
$626.83
$674.00
$841.60 		$834.67
$879.21
$926.38
$1,093.98 		$1,087.05
$1,131.59
$1,178.76
$1,346.36 		$252.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.82
$748.90
$843.24
$1,178.44
$1,790.76 		$912.20
$1,001.28
$1,095.62
$1,430.82 		$1,164.58
$1,253.66
$1,348.00
$1,683.20 		$1,416.96
$1,506.04
$1,600.38
$1,935.58 		$252.38
Toc - Plan #70 WPS Health Plan
Expanded Bronze

(POS) WPS POS HDHP Bronze $6,000 | Select Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-332-6249

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$344.41
$390.91
$440.16
$615.12
$934.73 		$607.88
$654.38
$703.63
$878.59 		$871.35
$917.85
$967.10
$1,142.06 		$1,134.82
$1,181.32
$1,230.57
$1,405.53 		$263.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.82
$781.82
$880.32
$1,230.24
$1,869.46 		$952.29
$1,045.29
$1,143.79
$1,493.71 		$1,215.76
$1,308.76
$1,407.26
$1,757.18 		$1,479.23
$1,572.23
$1,670.73
$2,020.65 		$263.47

ADVERTISEMENT

Common Ground Healthcare Cooperative

Local: 1-877-514-2442 | Toll Free: 1-877-514-2442 | TTY: 1-844-472-2442
Toc - Plan #71 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 		$286.68
$325.37
$366.36
$511.99
$778.01 		$505.98
$544.67
$585.66
$731.29 		$725.28
$763.97
$804.96
$950.59 		$944.58
$983.27
$1,024.26
$1,169.89 		$219.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.36
$650.74
$732.72
$1,023.98
$1,556.02 		$792.66
$870.04
$952.02
$1,243.28 		$1,011.96
$1,089.34
$1,171.32
$1,462.58 		$1,231.26
$1,308.64
$1,390.62
$1,681.88 		$219.30
Toc - Plan #72 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 		$411.35
$466.87
$525.69
$734.65
$1,116.38 		$726.02
$781.54
$840.36
$1,049.32 		$1,040.69
$1,096.21
$1,155.03
$1,363.99 		$1,355.36
$1,410.88
$1,469.70
$1,678.66 		$314.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.70
$933.74
$1,051.38
$1,469.30
$2,232.76 		$1,137.37
$1,248.41
$1,366.05
$1,783.97 		$1,452.04
$1,563.08
$1,680.72
$2,098.64 		$1,766.71
$1,877.75
$1,995.39
$2,413.31 		$314.67
Toc - Plan #73 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 		$436.77
$495.72
$558.18
$780.05
$1,185.36 		$770.89
$829.84
$892.30
$1,114.17 		$1,105.01
$1,163.96
$1,226.42
$1,448.29 		$1,439.13
$1,498.08
$1,560.54
$1,782.41 		$334.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.54
$991.44
$1,116.36
$1,560.10
$2,370.72 		$1,207.66
$1,325.56
$1,450.48
$1,894.22 		$1,541.78
$1,659.68
$1,784.60
$2,228.34 		$1,875.90
$1,993.80
$2,118.72
$2,562.46 		$334.12
Toc - Plan #74 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 		$382.70
$434.35
$489.08
$683.48
$1,038.62 		$675.46
$727.11
$781.84
$976.24 		$968.22
$1,019.87
$1,074.60
$1,269.00 		$1,260.98
$1,312.63
$1,367.36
$1,561.76 		$292.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.40
$868.70
$978.16
$1,366.96
$2,077.24 		$1,058.16
$1,161.46
$1,270.92
$1,659.72 		$1,350.92
$1,454.22
$1,563.68
$1,952.48 		$1,643.68
$1,746.98
$1,856.44
$2,245.24 		$292.76
Toc - Plan #75 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 		$371.58
$421.73
$474.87
$663.63
$1,008.44 		$655.83
$705.98
$759.12
$947.88 		$940.08
$990.23
$1,043.37
$1,232.13 		$1,224.33
$1,274.48
$1,327.62
$1,516.38 		$284.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.16
$843.46
$949.74
$1,327.26
$2,016.88 		$1,027.41
$1,127.71
$1,233.99
$1,611.51 		$1,311.66
$1,411.96
$1,518.24
$1,895.76 		$1,595.91
$1,696.21
$1,802.49
$2,180.01 		$284.25
Toc - Plan #76 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 		$413.16
$468.92
$528.00
$737.88
$1,121.29 		$729.22
$784.98
$844.06
$1,053.94 		$1,045.28
$1,101.04
$1,160.12
