Illinois Obamacare 2022 Rates

Obamacare > Rates > Illinois

Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

ADVERTISEMENT

ADVERTISEMENT

Oscar Health Plan, Inc.

Local:  | Toll Free: 

Toc - Plan #1 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$255.16
$289.61
$326.09
$455.72
$692.50 		$450.36
$484.81
$521.29
$650.92 		$645.56
$680.01
$716.49
$846.12 		$840.76
$875.21
$911.69
$1,041.32 		$195.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510.32
$579.22
$652.18
$911.44
$1,385.00 		$705.52
$774.42
$847.38
$1,106.64 		$900.72
$969.62
$1,042.58
$1,301.84 		$1,095.92
$1,164.82
$1,237.78
$1,497.04 		$195.20
Toc - Plan #2 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$254.23
$288.55
$324.90
$454.05
$689.97 		$448.71
$483.03
$519.38
$648.53 		$643.19
$677.51
$713.86
$843.01 		$837.67
$871.99
$908.34
$1,037.49 		$194.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508.46
$577.10
$649.80
$908.10
$1,379.94 		$702.94
$771.58
$844.28
$1,102.58 		$897.42
$966.06
$1,038.76
$1,297.06 		$1,091.90
$1,160.54
$1,233.24
$1,491.54 		$194.48
Toc - Plan #3 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $0 Ded+PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290.23
$329.41
$370.92
$518.36
$787.69 		$512.26
$551.44
$592.95
$740.39 		$734.29
$773.47
$814.98
$962.42 		$956.32
$995.50
$1,037.01
$1,184.45 		$222.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.46
$658.82
$741.84
$1,036.72
$1,575.38 		$802.49
$880.85
$963.87
$1,258.75 		$1,024.52
$1,102.88
$1,185.90
$1,480.78 		$1,246.55
$1,324.91
$1,407.93
$1,702.81 		$222.03
Toc - Plan #4 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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 		$334.47
$379.62
$427.45
$597.36
$907.75 		$590.34
$635.49
$683.32
$853.23 		$846.21
$891.36
$939.19
$1,109.10 		$1,102.08
$1,147.23
$1,195.06
$1,364.97 		$255.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.94
$759.24
$854.90
$1,194.72
$1,815.50 		$924.81
$1,015.11
$1,110.77
$1,450.59 		$1,180.68
$1,270.98
$1,366.64
$1,706.46 		$1,436.55
$1,526.85
$1,622.51
$1,962.33 		$255.87
Toc - Plan #5 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$329.99
$374.54
$421.73
$589.36
$895.59 		$582.43
$626.98
$674.17
$841.80 		$834.87
$879.42
$926.61
$1,094.24 		$1,087.31
$1,131.86
$1,179.05
$1,346.68 		$252.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.98
$749.08
$843.46
$1,178.72
$1,791.18 		$912.42
$1,001.52
$1,095.90
$1,431.16 		$1,164.86
$1,253.96
$1,348.34
$1,683.60 		$1,417.30
$1,506.40
$1,600.78
$1,936.04 		$252.44
Toc - Plan #6 Oscar Health Plan, Inc.
Catastrophic

(HMO) Secure (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$229.22
$260.16
$292.94
$409.38
$622.09 		$404.57
$435.51
$468.29
$584.73 		$579.92
$610.86
$643.64
$760.08 		$755.27
$786.21
$818.99
$935.43 		$175.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$458.44
$520.32
$585.88
$818.76
$1,244.18 		$633.79
$695.67
$761.23
$994.11 		$809.14
$871.02
$936.58
$1,169.46 		$984.49
$1,046.37
$1,111.93
$1,344.81 		$175.35
Toc - Plan #7 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $0 Ded+Specialist Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$290.31
$329.50
$371.01
$518.48
$787.89 		$512.39
$551.58
$593.09
$740.56 		$734.47
$773.66
$815.17
$962.64 		$956.55
$995.74
$1,037.25
$1,184.72 		$222.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.62
$659.00
$742.02
$1,036.96
$1,575.78 		$802.70
$881.08
$964.10
$1,259.04 		$1,024.78
$1,103.16
$1,186.18
$1,481.12 		$1,246.86
$1,325.24
$1,408.26
$1,703.20 		$222.08
Toc - Plan #8 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$352.34
$399.90
$450.29
$629.28
$956.25 		$621.88
$669.44
$719.83
$898.82 		$891.42
$938.98
$989.37
$1,168.36 		$1,160.96
$1,208.52
$1,258.91
$1,437.90 		$269.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.68
$799.80
$900.58
$1,258.56
$1,912.50 		$974.22
$1,069.34
$1,170.12
$1,528.10 		$1,243.76
$1,338.88
$1,439.66
$1,797.64 		$1,513.30
$1,608.42
$1,709.20
$2,067.18 		$269.54
Toc - Plan #9 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Simple- HSA (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269.07
$305.39
$343.87
$480.56
$730.25 		$474.91
$511.23
$549.71
$686.40 		$680.75
$717.07
$755.55
$892.24 		$886.59
$922.91
$961.39
$1,098.08 		$205.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538.14
$610.78
$687.74
$961.12
$1,460.50 		$743.98
$816.62
$893.58
$1,166.96 		$949.82
$1,022.46
$1,099.42
$1,372.80 		$1,155.66
$1,228.30
$1,305.26
$1,578.64 		$205.84
Toc - Plan #10 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- Specialist Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 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 		$329.96
$374.50
$421.69
$589.31
$895.51 		$582.38
$626.92
$674.11
$841.73 		$834.80
$879.34
$926.53
$1,094.15 		$1,087.22
$1,131.76
$1,178.95
$1,346.57 		$252.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.92
$749.00
$843.38
$1,178.62
$1,791.02 		$912.34
$1,001.42
$1,095.80
$1,431.04 		$1,164.76
$1,253.84
$1,348.22
$1,683.46 		$1,417.18
$1,506.26
$1,600.64
$1,935.88 		$252.42
Toc - Plan #11 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic- $0 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$347.48
$394.39
$444.08
$620.60
$943.06 		$613.30
$660.21
$709.90
$886.42 		$879.12
$926.03
$975.72
$1,152.24 		$1,144.94
$1,191.85
$1,241.54
$1,418.06 		$265.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.96
$788.78
$888.16
$1,241.20
$1,886.12 		$960.78
$1,054.60
$1,153.98
$1,507.02 		$1,226.60
$1,320.42
$1,419.80
$1,772.84 		$1,492.42
$1,586.24
$1,685.62
$2,038.66 		$265.82
Toc - Plan #12 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic- Low Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.80
$434.48
$489.22
$683.69
$1,038.93 		$675.64
$727.32
$782.06
$976.53 		$968.48
$1,020.16
$1,074.90
$1,269.37 		$1,261.32
$1,313.00
$1,367.74
$1,562.21 		$292.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.60
$868.96
$978.44
$1,367.38
$2,077.86 		$1,058.44
$1,161.80
$1,271.28
$1,660.22 		$1,351.28
$1,454.64
$1,564.12
$1,953.06 		$1,644.12
$1,747.48
$1,856.96
$2,245.90 		$292.84
Toc - Plan #13 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $0 PCP (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$255.81
$290.35
$326.93
$456.88
$694.28 		$451.51
$486.05
$522.63
$652.58 		$647.21
$681.75
$718.33
$848.28 		$842.91
$877.45
$914.03
$1,043.98 		$195.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$511.62
$580.70
$653.86
$913.76
$1,388.56 		$707.32
$776.40
$849.56
$1,109.46 		$903.02
$972.10
$1,045.26
$1,305.16 		$1,098.72
$1,167.80
$1,240.96
$1,500.86 		$195.70
Toc - Plan #14 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $3000 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.35
$312.52
$351.90
$491.78
$747.30 		$485.99
$523.16
$562.54
$702.42 		$696.63
$733.80
$773.18
$913.06 		$907.27
$944.44
$983.82
$1,123.70 		$210.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$550.70
$625.04
$703.80
$983.56
$1,494.60 		$761.34
$835.68
$914.44
$1,194.20 		$971.98
$1,046.32
$1,125.08
$1,404.84 		$1,182.62
$1,256.96
$1,335.72
$1,615.48 		$210.64
Toc - Plan #15 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $4700 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$256.08
$290.65
$327.27
$457.35
$694.99 		$451.98
$486.55
$523.17
$653.25 		$647.88
$682.45
$719.07
$849.15 		$843.78
$878.35
$914.97
$1,045.05 		$195.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$512.16
$581.30
$654.54
$914.70
$1,389.98 		$708.06
$777.20
$850.44
$1,110.60 		$903.96
$973.10
$1,046.34
$1,306.50 		$1,099.86
$1,169.00
$1,242.24
$1,502.40 		$195.90
Toc - Plan #16 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,375 $16,750 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.68
$373.05
$420.05
$587.02
$892.03 		$580.12
$624.49
$671.49
$838.46 		$831.56
$875.93
$922.93
$1,089.90 		$1,083.00
$1,127.37
$1,174.37
$1,341.34 		$251.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.36
$746.10
$840.10
$1,174.04
$1,784.06 		$908.80
$997.54
$1,091.54
$1,425.48 		$1,160.24
$1,248.98
$1,342.98
$1,676.92 		$1,411.68
$1,500.42
$1,594.42
$1,928.36 		$251.44
Toc - Plan #17 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- Specialist Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$348.92
$396.03
$445.92
$623.17
$946.97 		$615.84
$662.95
$712.84
$890.09 		$882.76
$929.87
$979.76
$1,157.01 		$1,149.68
$1,196.79
$1,246.68
$1,423.93 		$266.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.84
$792.06
$891.84
$1,246.34
$1,893.94 		$964.76
$1,058.98
$1,158.76
$1,513.26 		$1,231.68
$1,325.90
$1,425.68
$1,780.18 		$1,498.60
$1,592.82
$1,692.60
$2,047.10 		$266.92
Toc - Plan #18 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic- Low Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$339.14
$384.93
$433.43
$605.71
$920.44 		$598.58
$644.37
$692.87
$865.15 		$858.02
$903.81
$952.31
$1,124.59 		$1,117.46
$1,163.25
$1,211.75
$1,384.03 		$259.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.28
$769.86
$866.86
$1,211.42
$1,840.88 		$937.72
$1,029.30
$1,126.30
$1,470.86 		$1,197.16
$1,288.74
$1,385.74
$1,730.30 		$1,456.60
$1,548.18
$1,645.18
$1,989.74 		$259.44
Toc - Plan #19 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- $0 PCP (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$345.88
$392.58
$442.04
$617.75
$938.72 		$610.48
$657.18
$706.64
$882.35 		$875.08
$921.78
$971.24
$1,146.95 		$1,139.68
$1,186.38
$1,235.84
$1,411.55 		$264.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.76
$785.16
$884.08
$1,235.50
$1,877.44 		$956.36
$1,049.76
$1,148.68
$1,500.10 		$1,220.96
$1,314.36
$1,413.28
$1,764.70 		$1,485.56
$1,578.96
$1,677.88
$2,029.30 		$264.60
Toc - Plan #20 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- HSA (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$4,500 $9,000 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 		$349.10
$396.23
$446.15
$623.49
$947.46 		$616.16
$663.29
$713.21
$890.55 		$883.22
$930.35
$980.27
$1,157.61 		$1,150.28
$1,197.41
$1,247.33
$1,424.67 		$267.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.20
$792.46
$892.30
$1,246.98
$1,894.92 		$965.26
$1,059.52
$1,159.36
$1,514.04 		$1,232.32
$1,326.58
$1,426.42
$1,781.10 		$1,499.38
$1,593.64
$1,693.48
$2,048.16 		$267.06
Toc - Plan #21 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- $0 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338.46
$384.15
$432.55
$604.48
$918.57 		$597.38
$643.07
$691.47
$863.40 		$856.30
$901.99
$950.39
$1,122.32 		$1,115.22
$1,160.91
$1,209.31
$1,381.24 		$258.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$676.92
$768.30
$865.10
$1,208.96
$1,837.14 		$935.84
$1,027.22
$1,124.02
$1,467.88 		$1,194.76
$1,286.14
$1,382.94
$1,726.80 		$1,453.68
$1,545.06
$1,641.86
$1,985.72 		$258.92
Toc - Plan #22 Oscar Health Plan, Inc.
Gold

(HMO) Gold Simple (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,550 $13,100 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 		$356.70
$404.86
$455.87
$637.07
$968.09 		$629.58
$677.74
$728.75
$909.95 		$902.46
$950.62
$1,001.63
$1,182.83 		$1,175.34
$1,223.50
$1,274.51
$1,455.71 		$272.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.40
$809.72
$911.74
$1,274.14
$1,936.18 		$986.28
$1,082.60
$1,184.62
$1,547.02 		$1,259.16
$1,355.48
$1,457.50
$1,819.90 		$1,532.04
$1,628.36
$1,730.38
$2,092.78 		$272.88
Toc - Plan #23 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic- $0 PCP (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$6,750 $13,500 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 		$358.90
$407.35
$458.67
$641.00
$974.06 		$633.46
$681.91
$733.23
$915.56 		$908.02
$956.47
$1,007.79
$1,190.12 		$1,182.58
$1,231.03
$1,282.35
$1,464.68 		$274.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.80
$814.70
$917.34
$1,282.00
$1,948.12 		$992.36
$1,089.26
$1,191.90
$1,556.56 		$1,266.92
$1,363.82
$1,466.46
$1,831.12 		$1,541.48
$1,638.38
$1,741.02
$2,105.68 		$274.56
Toc - Plan #24 Oscar Health Plan, Inc.
Gold

(HMO) Gold Elite- $0 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$399.03
$452.90
$509.96
$712.66
$1,082.96 		$704.29
$758.16
$815.22
$1,017.92 		$1,009.55
$1,063.42
$1,120.48
$1,323.18 		$1,314.81
$1,368.68
$1,425.74
$1,628.44 		$305.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.06
$905.80
$1,019.92
$1,425.32
$2,165.92 		$1,103.32
$1,211.06
$1,325.18
$1,730.58 		$1,408.58
$1,516.32
$1,630.44
$2,035.84 		$1,713.84
$1,821.58
$1,935.70
$2,341.10 		$305.26
Toc - Plan #25 Oscar Health Plan, Inc.
Gold

(HMO) Gold Elite (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.37
$441.93
$497.61
$695.41
$1,056.74 		$687.23
$739.79
$795.47
$993.27 		$985.09
$1,037.65
$1,093.33
$1,291.13 		$1,282.95
$1,335.51
$1,391.19
$1,588.99 		$297.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.74
$883.86
$995.22
$1,390.82
$2,113.48 		$1,076.60
$1,181.72
$1,293.08
$1,688.68 		$1,374.46
$1,479.58
$1,590.94
$1,986.54 		$1,672.32
$1,777.44
$1,888.80
$2,284.40 		$297.86
Toc - Plan #26 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic- HSA (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,850 $5,700 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.94
$411.93
$463.83
$648.20
$985.01 		$640.59
$689.58
$741.48
$925.85 		$918.24
$967.23
$1,019.13
$1,203.50 		$1,195.89
$1,244.88
$1,296.78
$1,481.15 		$277.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.88
$823.86
$927.66
$1,296.40
$1,970.02 		$1,003.53
$1,101.51
$1,205.31
$1,574.05 		$1,281.18
$1,379.16
$1,482.96
$1,851.70 		$1,558.83
$1,656.81
$1,760.61
$2,129.35 		$277.65
Toc - Plan #27 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Super Simple (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$253.61
$287.85
$324.12
$452.95
$688.30 		$447.62
$481.86
$518.13
$646.96 		$641.63
$675.87
$712.14
$840.97 		$835.64
$869.88
$906.15
$1,034.98 		$194.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$507.22
$575.70
$648.24
$905.90
$1,376.60 		$701.23
$769.71
$842.25
$1,099.91 		$895.24
$963.72
$1,036.26
$1,293.92 		$1,089.25
$1,157.73
$1,230.27
$1,487.93 		$194.01
Toc - Plan #28 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $4000 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$274.28
$311.31
$350.53
$489.87
$744.41 		$484.11
$521.14
$560.36
$699.70 		$693.94
$730.97
$770.19
$909.53 		$903.77
$940.80
$980.02
$1,119.36 		$209.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.56
$622.62
$701.06
$979.74
$1,488.82 		$758.39
$832.45
$910.89
$1,189.57 		$968.22
$1,042.28
$1,120.72
$1,399.40 		$1,178.05
$1,252.11
$1,330.55
$1,609.23 		$209.83
Toc - Plan #29 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$284.96
$323.43
$364.18
$508.94
$773.39 		$502.96
$541.43
$582.18
$726.94 		$720.96
$759.43
$800.18
$944.94 		$938.96
$977.43
$1,018.18
$1,162.94 		$218.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.92
$646.86
$728.36
$1,017.88
$1,546.78 		$787.92
$864.86
$946.36
$1,235.88 		$1,005.92
$1,082.86
$1,164.36
$1,453.88 		$1,223.92
$1,300.86
$1,382.36
$1,671.88 		$218.00
Toc - Plan #30 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $1000 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.23
$323.74
$364.53
$509.42
$774.12 		$503.43
$541.94
$582.73
$727.62 		$721.63
$760.14
$800.93
$945.82 		$939.83
$978.34
$1,019.13
$1,164.02 		$218.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.46
$647.48
$729.06
$1,018.84
$1,548.24 		$788.66
$865.68
$947.26
$1,237.04 		$1,006.86
$1,083.88
$1,165.46
$1,455.24 		$1,225.06
$1,302.08
$1,383.66
$1,673.44 		$218.20
Toc - Plan #31 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Elite- $0 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$285.35
$323.88
$364.68
$509.64
$774.45 		$503.64
$542.17
$582.97
$727.93 		$721.93
$760.46
$801.26
$946.22 		$940.22
$978.75
$1,019.55
$1,164.51 		$218.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.70
$647.76
$729.36
$1,019.28
$1,548.90 		$788.99
$866.05
$947.65
$1,237.57 		$1,007.28
$1,084.34
$1,165.94
$1,455.86 		$1,225.57
$1,302.63
$1,384.23
$1,674.15 		$218.29
Toc - Plan #32 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- For Diabetes (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 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 		$331.81
$376.60
$424.05
$592.61
$900.53 		$585.64
$630.43
$677.88
$846.44 		$839.47
$884.26
$931.71
$1,100.27 		$1,093.30
$1,138.09
$1,185.54
$1,354.10 		$253.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.62
$753.20
$848.10
$1,185.22
$1,801.06 		$917.45
$1,007.03
$1,101.93
$1,439.05 		$1,171.28
$1,260.86
$1,355.76
$1,692.88 		$1,425.11
$1,514.69
$1,609.59
$1,946.71 		$253.83
Toc - Plan #33 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.65
$343.51
$386.79
$540.54
$821.40 		$534.18
$575.04
$618.32
$772.07 		$765.71
$806.57
$849.85
$1,003.60 		$997.24
$1,038.10
$1,081.38
$1,235.13 		$231.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.30
$687.02
$773.58
$1,081.08
$1,642.80 		$836.83
$918.55
$1,005.11
$1,312.61 		$1,068.36
$1,150.08
$1,236.64
$1,544.14 		$1,299.89
$1,381.61
$1,468.17
$1,775.67 		$231.53
Toc - Plan #34 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- Specialist Saver (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.63
$343.48
$386.76
$540.50
$821.34 		$534.14
$574.99
$618.27
$772.01 		$765.65
$806.50
$849.78
$1,003.52 		$997.16
$1,038.01
$1,081.29
$1,235.03 		$231.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.26
$686.96
$773.52
$1,081.00
$1,642.68 		$836.77
$918.47
$1,005.03
$1,312.51 		$1,068.28
$1,149.98
$1,236.54
$1,544.02 		$1,299.79
$1,381.49
$1,468.05
$1,775.53 		$231.51
Toc - Plan #35 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- PCP Saver (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,375 $16,750 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.80
$342.54
$385.70
$539.02
$819.09 		$532.68
$573.42
$616.58
$769.90 		$763.56
$804.30
$847.46
$1,000.78 		$994.44
$1,035.18
$1,078.34
$1,231.66 		$230.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.60
$685.08
$771.40
$1,078.04
$1,638.18 		$834.48
$915.96
$1,002.28
$1,308.92 		$1,065.36
$1,146.84
$1,233.16
$1,539.80 		$1,296.24
$1,377.72
$1,464.04
$1,770.68 		$230.88
Toc - Plan #36 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic- Low Ded (Select)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.04
$353.03
$397.51
$555.51
$844.16 		$548.98
$590.97
$635.45
$793.45 		$786.92
$828.91
$873.39
$1,031.39 		$1,024.86
$1,066.85
$1,111.33
$1,269.33 		$237.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.08
$706.06
$795.02
$1,111.02
$1,688.32 		$860.02
$944.00
$1,032.96
$1,348.96 		$1,097.96
$1,181.94
$1,270.90
$1,586.90 		$1,335.90
$1,419.88
$1,508.84
$1,824.84 		$237.94