$1,370.00 		$1,361.34
$1,417.10
$1,476.18
$1,686.06 		$316.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.32
$937.84
$1,056.00
$1,475.76
$2,242.58 		$1,142.38
$1,253.90
$1,372.06
$1,791.82 		$1,458.44
$1,569.96
$1,688.12
$2,107.88 		$1,774.50
$1,886.02
$2,004.18
$2,423.94 		$316.06
Toc - Plan #77 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 		$385.14
$437.12
$492.19
$687.84
$1,045.23 		$679.76
$731.74
$786.81
$982.46 		$974.38
$1,026.36
$1,081.43
$1,277.08 		$1,269.00
$1,320.98
$1,376.05
$1,571.70 		$294.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.28
$874.24
$984.38
$1,375.68
$2,090.46 		$1,064.90
$1,168.86
$1,279.00
$1,670.30 		$1,359.52
$1,463.48
$1,573.62
$1,964.92 		$1,654.14
$1,758.10
$1,868.24
$2,259.54 		$294.62
Toc - Plan #78 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 		$370.83
$420.88
$473.90
$662.28
$1,006.40 		$654.51
$704.56
$757.58
$945.96 		$938.19
$988.24
$1,041.26
$1,229.64 		$1,221.87
$1,271.92
$1,324.94
$1,513.32 		$283.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.66
$841.76
$947.80
$1,324.56
$2,012.80 		$1,025.34
$1,125.44
$1,231.48
$1,608.24 		$1,309.02
$1,409.12
$1,515.16
$1,891.92 		$1,592.70
$1,692.80
$1,798.84
$2,175.60 		$283.68
Toc - Plan #79 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 		$386.24
$438.37
$493.60
$689.80
$1,048.21 		$681.70
$733.83
$789.06
$985.26 		$977.16
$1,029.29
$1,084.52
$1,280.72 		$1,272.62
$1,324.75
$1,379.98
$1,576.18 		$295.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.48
$876.74
$987.20
$1,379.60
$2,096.42 		$1,067.94
$1,172.20
$1,282.66
$1,675.06 		$1,363.40
$1,467.66
$1,578.12
$1,970.52 		$1,658.86
$1,763.12
$1,873.58
$2,265.98 		$295.46
Toc - Plan #80 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 		$315.46
$358.04
$403.15
$563.40
$856.14 		$556.78
$599.36
$644.47
$804.72 		$798.10
$840.68
$885.79
$1,046.04 		$1,039.42
$1,082.00
$1,127.11
$1,287.36 		$241.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.92
$716.08
$806.30
$1,126.80
$1,712.28 		$872.24
$957.40
$1,047.62
$1,368.12 		$1,113.56
$1,198.72
$1,288.94
$1,609.44 		$1,354.88
$1,440.04
$1,530.26
$1,850.76 		$241.32
Toc - Plan #81 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 		$195.70
$222.10
$250.09
$349.49
$531.09 		$345.40
$371.80
$399.79
$499.19 		$495.10
$521.50
$549.49
$648.89 		$644.80
$671.20
$699.19
$798.59 		$149.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$391.40
$444.20
$500.18
$698.98
$1,062.18 		$541.10
$593.90
$649.88
$848.68 		$690.80
$743.60
$799.58
$998.38 		$840.50
$893.30
$949.28
$1,148.08 		$149.70
Toc - Plan #82 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 		$270.61
$307.13
$345.83
$483.29
$734.41 		$477.62
$514.14
$552.84
$690.30 		$684.63
$721.15
$759.85
$897.31 		$891.64
$928.16
$966.86
$1,104.32 		$207.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.22
$614.26
$691.66
$966.58
$1,468.82 		$748.23
$821.27
$898.67
$1,173.59 		$955.24
$1,028.28
$1,105.68
$1,380.60 		$1,162.25
$1,235.29
$1,312.69
$1,587.61 		$207.01
Toc - Plan #83 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 		$279.12
$316.80
$356.71
$498.50
$757.52 		$492.64
$530.32
$570.23
$712.02 		$706.16
$743.84
$783.75
$925.54 		$919.68
$957.36
$997.27
$1,139.06 		$213.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$558.24
$633.60
$713.42
$997.00
$1,515.04 		$771.76
$847.12
$926.94
$1,210.52 		$985.28
$1,060.64
$1,140.46
$1,424.04 		$1,198.80
$1,274.16
$1,353.98
$1,637.56 		$213.52
Toc - Plan #84 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 		$281.01
$318.93
$359.11
$501.86
$762.63 		$495.97