ADVERTISEMENT

Ambetter of Illinois

Local: 1-855-745-5507 | Toll Free: 1-855-745-5507 | TTY: 1-866-565-8576
Toc - Plan #37 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$7,200 $14,400 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 		$271.32
$307.94
$346.74
$484.57
$736.35 		$478.88
$515.50
$554.30
$692.13 		$686.44
$723.06
$761.86
$899.69 		$894.00
$930.62
$969.42
$1,107.25 		$207.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.64
$615.88
$693.48
$969.14
$1,472.70 		$750.20
$823.44
$901.04
$1,176.70 		$957.76
$1,031.00
$1,108.60
$1,384.26 		$1,165.32
$1,238.56
$1,316.16
$1,591.82 		$207.56
Toc - Plan #38 Ambetter of Illinois
Gold

(HMO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 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 		$313.35
$355.64
$400.45
$559.63
$850.41 		$553.06
$595.35
$640.16
$799.34 		$792.77
$835.06
$879.87
$1,039.05 		$1,032.48
$1,074.77
$1,119.58
$1,278.76 		$239.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.70
$711.28
$800.90
$1,119.26
$1,700.82 		$866.41
$950.99
$1,040.61
$1,358.97 		$1,106.12
$1,190.70
$1,280.32
$1,598.68 		$1,345.83
$1,430.41
$1,520.03
$1,838.39 		$239.71
Toc - Plan #39 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$264.19
$299.84
$337.62
$471.82
$716.98 		$466.29
$501.94
$539.72
$673.92 		$668.39
$704.04
$741.82
$876.02 		$870.49
$906.14
$943.92
$1,078.12 		$202.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528.38
$599.68
$675.24
$943.64
$1,433.96 		$730.48
$801.78
$877.34
$1,145.74 		$932.58
$1,003.88
$1,079.44
$1,347.84 		$1,134.68
$1,205.98
$1,281.54
$1,549.94 		$202.10
Toc - Plan #40 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$226.15
$256.67
$289.01
$403.89
$613.75 		$399.15
$429.67
$462.01
$576.89 		$572.15
$602.67
$635.01
$749.89 		$745.15
$775.67
$808.01
$922.89 		$173.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.30
$513.34
$578.02
$807.78
$1,227.50 		$625.30
$686.34
$751.02
$980.78 		$798.30
$859.34
$924.02
$1,153.78 		$971.30
$1,032.34
$1,097.02
$1,326.78 		$173.00
Toc - Plan #41 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 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 		$259.85
$294.92
$332.07
$464.07
$705.20 		$458.63
$493.70
$530.85
$662.85 		$657.41
$692.48
$729.63
$861.63 		$856.19
$891.26
$928.41
$1,060.41 		$198.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.70
$589.84
$664.14
$928.14
$1,410.40 		$718.48
$788.62
$862.92
$1,126.92 		$917.26
$987.40
$1,061.70
$1,325.70 		$1,116.04
$1,186.18
$1,260.48
$1,524.48 		$198.78
Toc - Plan #42 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 28

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.69
$319.71
$359.99
$503.08
$764.48 		$497.17
$535.19
$575.47
$718.56 		$712.65
$750.67
$790.95
$934.04 		$928.13
$966.15
$1,006.43
$1,149.52 		$215.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.38
$639.42
$719.98
$1,006.16
$1,528.96 		$778.86
$854.90
$935.46
$1,221.64 		$994.34
$1,070.38
$1,150.94
$1,437.12 		$1,209.82
$1,285.86
$1,366.42
$1,652.60 		$215.48
Toc - Plan #43 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$218.17
$247.62
$278.81
$389.64
$592.10 		$385.07
$414.52
$445.71
$556.54 		$551.97
$581.42
$612.61
$723.44 		$718.87
$748.32
$779.51
$890.34 		$166.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$436.34
$495.24
$557.62
$779.28
$1,184.20 		$603.24
$662.14
$724.52
$946.18 		$770.14
$829.04
$891.42
$1,113.08 		$937.04
$995.94
$1,058.32
$1,279.98 		$166.90
Toc - Plan #44 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care 22

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$240.07
$272.47
$306.80
$428.75
$651.52 		$423.72
$456.12
$490.45
$612.40 		$607.37
$639.77
$674.10
$796.05 		$791.02
$823.42
$857.75
$979.70 		$183.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$480.14
$544.94
$613.60
$857.50
$1,303.04 		$663.79
$728.59
$797.25
$1,041.15 		$847.44
$912.24
$980.90
$1,224.80 		$1,031.09
$1,095.89
$1,164.55
$1,408.45 		$183.65
Toc - Plan #45 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$246.44
$279.70
$314.94
$440.13
$668.82 		$434.96
$468.22
$503.46
$628.65 		$623.48
$656.74
$691.98
$817.17 		$812.00
$845.26
$880.50
$1,005.69 		$188.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.88
$559.40
$629.88
$880.26
$1,337.64 		$681.40
$747.92
$818.40
$1,068.78 		$869.92
$936.44
$1,006.92
$1,257.30 		$1,058.44
$1,124.96
$1,195.44
$1,445.82 		$188.52
Toc - Plan #46 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$262.51
$297.93
$335.47
$468.82
$712.42 		$463.32
$498.74
$536.28
$669.63 		$664.13
$699.55
$737.09
$870.44 		$864.94
$900.36
$937.90
$1,071.25 		$200.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.02
$595.86
$670.94
$937.64
$1,424.84 		$725.83
$796.67
$871.75
$1,138.45 		$926.64
$997.48
$1,072.56
$1,339.26 		$1,127.45
$1,198.29
$1,273.37
$1,540.07 		$200.81
Toc - Plan #47 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$6,100 $12,200 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 		$242.32
$275.02
$309.67
$432.77
$657.63 		$427.69
$460.39
$495.04
$618.14 		$613.06
$645.76
$680.41
$803.51 		$798.43
$831.13
$865.78
$988.88 		$185.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$484.64
$550.04
$619.34
$865.54
$1,315.26 		$670.01
$735.41
$804.71
$1,050.91 		$855.38
$920.78
$990.08
$1,236.28 		$1,040.75
$1,106.15
$1,175.45
$1,421.65 		$185.37
Toc - Plan #48 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 31

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 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 		$242.89
$275.67
$310.40
$433.78
$659.18 		$428.69
$461.47
$496.20
$619.58 		$614.49
$647.27
$682.00
$805.38 		$800.29
$833.07
$867.80
$991.18 		$185.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$485.78
$551.34
$620.80
$867.56
$1,318.36 		$671.58
$737.14
$806.60
$1,053.36 		$857.38
$922.94
$992.40
$1,239.16 		$1,043.18
$1,108.74
$1,178.20
$1,424.96 		$185.80
Toc - Plan #49 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 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 		$250.46
$284.26
$320.08
$447.30
$679.72 		$442.05
$475.85
$511.67
$638.89 		$633.64
$667.44
$703.26
$830.48 		$825.23
$859.03
$894.85
$1,022.07 		$191.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$500.92
$568.52
$640.16
$894.60
$1,359.44 		$692.51
$760.11
$831.75
$1,086.19 		$884.10
$951.70
$1,023.34
$1,277.78 		$1,075.69
$1,143.29
$1,214.93
$1,469.37 		$191.59
Toc - Plan #50 Ambetter of Illinois
Gold

(HMO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$292.79
$332.30
$374.17
$522.90
$794.59 		$516.76
$556.27
$598.14
$746.87 		$740.73
$780.24
$822.11
$970.84 		$964.70
$1,004.21
$1,046.08
$1,194.81 		$223.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.58
$664.60
$748.34
$1,045.80
$1,589.18 		$809.55
$888.57
$972.31
$1,269.77 		$1,033.52
$1,112.54
$1,196.28
$1,493.74 		$1,257.49
$1,336.51
$1,420.25
$1,717.71 		$223.97
Toc - Plan #51 Ambetter of Illinois
Bronze

(HMO) Ambetter Essential Care 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 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 		$202.27
$229.57
$258.49
$361.24
$548.95 		$357.00
$384.30
$413.22
$515.97 		$511.73
$539.03
$567.95
$670.70 		$666.46
$693.76
$722.68
$825.43 		$154.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$404.54
$459.14
$516.98
$722.48
$1,097.90 		$559.27
$613.87
$671.71
$877.21 		$714.00
$768.60
$826.44
$1,031.94 		$868.73
$923.33
$981.17
$1,186.67 		$154.73
Toc - Plan #52 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 4 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.59
$321.87
$362.42
$506.48
$769.65 		$500.53
$538.81
$579.36
$723.42 		$717.47
$755.75
$796.30
$940.36 		$934.41
$972.69
$1,013.24
$1,157.30 		$216.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.18
$643.74
$724.84
$1,012.96
$1,539.30 		$784.12
$860.68
$941.78
$1,229.90 		$1,001.06
$1,077.62
$1,158.72
$1,446.84 		$1,218.00
$1,294.56
$1,375.66
$1,663.78 		$216.94
Toc - Plan #53 Ambetter of Illinois
Gold

(HMO) Ambetter Secure Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$6,300 $12,600 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 		$327.52
$371.73
$418.56
$584.94
$888.87 		$578.07
$622.28
$669.11
$835.49 		$828.62
$872.83
$919.66
$1,086.04 		$1,079.17
$1,123.38
$1,170.21
$1,336.59 		$250.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.04
$743.46
$837.12
$1,169.88
$1,777.74 		$905.59
$994.01
$1,087.67
$1,420.43 		$1,156.14
$1,244.56
$1,338.22
$1,670.98 		$1,406.69
$1,495.11
$1,588.77
$1,921.53 		$250.55
Toc - Plan #54 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 11 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276.14
$313.40
$352.89
$493.16
$749.41 		$487.38
$524.64
$564.13
$704.40 		$698.62
$735.88
$775.37
$915.64 		$909.86
$947.12
$986.61
$1,126.88 		$211.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.28
$626.80
$705.78
$986.32
$1,498.82 		$763.52
$838.04
$917.02
$1,197.56 		$974.76
$1,049.28
$1,128.26
$1,408.80 		$1,186.00
$1,260.52
$1,339.50
$1,620.04 		$211.24
Toc - Plan #55 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care 5 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$236.38
$268.28
$302.08
$422.15
$641.50 		$417.20
$449.10
$482.90
$602.97 		$598.02
$629.92
$663.72
$783.79 		$778.84
$810.74
$844.54
$964.61 		$180.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$472.76
$536.56
$604.16
$844.30
$1,283.00 		$653.58
$717.38
$784.98
$1,025.12 		$834.40
$898.20
$965.80
$1,205.94 		$1,015.22
$1,079.02
$1,146.62
$1,386.76 		$180.82
Toc - Plan #56 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 28 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$294.43
$334.16
$376.27
$525.83
$799.05 		$519.66
$559.39
$601.50
$751.06 		$744.89
$784.62
$826.73
$976.29 		$970.12
$1,009.85
$1,051.96
$1,201.52 		$225.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.86
$668.32
$752.54
$1,051.66
$1,598.10 		$814.09
$893.55
$977.77
$1,276.89 		$1,039.32
$1,118.78
$1,203.00
$1,502.12 		$1,264.55
$1,344.01
$1,428.23
$1,727.35 		$225.23
Toc - Plan #57 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care 2 HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$228.04
$258.81
$291.42
$407.26
$618.87 		$402.48
$433.25
$465.86
$581.70 		$576.92
$607.69
$640.30
$756.14 		$751.36
$782.13
$814.74
$930.58 		$174.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.08
$517.62
$582.84
$814.52
$1,237.74 		$630.52
$692.06
$757.28
$988.96 		$804.96
$866.50
$931.72
$1,163.40 		$979.40
$1,040.94
$1,106.16
$1,337.84 		$174.44
Toc - Plan #58 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care 22 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$250.93
$284.79
$320.67
$448.13
$680.98 		$442.88
$476.74
$512.62
$640.08 		$634.83
$668.69
$704.57
$832.03 		$826.78
$860.64
$896.52
$1,023.98 		$191.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$501.86
$569.58
$641.34
$896.26
$1,361.96 		$693.81
$761.53
$833.29
$1,088.21 		$885.76
$953.48
$1,025.24
$1,280.16 		$1,077.71
$1,145.43
$1,217.19
$1,472.11 		$191.95
Toc - Plan #59 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care: $1,500 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$257.59
$292.35
$329.19
$460.04
$699.07 		$454.64
$489.40
$526.24
$657.09 		$651.69
$686.45
$723.29
$854.14 		$848.74
$883.50
$920.34
$1,051.19 		$197.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$515.18
$584.70
$658.38
$920.08
$1,398.14 		$712.23
$781.75
$855.43
$1,117.13 		$909.28
$978.80
$1,052.48
$1,314.18 		$1,106.33
$1,175.85
$1,249.53
$1,511.23 		$197.05
Toc - Plan #60 Ambetter of Illinois
Expanded Bronze

(HMO) Ambetter Essential Care: $0 Medical Deductible + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

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 		$274.38
$311.41
$350.64
$490.02
$744.63 		$484.27
$521.30
$560.53
$699.91 		$694.16
$731.19
$770.42
$909.80 		$904.05
$941.08
$980.31
$1,119.69 		$209.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.76
$622.82
$701.28
$980.04
$1,489.26 		$758.65
$832.71
$911.17
$1,189.93 		$968.54
$1,042.60
$1,121.06
$1,399.82 		$1,178.43
$1,252.49
$1,330.95
$1,609.71 		$209.89
Toc - Plan #61 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 31 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$6,450 $12,900 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 		$253.87
$288.14
$324.44
$453.40
$688.99 		$448.08
$482.35
$518.65
$647.61 		$642.29
$676.56
$712.86
$841.82 		$836.50
$870.77
$907.07
$1,036.03 		$194.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$507.74
$576.28
$648.88
$906.80
$1,377.98 		$701.95
$770.49
$843.09
$1,101.01 		$896.16
$964.70
$1,037.30
$1,295.22 		$1,090.37
$1,158.91
$1,231.51
$1,489.43 		$194.21
Toc - Plan #62 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 32 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261.79
$297.12
$334.55
$467.53
$710.46 		$462.05
$497.38
$534.81
$667.79 		$662.31
$697.64
$735.07
$868.05 		$862.57
$897.90
$935.33
$1,068.31 		$200.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.58
$594.24
$669.10
$935.06
$1,420.92 		$723.84
$794.50
$869.36
$1,135.32 		$924.10
$994.76
$1,069.62
$1,335.58 		$1,124.36
$1,195.02
$1,269.88
$1,535.84 		$200.26
Toc - Plan #63 Ambetter of Illinois
Gold

(HMO) Ambetter Secure Care 20 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$306.03
$347.33
$391.09
$546.54
$830.53 		$540.13
$581.43
$625.19
$780.64 		$774.23
$815.53
$859.29
$1,014.74 		$1,008.33
$1,049.63
$1,093.39
$1,248.84 		$234.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.06
$694.66
$782.18
$1,093.08
$1,661.06 		$846.16
$928.76
$1,016.28
$1,327.18 		$1,080.26
$1,162.86
$1,250.38
$1,561.28 		$1,314.36
$1,396.96
$1,484.48
$1,795.38 		$234.10
Toc - Plan #64 Ambetter of Illinois
Silver

(HMO) Ambetter Balanced Care 12 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 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 		$271.60
$308.25
$347.09
$485.06
$737.09 		$479.37
$516.02
$554.86
$692.83 		$687.14
$723.79
$762.63
$900.60 		$894.91
$931.56
$970.40
$1,108.37 		$207.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.20
$616.50
$694.18
$970.12
$1,474.18 		$750.97
$824.27
$901.95
$1,177.89 		$958.74
$1,032.04
$1,109.72
$1,385.66 		$1,166.51
$1,239.81
$1,317.49
$1,593.43 		$207.77
Toc - Plan #65 Ambetter of Illinois
Bronze

(HMO) Ambetter Essential Care 1 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 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 		$211.42
$239.95
$270.18
$377.58
$573.77 		$373.15
$401.68
$431.91
$539.31 		$534.88
$563.41
$593.64
$701.04 		$696.61
$725.14
$755.37
$862.77 		$161.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$422.84
$479.90
$540.36
$755.16
$1,147.54 		$584.57
$641.63
$702.09
$916.89 		$746.30
$803.36
$863.82
$1,078.62 		$908.03
$965.09
$1,025.55
$1,240.35 		$161.73

ADVERTISEMENT

Molina Healthcare

Local: 1-833-644-1623 | Toll Free: 1-833-644-1623 | TTY: 1-800-877-8339
Toc - Plan #66 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

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 		$314.60
$357.07
$402.06
$561.88
$853.83 		$555.27
$597.74
$642.73
$802.55 		$795.94
$838.41
$883.40
$1,043.22 		$1,036.61
$1,079.08
$1,124.07
$1,283.89 		$240.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.20
$714.14
$804.12
$1,123.76
$1,707.66 		$869.87
$954.81
$1,044.79
$1,364.43 		$1,110.54
$1,195.48
$1,285.46
$1,605.10 		$1,351.21
$1,436.15
$1,526.13
$1,845.77 		$240.67
Toc - Plan #67 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

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 		$286.66
$325.36
$366.35
$511.97
$777.99 		$505.95
$544.65
$585.64
$731.26 		$725.24
$763.94
$804.93
$950.55 		$944.53
$983.23
$1,024.22
$1,169.84 		$219.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.32
$650.72
$732.70
$1,023.94
$1,555.98 		$792.61
$870.01
$951.99
$1,243.23 		$1,011.90
$1,089.30
$1,171.28
$1,462.52 		$1,231.19
$1,308.59
$1,390.57
$1,681.81 		$219.29
Toc - Plan #68 Molina Healthcare
Silver

(HMO) Constant Care Silver 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

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 		$284.07
$322.42
$363.04
$507.35
$770.96 		$501.38
$539.73
$580.35
$724.66 		$718.69
$757.04
$797.66
$941.97 		$936.00
$974.35
$1,014.97
$1,159.28 		$217.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$568.14
$644.84
$726.08
$1,014.70
$1,541.92 		$785.45
$862.15
$943.39
$1,232.01 		$1,002.76
$1,079.46
$1,160.70
$1,449.32 		$1,220.07
$1,296.77
$1,378.01
$1,666.63 		$217.31
Toc - Plan #69 Molina Healthcare
Silver

(HMO) Constant Care Silver 7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

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 		$279.90
$317.69
$357.71
$499.90
$759.65 		$494.02
$531.81
$571.83
$714.02 		$708.14
$745.93
$785.95
$928.14 		$922.26
$960.05
$1,000.07
$1,142.26 		$214.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559.80
$635.38
$715.42
$999.80
$1,519.30 		$773.92
$849.50
$929.54
$1,213.92 		$988.04
$1,063.62
$1,143.66
$1,428.04 		$1,202.16
$1,277.74
$1,357.78
$1,642.16 		$214.12
Toc - Plan #70 Molina Healthcare
Silver

(HMO) Constant Care Silver 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

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 		$285.99
$324.60
$365.50
$510.78
$776.18 		$504.77
$543.38
$584.28
$729.56 		$723.55
$762.16
$803.06
$948.34 		$942.33
$980.94
$1,021.84
$1,167.12 		$218.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.98
$649.20
$731.00
$1,021.56
$1,552.36 		$790.76
$867.98
$949.78
$1,240.34 		$1,009.54
$1,086.76
$1,168.56
$1,459.12 		$1,228.32
$1,305.54
$1,387.34
$1,677.90 		$218.78
Toc - Plan #71 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

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 		$317.44
$360.29
$405.69
$566.95
$861.53 		$560.28
$603.13
$648.53
$809.79 		$803.12
$845.97
$891.37
$1,052.63 		$1,045.96
$1,088.81
$1,134.21
$1,295.47 		$242.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.88
$720.58
$811.38
$1,133.90
$1,723.06 		$877.72
$963.42
$1,054.22
$1,376.74 		$1,120.56
$1,206.26
$1,297.06
$1,619.58 		$1,363.40
$1,449.10
$1,539.90
$1,862.42 		$242.84
Toc - Plan #72 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 250 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-644-1623

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 		$289.51
$328.59
$369.99
$517.06
$785.73 		$510.98
$550.06
$591.46
$738.53 		$732.45
$771.53
$812.93
$960.00 		$953.92
$993.00
$1,034.40
$1,181.47 		$221.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.02
$657.18
$739.98
$1,034.12
$1,571.46 		$800.49
$878.65
$961.45
$1,255.59 		$1,021.96
$1,100.12
$1,182.92
$1,477.06 		$1,243.43
$1,321.59
$1,404.39
$1,698.53 		$221.47