$533.89
$574.07
$716.82 		$710.93
$748.85
$789.03
$931.78 		$925.89
$963.81
$1,003.99
$1,146.74 		$214.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.02
$637.86
$718.22
$1,003.72
$1,525.26 		$776.98
$852.82
$933.18
$1,218.68 		$991.94
$1,067.78
$1,148.14
$1,433.64 		$1,206.90
$1,282.74
$1,363.10
$1,648.60 		$214.96
Toc - Plan #85 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 		$438.66
$497.87
$560.60
$783.43
$1,190.50 		$774.23
$833.44
$896.17
$1,119.00 		$1,109.80
$1,169.01
$1,231.74
$1,454.57 		$1,445.37
$1,504.58
$1,567.31
$1,790.14 		$335.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.32
$995.74
$1,121.20
$1,566.86
$2,381.00 		$1,212.89
$1,331.31
$1,456.77
$1,902.43 		$1,548.46
$1,666.88
$1,792.34
$2,238.00 		$1,884.03
$2,002.45
$2,127.91
$2,573.57 		$335.57
Toc - Plan #86 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 		$426.69
$484.29
$545.30
$762.06
$1,158.02 		$753.10
$810.70
$871.71
$1,088.47 		$1,079.51
$1,137.11
$1,198.12
$1,414.88 		$1,405.92
$1,463.52
$1,524.53
$1,741.29 		$326.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.38
$968.58
$1,090.60
$1,524.12
$2,316.04 		$1,179.79
$1,294.99
$1,417.01
$1,850.53 		$1,506.20
$1,621.40
$1,743.42
$2,176.94 		$1,832.61
$1,947.81
$2,069.83
$2,503.35 		$326.41
Toc - Plan #87 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 		$268.81
$305.09
$343.53
$480.08
$729.53 		$474.44
$510.72
$549.16
$685.71 		$680.07
$716.35
$754.79
$891.34 		$885.70
$921.98
$960.42
$1,096.97 		$205.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.62
$610.18
$687.06
$960.16
$1,459.06 		$743.25
$815.81
$892.69
$1,165.79 		$948.88
$1,021.44
$1,098.32
$1,371.42 		$1,154.51
$1,227.07
$1,303.95
$1,577.05 		$205.63
Toc - Plan #88 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 		$276.64
$313.97
$353.53
$494.05
$750.76 		$488.26
$525.59
$565.15
$705.67 		$699.88
$737.21
$776.77
$917.29 		$911.50
$948.83
$988.39
$1,128.91 		$211.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.28
$627.94
$707.06
$988.10
$1,501.52 		$764.90
$839.56
$918.68
$1,199.72 		$976.52
$1,051.18
$1,130.30
$1,411.34 		$1,188.14
$1,262.80
$1,341.92
$1,622.96 		$211.62
Toc - Plan #89 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 		$315.40
$357.97
$403.07
$563.29
$855.97 		$556.67
$599.24
$644.34
$804.56 		$797.94
$840.51
$885.61
$1,045.83 		$1,039.21
$1,081.78
$1,126.88
$1,287.10 		$241.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.80
$715.94
$806.14
$1,126.58
$1,711.94 		$872.07
$957.21
$1,047.41
$1,367.85 		$1,113.34
$1,198.48
$1,288.68
$1,609.12 		$1,354.61
$1,439.75
$1,529.95
$1,850.39 		$241.27
Toc - Plan #90 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 		$416.29
$472.47
$532.00
$743.47
$1,129.77 		$734.74
$790.92
$850.45
$1,061.92 		$1,053.19
$1,109.37
$1,168.90
$1,380.37 		$1,371.64
$1,427.82
$1,487.35
$1,698.82 		$318.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.58
$944.94
$1,064.00
$1,486.94
$2,259.54 		$1,151.03
$1,263.39
$1,382.45
$1,805.39 		$1,469.48
$1,581.84
$1,700.90
$2,123.84 		$1,787.93
$1,900.29
$2,019.35
$2,442.29 		$318.45
Toc - Plan #91 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 		$388.24
$440.64
$496.16
$693.38
$1,053.67 		$685.24
$737.64
$793.16
$990.38 		$982.24
$1,034.64
$1,090.16
$1,287.38 		$1,279.24
$1,331.64
$1,387.16
$1,584.38 		$297.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.48
$881.28
$992.32
$1,386.76
$2,107.34 		$1,073.48
$1,178.28
$1,289.32
$1,683.76 		$1,370.48
$1,475.28
$1,586.32
$1,980.76 		$1,667.48
$1,772.28
$1,883.32
$2,277.76 		$297.00