ADVERTISEMENT

Blue Cross and Blue Shield of Illinois

Local: 1-800-538-8833 | Toll Free: 1-800-538-8833 | TTY: 1-800-526-0844
Toc - Plan #73 Blue Cross and Blue Shield of Illinois
Gold

(HMO) Blue Precision Gold HMO? 207

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$453.98
$515.27
$580.19
$810.81
$1,232.11 		$801.28
$862.57
$927.49
$1,158.11 		$1,148.58
$1,209.87
$1,274.79
$1,505.41 		$1,495.88
$1,557.17
$1,622.09
$1,852.71 		$347.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$907.96
$1,030.54
$1,160.38
$1,621.62
$2,464.22 		$1,255.26
$1,377.84
$1,507.68
$1,968.92 		$1,602.56
$1,725.14
$1,854.98
$2,316.22 		$1,949.86
$2,072.44
$2,202.28
$2,663.52 		$347.30
Toc - Plan #74 Blue Cross and Blue Shield of Illinois
Silver

(HMO) Blue Precision Silver HMO? 206

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$3,100 $9,300 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 		$394.04
$447.23
$503.58
$703.75
$1,069.42 		$695.48
$748.67
$805.02
$1,005.19 		$996.92
$1,050.11
$1,106.46
$1,306.63 		$1,298.36
$1,351.55
$1,407.90
$1,608.07 		$301.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.08
$894.46
$1,007.16
$1,407.50
$2,138.84 		$1,089.52
$1,195.90
$1,308.60
$1,708.94 		$1,390.96
$1,497.34
$1,610.04
$2,010.38 		$1,692.40
$1,798.78
$1,911.48
$2,311.82 		$301.44
Toc - Plan #75 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) Blue Precision Bronze HMO? 205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,400 $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 		$308.39
$350.02
$394.12
$550.78
$836.96 		$544.31
$585.94
$630.04
$786.70 		$780.23
$821.86
$865.96
$1,022.62 		$1,016.15
$1,057.78
$1,101.88
$1,258.54 		$235.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.78
$700.04
$788.24
$1,101.56
$1,673.92 		$852.70
$935.96
$1,024.16
$1,337.48 		$1,088.62
$1,171.88
$1,260.08
$1,573.40 		$1,324.54
$1,407.80
$1,496.00
$1,809.32 		$235.92
Toc - Plan #76 Blue Cross and Blue Shield of Illinois
Silver

(HMO) BlueCare Direct Silver? 212 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$3,200 $9,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.38
$396.55
$446.51
$624.00
$948.23 		$616.66
$663.83
$713.79
$891.28 		$883.94
$931.11
$981.07
$1,158.56 		$1,151.22
$1,198.39
$1,248.35
$1,425.84 		$267.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.76
$793.10
$893.02
$1,248.00
$1,896.46 		$966.04
$1,060.38
$1,160.30
$1,515.28 		$1,233.32
$1,327.66
$1,427.58
$1,782.56 		$1,500.60
$1,594.94
$1,694.86
$2,049.84 		$267.28
Toc - Plan #77 Blue Cross and Blue Shield of Illinois
Gold

(HMO) BlueCare Direct Gold? 409 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$402.53
$456.87
$514.44
$718.92
$1,092.47 		$710.47
$764.81
$822.38
$1,026.86 		$1,018.41
$1,072.75
$1,130.32
$1,334.80 		$1,326.35
$1,380.69
$1,438.26
$1,642.74 		$307.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.06
$913.74
$1,028.88
$1,437.84
$2,184.94 		$1,113.00
$1,221.68
$1,336.82
$1,745.78 		$1,420.94
$1,529.62
$1,644.76
$2,053.72 		$1,728.88
$1,837.56
$1,952.70
$2,361.66 		$307.94
Toc - Plan #78 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) BlueCare Direct Bronze? 401 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,400 $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 		$273.45
$310.36
$349.47
$488.38
$742.14 		$482.64
$519.55
$558.66
$697.57 		$691.83
$728.74
$767.85
$906.76 		$901.02
$937.93
$977.04
$1,115.95 		$209.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.90
$620.72
$698.94
$976.76
$1,484.28 		$756.09
$829.91
$908.13
$1,185.95 		$965.28
$1,039.10
$1,117.32
$1,395.14 		$1,174.47
$1,248.29
$1,326.51
$1,604.33 		$209.19
Toc - Plan #79 Blue Cross and Blue Shield of Illinois
Gold

(PPO) Blue Choice Preferred Gold PPO? 204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$530.84
$602.51
$678.42
$948.09
$1,440.71 		$936.94
$1,008.61
$1,084.52
$1,354.19 		$1,343.04
$1,414.71
$1,490.62
$1,760.29 		$1,749.14
$1,820.81
$1,896.72
$2,166.39 		$406.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,061.68
$1,205.02
$1,356.84
$1,896.18
$2,881.42 		$1,467.78
$1,611.12
$1,762.94
$2,302.28 		$1,873.88
$2,017.22
$2,169.04
$2,708.38 		$2,279.98
$2,423.32
$2,575.14
$3,114.48 		$406.10
Toc - Plan #80 Blue Cross and Blue Shield of Illinois
Silver

(PPO) Blue Choice Preferred Silver PPO? 203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$2,350 $7,050 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$447.39
$507.79
$571.76
$799.04
$1,214.22 		$789.64
$850.04
$914.01
$1,141.29 		$1,131.89
$1,192.29
$1,256.26
$1,483.54 		$1,474.14
$1,534.54
$1,598.51
$1,825.79 		$342.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.78
$1,015.58
$1,143.52
$1,598.08
$2,428.44 		$1,237.03
$1,357.83
$1,485.77
$1,940.33 		$1,579.28
$1,700.08
$1,828.02
$2,282.58 		$1,921.53
$2,042.33
$2,170.27
$2,624.83 		$342.25
Toc - Plan #81 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$4,500 $13,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.84
$412.96
$464.99
$649.82
$987.47 		$642.18
$691.30
$743.33
$928.16 		$920.52
$969.64
$1,021.67
$1,206.50 		$1,198.86
$1,247.98
$1,300.01
$1,484.84 		$278.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.68
$825.92
$929.98
$1,299.64
$1,974.94 		$1,006.02
$1,104.26
$1,208.32
$1,577.98 		$1,284.36
$1,382.60
$1,486.66
$1,856.32 		$1,562.70
$1,660.94
$1,765.00
$2,134.66 		$278.34
Toc - Plan #82 Blue Cross and Blue Shield of Illinois
Catastrophic

(PPO) Blue Choice Preferred Security PPO? 200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

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 		$304.14
$345.20
$388.70
$543.20
$825.45 		$536.81
$577.87
$621.37
$775.87 		$769.48
$810.54
$854.04
$1,008.54 		$1,002.15
$1,043.21
$1,086.71
$1,241.21 		$232.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.28
$690.40
$777.40
$1,086.40
$1,650.90 		$840.95
$923.07
$1,010.07
$1,319.07 		$1,073.62
$1,155.74
$1,242.74
$1,551.74 		$1,306.29
$1,388.41
$1,475.41
$1,784.41 		$232.67
Toc - Plan #83 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$6,100 $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 		$337.21
$382.73
$430.95
$602.25
$915.17 		$595.17
$640.69
$688.91
$860.21 		$853.13
$898.65
$946.87
$1,118.17 		$1,111.09
$1,156.61
$1,204.83
$1,376.13 		$257.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.42
$765.46
$861.90
$1,204.50
$1,830.34 		$932.38
$1,023.42
$1,119.86
$1,462.46 		$1,190.34
$1,281.38
$1,377.82
$1,720.42 		$1,448.30
$1,539.34
$1,635.78
$1,978.38 		$257.96
Toc - Plan #84 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 601

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,000 $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 		$323.81
$367.53
$413.83
$578.33
$878.83 		$571.53
$615.25
$661.55
$826.05 		$819.25
$862.97
$909.27
$1,073.77 		$1,066.97
$1,110.69
$1,156.99
$1,321.49 		$247.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.62
$735.06
$827.66
$1,156.66
$1,757.66 		$895.34
$982.78
$1,075.38
$1,404.38 		$1,143.06
$1,230.50
$1,323.10
$1,652.10 		$1,390.78
$1,478.22
$1,570.82
$1,899.82 		$247.72
Toc - Plan #85 Blue Cross and Blue Shield of Illinois
Gold

(HMO) Blue FocusCare Gold? 211

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 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 		$349.13
$396.27
$446.19
$623.55
$947.55 		$616.22
$663.36
$713.28
$890.64 		$883.31
$930.45
$980.37
$1,157.73 		$1,150.40
$1,197.54
$1,247.46
$1,424.82 		$267.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.26
$792.54
$892.38
$1,247.10
$1,895.10 		$965.35
$1,059.63
$1,159.47
$1,514.19 		$1,232.44
$1,326.72
$1,426.56
$1,781.28 		$1,499.53
$1,593.81
$1,693.65
$2,048.37 		$267.09
Toc - Plan #86 Blue Cross and Blue Shield of Illinois
Silver

(HMO) Blue FocusCare Silver? 210

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$4,200 $12,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$293.01
$332.57
$374.47
$523.32
$795.23 		$517.16
$556.72
$598.62
$747.47 		$741.31
$780.87
$822.77
$971.62 		$965.46
$1,005.02
$1,046.92
$1,195.77 		$224.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.02
$665.14
$748.94
$1,046.64
$1,590.46 		$810.17
$889.29
$973.09
$1,270.79 		$1,034.32
$1,113.44
$1,197.24
$1,494.94 		$1,258.47
$1,337.59
$1,421.39
$1,719.09 		$224.15
Toc - Plan #87 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) Blue FocusCare Bronze? 209

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$7,400 $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 		$214.62
$243.59
$274.28
$383.30
$582.47 		$378.80
$407.77
$438.46
$547.48 		$542.98
$571.95
$602.64
$711.66 		$707.16
$736.13
$766.82
$875.84 		$164.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$429.24
$487.18
$548.56
$766.60
$1,164.94 		$593.42
$651.36
$712.74
$930.78 		$757.60
$815.54
$876.92
$1,094.96 		$921.78
$979.72
$1,041.10
$1,259.14 		$164.18