Toc - Plan #92 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 		$385.81
$437.88
$493.05
$689.03
$1,047.05 		$680.94
$733.01
$788.18
$984.16 		$976.07
$1,028.14
$1,083.31
$1,279.29 		$1,271.20
$1,323.27
$1,378.44
$1,574.42 		$295.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.62
$875.76
$986.10
$1,378.06
$2,094.10 		$1,066.75
$1,170.89
$1,281.23
$1,673.19 		$1,361.88
$1,466.02
$1,576.36
$1,968.32 		$1,657.01
$1,761.15
$1,871.49
$2,263.45 		$295.13
Toc - Plan #93 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 		$374.68
$425.25
$478.82
$669.15
$1,016.85 		$661.30
$711.87
$765.44
$955.77 		$947.92
$998.49
$1,052.06
$1,242.39 		$1,234.54
$1,285.11
$1,338.68
$1,529.01 		$286.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.36
$850.50
$957.64
$1,338.30
$2,033.70 		$1,035.98
$1,137.12
$1,244.26
$1,624.92 		$1,322.60
$1,423.74
$1,530.88
$1,911.54 		$1,609.22
$1,710.36
$1,817.50
$2,198.16 		$286.62
Toc - Plan #94 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 		$373.92
$424.39
$477.86
$667.81
$1,014.80 		$659.96
$710.43
$763.90
$953.85 		$946.00
$996.47
$1,049.94
$1,239.89 		$1,232.04
$1,282.51
$1,335.98
$1,525.93 		$286.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.84
$848.78
$955.72
$1,335.62
$2,029.60 		$1,033.88
$1,134.82
$1,241.76
$1,621.66 		$1,319.92
$1,420.86
$1,527.80
$1,907.70 		$1,605.96
$1,706.90
$1,813.84
$2,193.74 		$286.04
Toc - Plan #95 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 		$389.34
$441.89
$497.57
$695.35
$1,056.65 		$687.18
$739.73
$795.41
$993.19 		$985.02
$1,037.57
$1,093.25
$1,291.03 		$1,282.86
$1,335.41
$1,391.09
$1,588.87 		$297.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.68
$883.78
$995.14
$1,390.70
$2,113.30 		$1,076.52
$1,181.62
$1,292.98
$1,688.54 		$1,374.36
$1,479.46
$1,590.82
$1,986.38 		$1,672.20
$1,777.30
$1,888.66
$2,284.22 		$297.84
Toc - Plan #96 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 		$318.45
$361.43
$406.97
$568.74
$864.26 		$562.06
$605.04
$650.58
$812.35 		$805.67
$848.65
$894.19
$1,055.96 		$1,049.28
$1,092.26
$1,137.80
$1,299.57 		$243.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.90
$722.86
$813.94
$1,137.48
$1,728.52 		$880.51
$966.47
$1,057.55
$1,381.09 		$1,124.12
$1,210.08
$1,301.16
$1,624.70 		$1,367.73
$1,453.69
$1,544.77
$1,868.31 		$243.61
Toc - Plan #97 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 		$318.53
$361.52
$407.07
$568.87
$864.46 		$562.20
$605.19
$650.74
$812.54 		$805.87
$848.86
$894.41
$1,056.21 		$1,049.54
$1,092.53
$1,138.08
$1,299.88 		$243.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.06
$723.04
$814.14
$1,137.74
$1,728.92 		$880.73
$966.71
$1,057.81
$1,381.41 		$1,124.40
$1,210.38
$1,301.48
$1,625.08 		$1,368.07
$1,454.05
$1,545.15
$1,868.75 		$243.67
Toc - Plan #98 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 		$271.84
$308.53
$347.40
$485.50
$737.76 		$479.79
$516.48
$555.35
$693.45 		$687.74
$724.43
$763.30
$901.40 		$895.69
$932.38
$971.25
$1,109.35 		$207.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.68
$617.06
$694.80
$971.00
$1,475.52 		$751.63
$825.01
$902.75
$1,178.95 		$959.58
$1,032.96
$1,110.70
$1,386.90 		$1,167.53
$1,240.91
$1,318.65
$1,594.85 		$207.95
Toc - Plan #99 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 		$273.64
$310.57
$349.70
$488.71
$742.64 		$482.97
$519.90
$559.03
$698.04 		$692.30
$729.23
$768.36
$907.37 		$901.63
$938.56
$977.69
$1,116.70 		$209.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.28
$621.14
$699.40
$977.42
$1,485.28 		$756.61
$830.47
$908.73
$1,186.75 		$965.94
$1,039.80
$1,118.06
$1,396.08 		$1,175.27
$1,249.13
$1,327.39
$1,605.41 		$209.33
Toc - Plan #100 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 		$282.17
$320.25
$360.60
$503.94
$765.78 		$498.02
$536.10
$576.45
$719.79 		$713.87
$751.95
$792.30
$935.64 		$929.72
$967.80
$1,008.15
$1,151.49 		$215.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$564.34
$640.50
$721.20
$1,007.88
$1,531.56 		$780.19
$856.35
$937.05
$1,223.73 		$996.04
$1,072.20
$1,152.90
$1,439.58 		$1,211.89
$1,288.05
$1,368.75
$1,655.43 		$215.85
Toc - Plan #101 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 		$279.67
$317.41
$357.40
$499.47
$758.99 		$493.61
$531.35
$571.34
$713.41 		$707.55
$745.29
$785.28
$927.35 		$921.49
$959.23
$999.22
$1,141.29 		$213.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559.34
$634.82
$714.80
$998.94
$1,517.98 		$773.28
$848.76
$928.74
$1,212.88 		$987.22
$1,062.70
$1,142.68
$1,426.82 		$1,201.16
$1,276.64
$1,356.62
$1,640.76 		$213.94
Toc - Plan #102 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 		$284.05
$322.39
$363.00
$507.30
$770.89 		$501.34
$539.68
$580.29
$724.59 		$718.63
$756.97
$797.58
$941.88 		$935.92
$974.26
$1,014.87
$1,159.17 		$217.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568.10
$644.78
$726.00
$1,014.60
$1,541.78 		$785.39
$862.07
$943.29
$1,231.89 		$1,002.68
$1,079.36
$1,160.58
$1,449.18 		$1,219.97
$1,296.65
$1,377.87
$1,666.47 		$217.29
Toc - Plan #103 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 		$429.83
$487.85
$549.31
$767.66
$1,166.54 		$758.64
$816.66
$878.12
$1,096.47 		$1,087.45
$1,145.47
$1,206.93
$1,425.28 		$1,416.26
$1,474.28
$1,535.74
$1,754.09 		$328.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.66
$975.70
$1,098.62
$1,535.32
$2,333.08 		$1,188.47
$1,304.51
$1,427.43
$1,864.13 		$1,517.28
$1,633.32
$1,756.24
$2,192.94 		$1,846.09
$1,962.13
$2,085.05
$2,521.75 		$328.81
Toc - Plan #104 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 		$441.81
$501.44
$564.62
$789.05
$1,199.04 		$779.79
$839.42
$902.60
$1,127.03 		$1,117.77
$1,177.40
$1,240.58
$1,465.01 		$1,455.75
$1,515.38
$1,578.56
$1,802.99 		$337.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.62
$1,002.88
$1,129.24
$1,578.10
$2,398.08 		$1,221.60
$1,340.86
$1,467.22
$1,916.08 		$1,559.58
$1,678.84
$1,805.20
$2,254.06 		$1,897.56
$2,016.82
$2,143.18
$2,592.04 		$337.98
Toc - Plan #105 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 		$289.72
$328.82
$370.25
$517.42
$786.27 		$511.35
$550.45
$591.88
$739.05 		$732.98
$772.08
$813.51
$960.68 		$954.61
$993.71
$1,035.14
$1,182.31 		$221.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.44
$657.64
$740.50
$1,034.84
$1,572.54 		$801.07
$879.27
$962.13
$1,256.47 		$1,022.70
$1,100.90
$1,183.76
$1,478.10 		$1,244.33
$1,322.53
$1,405.39
$1,699.73 		$221.63
Toc - Plan #106 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 		$414.48
$470.42
$529.69
$740.24
$1,124.86 		$731.55
$787.49
$846.76
$1,057.31 		$1,048.62
$1,104.56
$1,163.83
$1,374.38 		$1,365.69
$1,421.63
$1,480.90
$1,691.45 		$317.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.96
$940.84
$1,059.38
$1,480.48
$2,249.72 		$1,146.03
$1,257.91
$1,376.45
$1,797.55 		$1,463.10
$1,574.98
$1,693.52
$2,114.62 		$1,780.17
$1,892.05
$2,010.59
$2,431.69 		$317.07
Toc - Plan #107 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 		$439.91
$499.28
$562.19
$785.65
$1,193.88 		$776.43
$835.80
$898.71
$1,122.17 		$1,112.95
$1,172.32
$1,235.23
$1,458.69 		$1,449.47
$1,508.84
$1,571.75
$1,795.21 		$336.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.82