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0325 | Toll Free: 1-888-200-0325 | TTY: 1-888-200-0325
Toc - Plan #88 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$7,900 $15,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$236.73
$268.69
$302.54
$422.80
$642.49 		$417.83
$449.79
$483.64
$603.90 		$598.93
$630.89
$664.74
$785.00 		$780.03
$811.99
$845.84
$966.10 		$181.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$473.46
$537.38
$605.08
$845.60
$1,284.98 		$654.56
$718.48
$786.18
$1,026.70 		$835.66
$899.58
$967.28
$1,207.80 		$1,016.76
$1,080.68
$1,148.38
$1,388.90 		$181.10
Toc - Plan #89 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential+ (Low Premium)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

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 		$226.50
$257.08
$289.47
$404.53
$614.72 		$399.77
$430.35
$462.74
$577.80 		$573.04
$603.62
$636.01
$751.07 		$746.31
$776.89
$809.28
$924.34 		$173.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$453.00
$514.16
$578.94
$809.06
$1,229.44 		$626.27
$687.43
$752.21
$982.33 		$799.54
$860.70
$925.48
$1,155.60 		$972.81
$1,033.97
$1,098.75
$1,328.87 		$173.27
Toc - Plan #90 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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 		$231.84
$263.14
$296.29
$414.07
$629.21 		$409.20
$440.50
$473.65
$591.43 		$586.56
$617.86
$651.01
$768.79 		$763.92
$795.22
$828.37
$946.15 		$177.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$463.68
$526.28
$592.58
$828.14
$1,258.42 		$641.04
$703.64
$769.94
$1,005.50 		$818.40
$881.00
$947.30
$1,182.86 		$995.76
$1,058.36
$1,124.66
$1,360.22 		$177.36
Toc - Plan #91 UnitedHealthcare
Silver

(HMO) UHC Silver Value+ ($3 Rx + 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

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 		$278.07
$315.61
$355.37
$496.63
$754.68 		$490.79
$528.33
$568.09
$709.35 		$703.51
$741.05
$780.81
$922.07 		$916.23
$953.77
$993.53
$1,134.79 		$212.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.14
$631.22
$710.74
$993.26
$1,509.36 		$768.86
$843.94
$923.46
$1,205.98 		$981.58
$1,056.66
$1,136.18
$1,418.70 		$1,194.30
$1,269.38
$1,348.90
$1,631.42 		$212.72
Toc - Plan #92 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($3 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.25
$318.08
$358.16
$500.53
$760.60 		$494.64
$532.47
$572.55
$714.92 		$709.03
$746.86
$786.94
$929.31 		$923.42
$961.25
$1,001.33
$1,143.70 		$214.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.50
$636.16
$716.32
$1,001.06
$1,521.20 		$774.89
$850.55
$930.71
$1,215.45 		$989.28
$1,064.94
$1,145.10
$1,429.84 		$1,203.67
$1,279.33
$1,359.49
$1,644.23 		$214.39
Toc - Plan #93 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ Extra ($3 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$4,600 $9,200 Annual Deductible
$8,100 $16,200 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 		$295.47
$335.36
$377.61
$527.71
$801.91 		$521.50
$561.39
$603.64
$753.74 		$747.53
$787.42
$829.67
$979.77 		$973.56
$1,013.45
$1,055.70
$1,205.80 		$226.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.94
$670.72
$755.22
$1,055.42
$1,603.82 		$816.97
$896.75
$981.25
$1,281.45 		$1,043.00
$1,122.78
$1,207.28
$1,507.48 		$1,269.03
$1,348.81
$1,433.31
$1,733.51 		$226.03
Toc - Plan #94 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

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 		$273.29
$310.18
$349.26
$488.10
$741.71 		$482.36
$519.25
$558.33
$697.17 		$691.43
$728.32
$767.40
$906.24 		$900.50
$937.39
$976.47
$1,115.31 		$209.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.58
$620.36
$698.52
$976.20
$1,483.42 		$755.65
$829.43
$907.59
$1,185.27 		$964.72
$1,038.50
$1,116.66
$1,394.34 		$1,173.79
$1,247.57
$1,325.73
$1,603.41 		$209.07
Toc - Plan #95 UnitedHealthcare
Gold

(HMO) UHC Gold Value+ ($2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331.59
$376.35
$423.77
$592.22
$899.94 		$585.26
$630.02
$677.44
$845.89 		$838.93
$883.69
$931.11
$1,099.56 		$1,092.60
$1,137.36
$1,184.78
$1,353.23 		$253.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.18
$752.70
$847.54
$1,184.44
$1,799.88 		$916.85
$1,006.37
$1,101.21
$1,438.11 		$1,170.52
$1,260.04
$1,354.88
$1,691.78 		$1,424.19
$1,513.71
$1,608.55
$1,945.45 		$253.67
Toc - Plan #96 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($2 Rx + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$335.80
$381.13
$429.15
$599.74
$911.36 		$592.69
$638.02
$686.04
$856.63 		$849.58
$894.91
$942.93
$1,113.52 		$1,106.47
$1,151.80
$1,199.82
$1,370.41 		$256.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.60
$762.26
$858.30
$1,199.48
$1,822.72 		$928.49
$1,019.15
$1,115.19
$1,456.37 		$1,185.38
$1,276.04
$1,372.08
$1,713.26 		$1,442.27
$1,532.93
$1,628.97
$1,970.15 		$256.89
Toc - Plan #97 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ Extra ($2 Rx + Dental + Vision + 3 Free Primary Care & 6 Free Virtual Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.85
$392.54
$442.00
$617.69
$938.64 		$610.43
$657.12
$706.58
$882.27 		$875.01
$921.70
$971.16
$1,146.85 		$1,139.59
$1,186.28
$1,235.74
$1,411.43 		$264.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.70
$785.08
$884.00
$1,235.38
$1,877.28 		$956.28
$1,049.66
$1,148.58
$1,499.96 		$1,220.86
$1,314.24
$1,413.16
$1,764.54 		$1,485.44
$1,578.82
$1,677.74
$2,029.12 		$264.58

ADVERTISEMENT

Bright HealthCare

Local: 1-855-827-4448 | Toll Free: 1-855-827-4448

Toc - Plan #98 Bright HealthCare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$327.65
$371.88
$418.73
$585.18
$889.23 		$578.30
$622.53
$669.38
$835.83 		$828.95
$873.18
$920.03
$1,086.48 		$1,079.60
$1,123.83
$1,170.68
$1,337.13 		$250.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.30
$743.76
$837.46
$1,170.36
$1,778.46 		$905.95
$994.41
$1,088.11
$1,421.01 		$1,156.60
$1,245.06
$1,338.76
$1,671.66 		$1,407.25
$1,495.71
$1,589.41
$1,922.31 		$250.65
Toc - Plan #99 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$278.40
$315.98
$355.79
$497.22
$755.57 		$491.37
$528.95
$568.76
$710.19 		$704.34
$741.92
$781.73
$923.16 		$917.31
$954.89
$994.70
$1,136.13 		$212.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.80
$631.96
$711.58
$994.44
$1,511.14 		$769.77
$844.93
$924.55
$1,207.41 		$982.74
$1,057.90
$1,137.52
$1,420.38 		$1,195.71
$1,270.87
$1,350.49
$1,633.35 		$212.97
Toc - Plan #100 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.72
$319.75
$360.04
$503.15
$764.58 		$497.23
$535.26
$575.55
$718.66 		$712.74
$750.77
$791.06
$934.17 		$928.25
$966.28
$1,006.57
$1,149.68 		$215.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.44
$639.50
$720.08
$1,006.30
$1,529.16 		$778.95
$855.01
$935.59
$1,221.81 		$994.46
$1,070.52
$1,151.10
$1,437.32 		$1,209.97
$1,286.03
$1,366.61
$1,652.83 		$215.51
Toc - Plan #101 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$294.53
$334.29
$376.41
$526.03
$799.35 		$519.84
$559.60
$601.72
$751.34 		$745.15
$784.91
$827.03
$976.65 		$970.46
$1,010.22
$1,052.34
$1,201.96 		$225.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.06
$668.58
$752.82
$1,052.06
$1,598.70 		$814.37
$893.89
$978.13
$1,277.37 		$1,039.68
$1,119.20
$1,203.44
$1,502.68 		$1,264.99
$1,344.51
$1,428.75
$1,727.99 		$225.31
Toc - Plan #102 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.59
$321.88
$362.43
$506.49
$769.67 		$500.54
$538.83
$579.38
$723.44 		$717.49
$755.78
$796.33
$940.39 		$934.44
$972.73
$1,013.28
$1,157.34 		$216.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.18
$643.76
$724.86
$1,012.98
$1,539.34 		$784.13
$860.71
$941.81
$1,229.93 		$1,001.08
$1,077.66
$1,158.76
$1,446.88 		$1,218.03
$1,294.61
$1,375.71
$1,663.83 		$216.95
Toc - Plan #103 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$226.04
$256.55
$288.87
$403.70
$613.46 		$398.96
$429.47
$461.79
$576.62 		$571.88
$602.39
$634.71
$749.54 		$744.80
$775.31
$807.63
$922.46 		$172.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$452.08
$513.10
$577.74
$807.40
$1,226.92 		$625.00
$686.02
$750.66
$980.32 		$797.92
$858.94
$923.58
$1,153.24 		$970.84
$1,031.86
$1,096.50
$1,326.16 		$172.92
Toc - Plan #104 Bright HealthCare
Expanded Bronze

(HMO) Bronze 5300 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$247.36
$280.75
$316.12
$441.78
$671.33 		$436.59
$469.98
$505.35
$631.01 		$625.82
$659.21
$694.58
$820.24 		$815.05
$848.44
$883.81
$1,009.47 		$189.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.72
$561.50
$632.24
$883.56
$1,342.66 		$683.95
$750.73
$821.47
$1,072.79 		$873.18
$939.96
$1,010.70
$1,262.02 		$1,062.41
$1,129.19
$1,199.93
$1,451.25 		$189.23
Toc - Plan #105 Bright HealthCare
Expanded Bronze