$998.56
$1,124.38
$1,571.30
$2,387.76 		$1,216.34
$1,335.08
$1,460.90
$1,907.82 		$1,552.86
$1,671.60
$1,797.42
$2,244.34 		$1,889.38
$2,008.12
$2,133.94
$2,580.86 		$336.52
Toc - Plan #108 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value Premier Gold $1800 Deductible (Dental Exam+ 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 		$425.30
$482.71
$543.52
$759.57
$1,154.25 		$750.65
$808.06
$868.87
$1,084.92 		$1,076.00
$1,133.41
$1,194.22
$1,410.27 		$1,401.35
$1,458.76
$1,519.57
$1,735.62 		$325.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.60
$965.42
$1,087.04
$1,519.14
$2,308.50 		$1,175.95
$1,290.77
$1,412.39
$1,844.49 		$1,501.30
$1,616.12
$1,737.74
$2,169.84 		$1,826.65
$1,941.47
$2,063.09
$2,495.19 		$325.35
Toc - Plan #109 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value Plus Gold $2000 Deductible (Dental Exam+ 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 		$397.27
$450.89
$507.70
$709.51
$1,078.16 		$701.17
$754.79
$811.60
$1,013.41 		$1,005.07
$1,058.69
$1,115.50
$1,317.31 		$1,308.97
$1,362.59
$1,419.40
$1,621.21 		$303.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.54
$901.78
$1,015.40
$1,419.02
$2,156.32 		$1,098.44
$1,205.68
$1,319.30
$1,722.92 		$1,402.34
$1,509.58
$1,623.20
$2,026.82 		$1,706.24
$1,813.48
$1,927.10
$2,330.72 		$303.90
Toc - Plan #110 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value 2 Gold $3000 Deductible (Dental Exam+ 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 		$394.83
$448.12
$504.58
$705.15
$1,071.55 		$696.87
$750.16
$806.62
$1,007.19 		$998.91
$1,052.20
$1,108.66
$1,309.23 		$1,300.95
$1,354.24
$1,410.70
$1,611.27 		$302.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.66
$896.24
$1,009.16
$1,410.30
$2,143.10 		$1,091.70
$1,198.28
$1,311.20
$1,712.34 		$1,393.74
$1,500.32
$1,613.24
$2,014.38 		$1,695.78
$1,802.36
$1,915.28
$2,316.42 		$302.04
Toc - Plan #111 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Value 1 Gold $3600 Deductible (Dental Exam+ 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 		$383.69
$435.48
$490.35
$685.26
$1,041.32 		$677.21
$729.00
$783.87
$978.78 		$970.73
$1,022.52
$1,077.39
$1,272.30 		$1,264.25
$1,316.04
$1,370.91
$1,565.82 		$293.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.38
$870.96
$980.70
$1,370.52
$2,082.64 		$1,060.90
$1,164.48
$1,274.22
$1,664.04 		$1,354.42
$1,458.00
$1,567.74
$1,957.56 		$1,647.94
$1,751.52
$1,861.26
$2,251.08 		$293.52
Toc - Plan #112 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value Plus Silver $4000 Deductible (Dental Exam+ 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 		$382.95
$434.64
$489.40
$683.93
$1,039.30 		$675.90
$727.59
$782.35
$976.88 		$968.85
$1,020.54
$1,075.30
$1,269.83 		$1,261.80
$1,313.49
$1,368.25
$1,562.78 		$292.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.90
$869.28
$978.80
$1,367.86
$2,078.60 		$1,058.85
$1,162.23
$1,271.75
$1,660.81 		$1,351.80
$1,455.18
$1,564.70
$1,953.76 		$1,644.75
$1,748.13
$1,857.65
$2,246.71 		$292.95
Toc - Plan #113 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value Premier Silver $3000 Deductible (Dental Exam+ 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 		$398.36
$452.13
$509.09
$711.45
$1,081.12 		$703.10
$756.87
$813.83
$1,016.19 		$1,007.84
$1,061.61
$1,118.57
$1,320.93 		$1,312.58
$1,366.35
$1,423.31
$1,625.67 		$304.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.72
$904.26
$1,018.18
$1,422.90
$2,162.24 		$1,101.46
$1,209.00
$1,322.92
$1,727.64 		$1,406.20
$1,513.74
$1,627.66
$2,032.38 		$1,710.94
$1,818.48
$1,932.40
$2,337.12 		$304.74
Toc - Plan #114 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value 1 Silver $7500 Deductible (Dental Exam+ 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 		$327.48
$371.68
$418.51
$584.86
$888.76 		$578.00
$622.20
$669.03
$835.38 		$828.52
$872.72
$919.55
$1,085.90 		$1,079.04
$1,123.24
$1,170.07
$1,336.42 		$250.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.96
$743.36
$837.02
$1,169.72
$1,777.52 		$905.48
$993.88
$1,087.54
$1,420.24 		$1,156.00
$1,244.40
$1,338.06
$1,670.76 		$1,406.52
$1,494.92
$1,588.58
$1,921.28 		$250.52
Toc - Plan #115 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Value 2 Silver $6500 Deductible (Dental Exam+ 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 		$327.54
$371.75
$418.59
$584.98
$888.93 		$578.10
$622.31
$669.15
$835.54 		$828.66
$872.87
$919.71
$1,086.10 		$1,079.22
$1,123.43
$1,170.27
$1,336.66 		$250.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.08
$743.50
$837.18
$1,169.96
$1,777.86 		$905.64
$994.06
$1,087.74
$1,420.52 		$1,156.20
$1,244.62
$1,338.30
$1,671.08 		$1,406.76
$1,495.18
$1,588.86
$1,921.64 		$250.56
Toc - Plan #116 Common Ground Healthcare Cooperative
Bronze

(EPO) CGHC Value 1 Bronze $8700 Deductible (Dental Exam+ 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 		$280.86
$318.77
$358.93
$501.60
$762.23 		$495.71
$533.62
$573.78
$716.45 		$710.56
$748.47
$788.63
$931.30 		$925.41
$963.32
$1,003.48
$1,146.15 		$214.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.72
$637.54
$717.86
$1,003.20
$1,524.46 		$776.57
$852.39
$932.71
$1,218.05 		$991.42
$1,067.24
$1,147.56
$1,432.90 		$1,206.27
$1,282.09
$1,362.41
$1,647.75 		$214.85
Toc - Plan #117 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value Plus Bronze $8700 Deductible ($35 PCP Copay+ Dental Exam+ 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 		$282.66
$320.81
$361.23
$504.81
$767.11 		$498.89
$537.04
$577.46
$721.04 		$715.12
$753.27
$793.69
$937.27 		$931.35
$969.50
$1,009.92
$1,153.50 		$216.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.32
$641.62
$722.46
$1,009.62
$1,534.22 		$781.55
$857.85
$938.69
$1,225.85 		$997.78
$1,074.08
$1,154.92
$1,442.08 		$1,214.01
$1,290.31
$1,371.15
$1,658.31 		$216.23
Toc - Plan #118 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value Premier Bronze $8150 Deductible (Dental Exam+ 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 		$291.19
$330.48
$372.12
$520.04
$790.25 		$513.94
$553.23
$594.87
$742.79 		$736.69
$775.98
$817.62
$965.54 		$959.44
$998.73
$1,040.37
$1,188.29 		$222.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.38
$660.96
$744.24
$1,040.08
$1,580.50 		$805.13
$883.71
$966.99
$1,262.83 		$1,027.88
$1,106.46
$1,189.74
$1,485.58 		$1,250.63
$1,329.21
$1,412.49
$1,708.33 		$222.75
Toc - Plan #119 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Value 2 Bronze $6000 Deductible (Dental Exam+ 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 		$288.70
$327.66
$368.94
$515.59
$783.49 		$509.54
$548.50
$589.78
$736.43 		$730.38
$769.34
$810.62
$957.27 		$951.22
$990.18
$1,031.46
$1,178.11 		$220.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.40
$655.32
$737.88
$1,031.18
$1,566.98 		$798.24
$876.16
$958.72
$1,252.02 		$1,019.08
$1,097.00
$1,179.56
$1,472.86 		$1,239.92
$1,317.84
$1,400.40
$1,693.70 		$220.84
Toc - Plan #120 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC HSA Bronze $7000 Deductible (Dental Exam+ 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 		$293.07
$332.62
$374.53
$523.40
$795.36 		$517.26
$556.81
$598.72
$747.59 		$741.45
$781.00
$822.91
$971.78 		$965.64
$1,005.19
$1,047.10
$1,195.97 		$224.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.14
$665.24
$749.06
$1,046.80
$1,590.72 		$810.33
$889.43
$973.25
$1,270.99 		$1,034.52
$1,113.62
$1,197.44
$1,495.18 		$1,258.71
$1,337.81
$1,421.63
$1,719.37 		$224.19
Toc - Plan #121 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC HSA Silver $3000 Deductible (Dental Exam+ 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 		$438.85
$498.08
$560.84
$783.77
$1,191.01 		$774.56
$833.79
$896.55
$1,119.48 		$1,110.27
$1,169.50
$1,232.26
$1,455.19 		$1,445.98
$1,505.21
$1,567.97
$1,790.90 		$335.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$877.70
$996.16
$1,121.68
$1,567.54
$2,382.02 		$1,213.41
$1,331.87
$1,457.39
$1,903.25 		$1,549.12
$1,667.58
$1,793.10
$2,238.96 		$1,884.83
$2,003.29
$2,128.81
$2,574.67 		$335.71
Toc - Plan #122 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC HSA Gold $2800 Deductible (Dental Exam+ 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 		$450.83
$511.68
$576.14
$805.16
$1,223.51 		$795.70
$856.55
$921.01
$1,150.03 		$1,140.57
$1,201.42
$1,265.88
$1,494.90 		$1,485.44
$1,546.29
$1,610.75
$1,839.77 		$344.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.66
$1,023.36
$1,152.28
$1,610.32
$2,447.02 		$1,246.53
$1,368.23
$1,497.15
$1,955.19 		$1,591.40
$1,713.10
$1,842.02
$2,300.06 		$1,936.27
$2,057.97
$2,186.89
$2,644.93 		$344.87
Toc - Plan #123 Common Ground Healthcare Cooperative
Expanded Bronze

(EPO) CGHC Solutions Bronze $0 Deductible (Dental Exam+ 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 		$298.74
$339.06
$381.77
$533.53
$810.75 		$527.27
$567.59
$610.30
$762.06 		$755.80
$796.12
$838.83
$990.59 		$984.33
$1,024.65
$1,067.36
$1,219.12 		$228.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.48
$678.12
$763.54
$1,067.06
$1,621.50 		$826.01
$906.65
$992.07
$1,295.59 		$1,054.54
$1,135.18
$1,220.60
$1,524.12 		$1,283.07
$1,363.71
$1,449.13
$1,752.65 		$228.53
Toc - Plan #124 Common Ground Healthcare Cooperative
Silver

(EPO) CGHC Solutions Silver $0 Deductible (Dental Exam+ 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 		$423.49
$480.65
$541.21
$756.34
$1,149.33 		$747.45
$804.61
$865.17
$1,080.30 		$1,071.41
$1,128.57
$1,189.13
$1,404.26 		$1,395.37
$1,452.53
$1,513.09
$1,728.22 		$323.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.98
$961.30
$1,082.42
$1,512.68
$2,298.66 		$1,170.94
$1,285.26
$1,406.38
$1,836.64 		$1,494.90
$1,609.22
$1,730.34
$2,160.60 		$1,818.86
$1,933.18
$2,054.30
$2,484.56 		$323.96
Toc - Plan #125 Common Ground Healthcare Cooperative
Gold

(EPO) CGHC Solutions Gold $0 Deductible (Dental Exam+ 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 		$448.93
$509.53
$573.72
$801.78
$1,218.38 		$792.36
$852.96
$917.15
$1,145.21 		$1,135.79
$1,196.39
$1,260.58
$1,488.64 		$1,479.22
$1,539.82
$1,604.01
$1,832.07 		$343.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$897.86
$1,019.06
$1,147.44
$1,603.56
$2,436.76 		$1,241.29
$1,362.49
$1,490.87
$1,946.99 		$1,584.72
$1,705.92
$1,834.30
$2,290.42 		$1,928.15
$2,049.35
$2,177.73
$2,633.85 		$343.43

‡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 Ozaukee County here.

Ozaukee County is in “Rating Area 12” of Wisconsin.

Currently, there are 125 plans offered in Rating Area 12.

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2022 Obamacare Plans for Ozaukee County, WI

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