(HMO) Bronze $0 Medical Deductible ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$255.16
$289.60
$326.09
$455.71
$692.50 		$450.36
$484.80
$521.29
$650.91 		$645.56
$680.00
$716.49
$846.11 		$840.76
$875.20
$911.69
$1,041.31 		$195.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510.32
$579.20
$652.18
$911.42
$1,385.00 		$705.52
$774.40
$847.38
$1,106.62 		$900.72
$969.60
$1,042.58
$1,301.82 		$1,095.92
$1,164.80
$1,237.78
$1,497.02 		$195.20
Toc - Plan #106 Bright HealthCare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$233.20
$264.68
$298.02
$416.49
$632.89 		$411.59
$443.07
$476.41
$594.88 		$589.98
$621.46
$654.80
$773.27 		$768.37
$799.85
$833.19
$951.66 		$178.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$466.40
$529.36
$596.04
$832.98
$1,265.78 		$644.79
$707.75
$774.43
$1,011.37 		$823.18
$886.14
$952.82
$1,189.76 		$1,001.57
$1,064.53
$1,131.21
$1,368.15 		$178.39
Toc - Plan #107 Bright HealthCare
Catastrophic

(HMO) Catastrophic 8700 ($0 Primary Care)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$210.04
$238.40
$268.43
$375.13
$570.05 		$370.72
$399.08
$429.11
$535.81 		$531.40
$559.76
$589.79
$696.49 		$692.08
$720.44
$750.47
$857.17 		$160.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$420.08
$476.80
$536.86
$750.26
$1,140.10 		$580.76
$637.48
$697.54
$910.94 		$741.44
$798.16
$858.22
$1,071.62 		$902.12
$958.84
$1,018.90
$1,232.30 		$160.68
Toc - Plan #108 Bright HealthCare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$357.64
$405.92
$457.06
$638.74
$970.63 		$631.23
$679.51
$730.65
$912.33 		$904.82
$953.10
$1,004.24
$1,185.92 		$1,178.41
$1,226.69
$1,277.83
$1,459.51 		$273.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.28
$811.84
$914.12
$1,277.48
$1,941.26 		$988.87
$1,085.43
$1,187.71
$1,551.07 		$1,262.46
$1,359.02
$1,461.30
$1,824.66 		$1,536.05
$1,632.61
$1,734.89
$2,098.25 		$273.59
Toc - Plan #109 Bright HealthCare
Expanded Bronze

(HMO) Bronze 7200 + Adult Dental & Vision ($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

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

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.94
$276.87
$311.75
$435.67
$662.05 		$430.55
$463.48
$498.36
$622.28 		$617.16
$650.09
$684.97
$808.89 		$803.77
$836.70
$871.58
$995.50 		$186.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$487.88
$553.74
$623.50
$871.34
$1,324.10 		$674.49
$740.35
$810.11
$1,057.95 		$861.10
$926.96
$996.72
$1,244.56 		$1,047.71
$1,113.57
$1,183.33
$1,431.17 		$186.61
Toc - Plan #110 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$294.33
$334.07
$376.16
$525.68
$798.82 		$519.50
$559.24
$601.33
$750.85 		$744.67
$784.41
$826.50
$976.02 		$969.84
$1,009.58
$1,051.67
$1,201.19 		$225.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.66
$668.14
$752.32
$1,051.36
$1,597.64 		$813.83
$893.31
$977.49
$1,276.53 		$1,039.00
$1,118.48
$1,202.66
$1,501.70 		$1,264.17
$1,343.65
$1,427.83
$1,726.87 		$225.17
Toc - Plan #111 Bright HealthCare
Expanded Bronze

(HMO) Bronze 8700 ($25 Generic)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$223.68
$253.88
$285.87
$399.50
$607.07 		$394.80
$425.00
$456.99
$570.62 		$565.92
$596.12
$628.11
$741.74 		$737.04
$767.24
$799.23
$912.86 		$171.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447.36
$507.76
$571.74
$799.00
$1,214.14 		$618.48
$678.88
$742.86
$970.12 		$789.60
$850.00
$913.98
$1,141.24 		$960.72
$1,021.12
$1,085.10
$1,312.36 		$171.12
Toc - Plan #112 Bright HealthCare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$270.00
$306.45
$345.06
$482.22
$732.78 		$476.55
$513.00
$551.61
$688.77 		$683.10
$719.55
$758.16
$895.32 		$889.65
$926.10
$964.71
$1,101.87 		$206.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.00
$612.90
$690.12
$964.44
$1,465.56 		$746.55
$819.45
$896.67
$1,170.99 		$953.10
$1,026.00
$1,103.22
$1,377.54 		$1,159.65
$1,232.55
$1,309.77
$1,584.09 		$206.55

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #113 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5000 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287.21
$325.99
$367.06
$512.96
$779.50 		$506.93
$545.71
$586.78
$732.68 		$726.65
$765.43
$806.50
$952.40 		$946.37
$985.15
$1,026.22
$1,172.12 		$219.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.42
$651.98
$734.12
$1,025.92
$1,559.00 		$794.14
$871.70
$953.84
$1,245.64 		$1,013.86
$1,091.42
$1,173.56
$1,465.36 		$1,233.58
$1,311.14
$1,393.28
$1,685.08 		$219.72
Toc - Plan #114 Cigna Healthcare
Silver

(HMO) Cigna Connect 3000 ($0 PCP, $0 Tier 1 Rx, $0 Telehealth)

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

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 		$346.18
$392.91
$442.41
$618.27
$939.52 		$611.01
$657.74
$707.24
$883.10 		$875.84
$922.57
$972.07
$1,147.93 		$1,140.67
$1,187.40
$1,236.90
$1,412.76 		$264.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.36
$785.82
$884.82
$1,236.54
$1,879.04 		$957.19
$1,050.65
$1,149.65
$1,501.37 		$1,222.02
$1,315.48
$1,414.48
$1,766.20 		$1,486.85
$1,580.31
$1,679.31
$2,031.03 		$264.83
Toc - Plan #115 Cigna Healthcare
Gold

(HMO) Cigna Connect 1000 ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$381.34
$432.83
$487.36
$681.08
$1,034.97 		$673.07
$724.56
$779.09
$972.81 		$964.80
$1,016.29
$1,070.82
$1,264.54 		$1,256.53
$1,308.02
$1,362.55
$1,556.27 		$291.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.68
$865.66
$974.72
$1,362.16
$2,069.94 		$1,054.41
$1,157.39
$1,266.45
$1,653.89 		$1,346.14
$1,449.12
$1,558.18
$1,945.62 		$1,637.87
$1,740.85
$1,849.91
$2,237.35 		$291.73
Toc - Plan #116 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7500 ($0 PCP, $0 Telehealth)

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

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 		$287.84
$326.70
$367.86
$514.08
$781.20 		$508.04
$546.90
$588.06
$734.28 		$728.24
$767.10
$808.26
$954.48 		$948.44
$987.30
$1,028.46
$1,174.68 		$220.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.68
$653.40
$735.72
$1,028.16
$1,562.40 		$795.88
$873.60
$955.92
$1,248.36 		$1,016.08
$1,093.80
$1,176.12
$1,468.56 		$1,236.28
$1,314.00
$1,396.32
$1,688.76 		$220.20
Toc - Plan #117 Cigna Healthcare
Silver

(HMO) Cigna Connect 6000 ($0 PCP, $0 Tier 1 Rx, $0 Telehealth)

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

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 		$337.47
$383.03
$431.29
$602.73
$915.90 		$595.64
$641.20
$689.46
$860.90 		$853.81
$899.37
$947.63
$1,119.07 		$1,111.98
$1,157.54
$1,205.80
$1,377.24 		$258.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.94
$766.06
$862.58
$1,205.46
$1,831.80 		$933.11
$1,024.23
$1,120.75
$1,463.63 		$1,191.28
$1,282.40
$1,378.92
$1,721.80 		$1,449.45
$1,540.57
$1,637.09
$1,979.97 		$258.17
Toc - Plan #118 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8700 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276.71
$314.06
$353.63
$494.20
$750.98 		$488.39
$525.74
$565.31
$705.88 		$700.07
$737.42
$776.99
$917.56 		$911.75
$949.10
$988.67
$1,129.24 		$211.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.42
$628.12
$707.26
$988.40
$1,501.96 		$765.10
$839.80
$918.94
$1,200.08 		$976.78
$1,051.48
$1,130.62
$1,411.76 		$1,188.46
$1,263.16
$1,342.30
$1,623.44 		$211.68
Toc - Plan #119 Cigna Healthcare
Silver

(HMO) Cigna Connect 8500 ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$346.10
$392.82
$442.31
$618.13
$939.31 		$610.87
$657.59
$707.08
$882.90 		$875.64
$922.36
$971.85
$1,147.67 		$1,140.41
$1,187.13
$1,236.62
$1,412.44 		$264.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.20
$785.64
$884.62
$1,236.26
$1,878.62 		$956.97
$1,050.41
$1,149.39
$1,501.03 		$1,221.74
$1,315.18
$1,414.16
$1,765.80 		$1,486.51
$1,579.95
$1,678.93
$2,030.57 		$264.77
Toc - Plan #120 Cigna Healthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.20
$391.80
$441.16
$616.52
$936.86 		$609.28
$655.88
$705.24
$880.60 		$873.36
$919.96
$969.32
$1,144.68 		$1,137.44
$1,184.04
$1,233.40
$1,408.76 		$264.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.40
$783.60
$882.32
$1,233.04
$1,873.72 		$954.48
$1,047.68
$1,146.40
$1,497.12 		$1,218.56
$1,311.76
$1,410.48
$1,761.20 		$1,482.64
$1,575.84
$1,674.56
$2,025.28 		$264.08
Toc - Plan #121 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine 7500 ($0 PCP, $0 Telehealth)

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

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 		$311.59
$353.65
$398.21
$556.49
$845.64 		$549.95
$592.01
$636.57
$794.85 		$788.31
$830.37
$874.93
$1,033.21 		$1,026.67
$1,068.73
$1,113.29
$1,271.57 		$238.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.18
$707.30
$796.42
$1,112.98
$1,691.28 		$861.54
$945.66
$1,034.78
$1,351.34 		$1,099.90
$1,184.02
$1,273.14
$1,589.70 		$1,338.26
$1,422.38
$1,511.50
$1,828.06 		$238.36
Toc - Plan #122 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine 5000 ($0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.91
$352.88
$397.34
$555.28
$843.80 		$548.75
$590.72
$635.18
$793.12 		$786.59
$828.56
$873.02
$1,030.96 		$1,024.43
$1,066.40
$1,110.86
$1,268.80 		$237.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.82
$705.76
$794.68
$1,110.56
$1,687.60 		$859.66
$943.60
$1,032.52
$1,348.40 		$1,097.50
$1,181.44
$1,270.36
$1,586.24 		$1,335.34
$1,419.28
$1,508.20
$1,824.08 		$237.84
Toc - Plan #123 Cigna Healthcare
Bronze

(HMO) Cigna Plus with Northwestern Medicine 8700 ($0 Telehealth)

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

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 		$299.53
$339.97
$382.80
$534.97
$812.93 		$528.67
$569.11
$611.94
$764.11 		$757.81
$798.25
$841.08
$993.25 		$986.95
$1,027.39
$1,070.22
$1,222.39 		$229.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.06
$679.94
$765.60
$1,069.94
$1,625.86 		$828.20
$909.08
$994.74
$1,299.08 		$1,057.34
$1,138.22
$1,223.88
$1,528.22 		$1,286.48
$1,367.36
$1,453.02
$1,757.36 		$229.14
Toc - Plan #124 Cigna Healthcare
Silver

(HMO) Cigna Plus with Northwestern Medicine 6000 ($0 PCP, $0 Tier 1 Rx, $0 Telehealth)

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

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 		$362.94
$411.93
$463.83
$648.20
$985.01 		$640.59
$689.58
$741.48
$925.85 		$918.24
$967.23
$1,019.13
$1,203.50 		$1,195.89
$1,244.88
$1,296.78
$1,481.15 		$277.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.88
$823.86
$927.66
$1,296.40
$1,970.02 		$1,003.53
$1,101.51
$1,205.31
$1,574.05 		$1,281.18
$1,379.16
$1,482.96
$1,851.70 		$1,558.83
$1,656.81
$1,760.61
$2,129.35 		$277.65
Toc - Plan #125 Cigna Healthcare
Silver

(HMO) Cigna Plus with Northwestern Medicine 3000 ($0 PCP, $0 Tier 1 Rx, $0 Telehealth)

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

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 		$373.80
$424.26
$477.72
$667.61
$1,014.49 		$659.76
$710.22
$763.68
$953.57 		$945.72
$996.18
$1,049.64
$1,239.53 		$1,231.68
$1,282.14
$1,335.60
$1,525.49 		$285.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.60
$848.52
$955.44
$1,335.22
$2,028.98 		$1,033.56
$1,134.48
$1,241.40
$1,621.18 		$1,319.52
$1,420.44
$1,527.36
$1,907.14 		$1,605.48
$1,706.40
$1,813.32
$2,193.10 		$285.96
Toc - Plan #126 Cigna Healthcare
Silver

(HMO) Cigna Plus with Northwestern Medicine 3500 Enhanced Diabetes Care ($0 Pref Insulin)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.70
$423.01
$476.31
$665.64
$1,011.50 		$657.81
$708.12
$761.42
$950.75 		$942.92
$993.23
$1,046.53
$1,235.86 		$1,228.03
$1,278.34
$1,331.64
$1,520.97 		$285.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.40
$846.02
$952.62
$1,331.28
$2,023.00 		$1,030.51
$1,131.13
$1,237.73
$1,616.39 		$1,315.62
$1,416.24
$1,522.84
$1,901.50 		$1,600.73
$1,701.35
$1,807.95
$2,186.61 		$285.11
Toc - Plan #127 Cigna Healthcare
Gold

(HMO) Cigna Plus Northwestern Medicine 750 ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 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 		$422.65
$479.70
$540.14
$754.85
$1,147.07 		$745.98
$803.03
$863.47
$1,078.18 		$1,069.31
$1,126.36
$1,186.80
$1,401.51 		$1,392.64
$1,449.69
$1,510.13
$1,724.84 		$323.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.30
$959.40
$1,080.28
$1,509.70
$2,294.14 		$1,168.63
$1,282.73
$1,403.61
$1,833.03 		$1,491.96
$1,606.06
$1,726.94
$2,156.36 		$1,815.29
$1,929.39
$2,050.27
$2,479.69 		$323.33
Toc - Plan #128 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289.45
$328.52
$369.91
$516.95
$785.56 		$510.88
$549.95
$591.34
$738.38 		$732.31
$771.38
$812.77
$959.81 		$953.74
$992.81
$1,034.20
$1,181.24 		$221.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.90
$657.04
$739.82
$1,033.90
$1,571.12 		$800.33
$878.47
$961.25
$1,255.33 		$1,021.76
$1,099.90
$1,182.68
$1,476.76 		$1,243.19
$1,321.33
$1,404.11
$1,698.19 		$221.43
Toc - Plan #129 Cigna Healthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.25
$330.57
$372.22
$520.17
$790.46 		$514.06
$553.38
$595.03
$742.98 		$736.87
$776.19
$817.84
$965.79 		$959.68
$999.00
$1,040.65
$1,188.60 		$222.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.50
$661.14
$744.44
$1,040.34
$1,580.92 		$805.31
$883.95
$967.25
$1,263.15 		$1,028.12
$1,106.76
$1,190.06
$1,485.96 		$1,250.93
$1,329.57
$1,412.87
$1,708.77 		$222.81
Toc - Plan #130 Cigna Healthcare
Silver

(HMO) Cigna Connect 0 ($0 Tier 1 Rx, $0 Medical Deductible, $0 Telehealth)

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

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 		$341.12
$387.17
$435.95
$609.24
$925.80 		$602.08
$648.13
$696.91
$870.20 		$863.04
$909.09
$957.87
$1,131.16 		$1,124.00
$1,170.05
$1,218.83
$1,392.12 		$260.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.24
$774.34
$871.90
$1,218.48
$1,851.60 		$943.20
$1,035.30
$1,132.86
$1,479.44 		$1,204.16
$1,296.26
$1,393.82
$1,740.40 		$1,465.12
$1,557.22
$1,654.78
$2,001.36 		$260.96
Toc - Plan #131 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$342.81
$389.08
$438.11
$612.25
$930.37 		$605.06
$651.33
$700.36
$874.50 		$867.31
$913.58
$962.61
$1,136.75 		$1,129.56
$1,175.83
$1,224.86
$1,399.00 		$262.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.62
$778.16
$876.22
$1,224.50
$1,860.74 		$947.87
$1,040.41
$1,138.47
$1,486.75 		$1,210.12
$1,302.66
$1,400.72
$1,749.00 		$1,472.37
$1,564.91
$1,662.97
$2,011.25 		$262.25
Toc - Plan #132 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine HSA 7000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.33
$355.62
$400.43
$559.60
$850.36 		$553.02
$595.31
$640.12
$799.29 		$792.71
$835.00
$879.81
$1,038.98 		$1,032.40
$1,074.69
$1,119.50
$1,278.67 		$239.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.66
$711.24
$800.86
$1,119.20
$1,700.72 		$866.35
$950.93
$1,040.55
$1,358.89 		$1,106.04
$1,190.62
$1,280.24
$1,598.58 		$1,345.73
$1,430.31
$1,519.93
$1,838.27 		$239.69
Toc - Plan #133 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Plus Northwestern Medicine 6800 Enhanced Diabetes Care ($0 Pref Insulin)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$315.28
$357.84
$402.92
$563.09
$855.66 		$556.47
$599.03
$644.11
$804.28 		$797.66
$840.22
$885.30
$1,045.47 		$1,038.85
$1,081.41
$1,126.49
$1,286.66 		$241.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.56
$715.68
$805.84
$1,126.18
$1,711.32 		$871.75
$956.87
$1,047.03
$1,367.37 		$1,112.94
$1,198.06
$1,288.22
$1,608.56 		$1,354.13
$1,439.25
$1,529.41
$1,849.75 		$241.19
Toc - Plan #134 Cigna Healthcare
Silver

(HMO) Cigna Plus with Northwestern Medicine 8500 ($3 Tier 1 Rx, $0 Telehealth)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.74
$423.06
$476.36
$665.71
$1,011.62 		$657.89
$708.21
$761.51
$950.86 		$943.04
$993.36
$1,046.66
$1,236.01 		$1,228.19
$1,278.51
$1,331.81
$1,521.16 		$285.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.48
$846.12
$952.72
$1,331.42
$2,023.24 		$1,030.63
$1,131.27
$1,237.87
$1,616.57 		$1,315.78
$1,416.42
$1,523.02
$1,901.72 		$1,600.93
$1,701.57
$1,808.17
$2,186.87 		$285.15
Toc - Plan #135 Cigna Healthcare
Silver

(HMO) Cigna Plus with Northwestern Medicine 0 ($0 Tier 1 Rx, $0 Medical Deductible)

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

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 		$369.39
$419.25
$472.08
$659.72
$1,002.52 		$651.97
$701.83
$754.66
$942.30 		$934.55
$984.41
$1,037.24
$1,224.88 		$1,217.13
$1,266.99
$1,319.82
$1,507.46 		$282.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.78
$838.50
$944.16
$1,319.44
$2,005.04 		$1,021.36
$1,121.08
$1,226.74
$1,602.02 		$1,303.94
$1,403.66
$1,509.32
$1,884.60 		$1,586.52
$1,686.24
$1,791.90
$2,167.18 		$282.58
Toc - Plan #136 Cigna Healthcare
Silver

(HMO) Cigna Plus with Northwestern Medicine 4200 Enhanced Asthma COPD Care ($3 Tier 1 Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369.34
$419.21
$472.02
$659.65
$1,002.40 		$651.89
$701.76
$754.57
$942.20 		$934.44
$984.31
$1,037.12
$1,224.75 		$1,216.99
$1,266.86
$1,319.67
$1,507.30 		$282.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.68
$838.42
$944.04
$1,319.30
$2,004.80 		$1,021.23
$1,120.97
$1,226.59
$1,601.85 		$1,303.78
$1,403.52
$1,509.14
$1,884.40 		$1,586.33
$1,686.07
$1,791.69
$2,166.95 		$282.55
Toc - Plan #137 Cigna Healthcare
Gold

(HMO) Cigna Plus with Northwestern Medicine1250 Enhanced Diabetes Care ($0 Pref Insulin)

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$422.01
$478.98
$539.33
$753.71
$1,145.34 		$744.85
$801.82
$862.17
$1,076.55 		$1,067.69
$1,124.66
$1,185.01
$1,399.39 		$1,390.53
$1,447.50
$1,507.85
$1,722.23 		$322.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.02
$957.96
$1,078.66
$1,507.42
$2,290.68 		$1,166.86
$1,280.80
$1,401.50
$1,830.26 		$1,489.70
$1,603.64
$1,724.34
$2,153.10 		$1,812.54
$1,926.48
$2,047.18
$2,475.94 		$322.84

‡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 Cook County here.

Cook County is in “Rating Area 1” of Illinois.

Currently, there are 137 plans offered in Rating Area 1.

Top

2022 Obamacare Plans for Cook County, IL

Plan Browser: 137 Plans
scroll down for more
Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork