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Harvard Pilgrim Health Care

Local: 1-877-907-4742 | Toll Free: 1-877-907-4742 | TTY: 1-800-637-8257

Toc - Plan #1 Harvard Pilgrim Health Care
Gold

(HMO) ElevateHealth HMO Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$370.33
$420.32
$473.28
$661.40
$1,005.06
$653.63
$703.62
$756.58
$944.70
$936.93
$986.92
$1,039.88
$1,228.00
$1,220.23
$1,270.22
$1,323.18
$1,511.30
$283.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.66
$840.64
$946.56
$1,322.80
$2,010.12
$1,023.96
$1,123.94
$1,229.86
$1,606.10
$1,307.26
$1,407.24
$1,513.16
$1,889.40
$1,590.56
$1,690.54
$1,796.46
$2,172.70
$283.30
Toc - Plan #2 Harvard Pilgrim Health Care
Silver

(HMO) ElevateHealth HMO Silver 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$340.35
$386.29
$434.96
$607.86
$923.70
$600.72
$646.66
$695.33
$868.23
$861.09
$907.03
$955.70
$1,128.60
$1,121.46
$1,167.40
$1,216.07
$1,388.97
$260.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.70
$772.58
$869.92
$1,215.72
$1,847.40
$941.07
$1,032.95
$1,130.29
$1,476.09
$1,201.44
$1,293.32
$1,390.66
$1,736.46
$1,461.81
$1,553.69
$1,651.03
$1,996.83
$260.37
Toc - Plan #3 Harvard Pilgrim Health Care
Silver

(HMO) ElevateHealth HMO Silver 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$338.09
$383.73
$432.07
$603.82
$917.56
$596.73
$642.37
$690.71
$862.46
$855.37
$901.01
$949.35
$1,121.10
$1,114.01
$1,159.65
$1,207.99
$1,379.74
$258.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$676.18
$767.46
$864.14
$1,207.64
$1,835.12
$934.82
$1,026.10
$1,122.78
$1,466.28
$1,193.46
$1,284.74
$1,381.42
$1,724.92
$1,452.10
$1,543.38
$1,640.06
$1,983.56
$258.64
Toc - Plan #4 Harvard Pilgrim Health Care
Silver

(HMO) ElevateHealth HMO Silver 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$305.84
$347.13
$390.87
$546.24
$830.06
$539.81
$581.10
$624.84
$780.21
$773.78
$815.07
$858.81
$1,014.18
$1,007.75
$1,049.04
$1,092.78
$1,248.15
$233.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$611.68
$694.26
$781.74
$1,092.48
$1,660.12
$845.65
$928.23
$1,015.71
$1,326.45
$1,079.62
$1,162.20
$1,249.68
$1,560.42
$1,313.59
$1,396.17
$1,483.65
$1,794.39
$233.97
Toc - Plan #5 Harvard Pilgrim Health Care
Silver

(HMO) ElevateHealth HMO Silver 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$296.23
$336.22
$378.58
$529.06
$803.96
$522.84
$562.83
$605.19
$755.67
$749.45
$789.44
$831.80
$982.28
$976.06
$1,016.05
$1,058.41
$1,208.89
$226.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$592.46
$672.44
$757.16
$1,058.12
$1,607.92
$819.07
$899.05
$983.77
$1,284.73
$1,045.68
$1,125.66
$1,210.38
$1,511.34
$1,272.29
$1,352.27
$1,436.99
$1,737.95
$226.61
Toc - Plan #6 Harvard Pilgrim Health Care
Expanded Bronze

(HMO) ElevateHealth HMO Bronze 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$277.00
$314.39
$354.00
$494.72
$751.77
$488.90
$526.29
$565.90
$706.62
$700.80
$738.19
$777.80
$918.52
$912.70
$950.09
$989.70
$1,130.42
$211.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$554.00
$628.78
$708.00
$989.44
$1,503.54
$765.90
$840.68
$919.90
$1,201.34
$977.80
$1,052.58
$1,131.80
$1,413.24
$1,189.70
$1,264.48
$1,343.70
$1,625.14
$211.90
Toc - Plan #7 Harvard Pilgrim Health Care
Expanded Bronze

(HMO) ElevateHealth HMO Bronze 7200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$255.50
$290.00
$326.53
$456.33
$693.44
$450.96
$485.46
$521.99
$651.79
$646.42
$680.92
$717.45
$847.25
$841.88
$876.38
$912.91
$1,042.71
$195.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$511.00
$580.00
$653.06
$912.66
$1,386.88
$706.46
$775.46
$848.52
$1,108.12
$901.92
$970.92
$1,043.98
$1,303.58
$1,097.38
$1,166.38
$1,239.44
$1,499.04
$195.46
Toc - Plan #8 Harvard Pilgrim Health Care
Expanded Bronze

(HMO) ElevateHealth HMO Bronze 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$244.19
$277.16
$312.08
$436.13
$662.73
$431.00
$463.97
$498.89
$622.94
$617.81
$650.78
$685.70
$809.75
$804.62
$837.59
$872.51
$996.56
$186.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$488.38
$554.32
$624.16
$872.26
$1,325.46
$675.19
$741.13
$810.97
$1,059.07
$862.00
$927.94
$997.78
$1,245.88
$1,048.81
$1,114.75
$1,184.59
$1,432.69
$186.81
Toc - Plan #9 Harvard Pilgrim Health Care
Catastrophic

(HMO) ElevateHealth HMO Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$173.49
$196.91
$221.72
$309.85
$470.85
$306.21
$329.63
$354.44
$442.57
$438.93
$462.35
$487.16
$575.29
$571.65
$595.07
$619.88
$708.01
$132.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$346.98
$393.82
$443.44
$619.70
$941.70
$479.70
$526.54
$576.16
$752.42
$612.42
$659.26
$708.88
$885.14
$745.14
$791.98
$841.60
$1,017.86
$132.72
Toc - Plan #10 Harvard Pilgrim Health Care
Silver

(HMO) ElevateHealth HMO HSA Silver 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.16
$359.97
$405.33
$566.44
$860.76
$559.79
$602.60
$647.96
$809.07
$802.42
$845.23
$890.59
$1,051.70
$1,045.05
$1,087.86
$1,133.22
$1,294.33
$242.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.32
$719.94
$810.66
$1,132.88
$1,721.52
$876.95
$962.57
$1,053.29
$1,375.51
$1,119.58
$1,205.20
$1,295.92
$1,618.14
$1,362.21
$1,447.83
$1,538.55
$1,860.77
$242.63
Toc - Plan #11 Harvard Pilgrim Health Care
Expanded Bronze

(HMO) ElevateHealth HMO HSA Bronze 7000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-907-4742

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
$252.68
$286.79
$322.92
$451.28
$685.76
$445.98
$480.09
$516.22
$644.58
$639.28
$673.39
$709.52
$837.88
$832.58
$866.69
$902.82
$1,031.18
$193.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$505.36
$573.58
$645.84
$902.56
$1,371.52
$698.66
$766.88
$839.14
$1,095.86
$891.96
$960.18
$1,032.44
$1,289.16
$1,085.26
$1,153.48
$1,225.74
$1,482.46
$193.30

ADVERTISEMENT

Ambetter from New Hampshire Healthy Families

Local: 1-844-265-1278 | Toll Free: 1-844-265-1278 | TTY: 1-855-742-0123

Toc - Plan #12 Ambetter from New Hampshire Healthy Families
Gold

(EPO) Ambetter Secure Care 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$294.34
$334.07
$376.15
$525.67
$798.81
$519.50
$559.23
$601.31
$750.83
$744.66
$784.39
$826.47
$975.99
$969.82
$1,009.55
$1,051.63
$1,201.15
$225.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$588.68
$668.14
$752.30
$1,051.34
$1,597.62
$813.84
$893.30
$977.46
$1,276.50
$1,039.00
$1,118.46
$1,202.62
$1,501.66
$1,264.16
$1,343.62
$1,427.78
$1,726.82
$225.16
Toc - Plan #13 Ambetter from New Hampshire Healthy Families
Expanded Bronze

(EPO) Ambetter Essential Care 2 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$214.76
$243.75
$274.45
$383.55
$582.84
$379.05
$408.04
$438.74
$547.84
$543.34
$572.33
$603.03
$712.13
$707.63
$736.62
$767.32
$876.42
$164.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$429.52
$487.50
$548.90
$767.10
$1,165.68
$593.81
$651.79
$713.19
$931.39
$758.10
$816.08
$877.48
$1,095.68
$922.39
$980.37
$1,041.77
$1,259.97
$164.29
Toc - Plan #14 Ambetter from New Hampshire Healthy Families
Expanded Bronze

(EPO) Ambetter Essential Care 10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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
$206.85
$234.76
$264.34
$369.41
$561.35
$365.08
$392.99
$422.57
$527.64
$523.31
$551.22
$580.80
$685.87
$681.54
$709.45
$739.03
$844.10
$158.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$413.70
$469.52
$528.68
$738.82
$1,122.70
$571.93
$627.75
$686.91
$897.05
$730.16
$785.98
$845.14
$1,055.28
$888.39
$944.21
$1,003.37
$1,213.51
$158.23
Toc - Plan #15 Ambetter from New Hampshire Healthy Families
Silver

(EPO) Ambetter Balanced Care 11

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$251.36
$285.28
$321.23
$448.91
$682.16
$443.64
$477.56
$513.51
$641.19
$635.92
$669.84
$705.79
$833.47
$828.20
$862.12
$898.07
$1,025.75
$192.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$502.72
$570.56
$642.46
$897.82
$1,364.32
$695.00
$762.84
$834.74
$1,090.10
$887.28
$955.12
$1,027.02
$1,282.38
$1,079.56
$1,147.40
$1,219.30
$1,474.66
$192.28
Toc - Plan #16 Ambetter from New Hampshire Healthy Families
Silver

(EPO) Ambetter Balanced Care 12

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$248.42
$281.94
$317.47
$443.66
$674.18
$438.45
$471.97
$507.50
$633.69
$628.48
$662.00
$697.53
$823.72
$818.51
$852.03
$887.56
$1,013.75
$190.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$496.84
$563.88
$634.94
$887.32
$1,348.36
$686.87
$753.91
$824.97
$1,077.35
$876.90
$943.94
$1,015.00
$1,267.38
$1,066.93
$1,133.97
$1,205.03
$1,457.41
$190.03
Toc - Plan #17 Ambetter from New Hampshire Healthy Families
Silver

(EPO) Ambetter Balanced Care 28

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$264.71
$300.43
$338.28
$472.75
$718.39
$467.20
$502.92
$540.77
$675.24
$669.69
$705.41
$743.26
$877.73
$872.18
$907.90
$945.75
$1,080.22
$202.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$529.42
$600.86
$676.56
$945.50
$1,436.78
$731.91
$803.35
$879.05
$1,147.99
$934.40
$1,005.84
$1,081.54
$1,350.48
$1,136.89
$1,208.33
$1,284.03
$1,552.97
$202.49
Toc - Plan #18 Ambetter from New Hampshire Healthy Families
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$229.82
$260.83
$293.70
$410.44
$623.70
$405.62
$436.63
$469.50
$586.24
$581.42
$612.43
$645.30
$762.04
$757.22
$788.23
$821.10
$937.84
$175.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$459.64
$521.66
$587.40
$820.88
$1,247.40
$635.44
$697.46
$763.20
$996.68
$811.24
$873.26
$939.00
$1,172.48
$987.04
$1,049.06
$1,114.80
$1,348.28
$175.80
Toc - Plan #19 Ambetter from New Hampshire Healthy Families
Expanded Bronze

(EPO) Ambetter Essential Care: $0 Medical Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$240.88
$273.39
$307.83
$430.19
$653.72
$425.14
$457.65
$492.09
$614.45
$609.40
$641.91
$676.35
$798.71
$793.66
$826.17
$860.61
$982.97
$184.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$481.76
$546.78
$615.66
$860.38
$1,307.44
$666.02
$731.04
$799.92
$1,044.64
$850.28
$915.30
$984.18
$1,228.90
$1,034.54
$1,099.56
$1,168.44
$1,413.16
$184.26
Toc - Plan #20 Ambetter from New Hampshire Healthy Families
Silver

(EPO) Ambetter Balanced Care 32

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$241.46
$274.04
$308.57
$431.22
$655.29
$426.17
$458.75
$493.28
$615.93
$610.88
$643.46
$677.99
$800.64
$795.59
$828.17
$862.70
$985.35
$184.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$482.92
$548.08
$617.14
$862.44
$1,310.58
$667.63
$732.79
$801.85
$1,047.15
$852.34
$917.50
$986.56
$1,231.86
$1,037.05
$1,102.21
$1,171.27
$1,416.57
$184.71
Toc - Plan #21 Ambetter from New Hampshire Healthy Families
Gold

(EPO) Ambetter Secure Care 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$276.80
$314.15
$353.73
$494.34
$751.20
$488.54
$525.89
$565.47
$706.08
$700.28
$737.63
$777.21
$917.82
$912.02
$949.37
$988.95
$1,129.56
$211.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$553.60
$628.30
$707.46
$988.68
$1,502.40
$765.34
$840.04
$919.20
$1,200.42
$977.08
$1,051.78
$1,130.94
$1,412.16
$1,188.82
$1,263.52
$1,342.68
$1,623.90
$211.74
Toc - Plan #22 Ambetter from New Hampshire Healthy Families
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$232.32
$263.67
$296.89
$414.91
$630.49
$410.04
$441.39
$474.61
$592.63
$587.76
$619.11
$652.33
$770.35
$765.48
$796.83
$830.05
$948.07
$177.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$464.64
$527.34
$593.78
$829.82
$1,260.98
$642.36
$705.06
$771.50
$1,007.54
$820.08
$882.78
$949.22
$1,185.26
$997.80
$1,060.50
$1,126.94
$1,362.98
$177.72
Toc - Plan #23 Ambetter from New Hampshire Healthy Families
Expanded Bronze

(EPO) Ambetter Essential Care 10 + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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
$223.76
$253.95
$285.95
$399.61
$607.25
$394.93
$425.12
$457.12
$570.78
$566.10
$596.29
$628.29
$741.95
$737.27
$767.46
$799.46
$913.12
$171.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$447.52
$507.90
$571.90
$799.22
$1,214.50
$618.69
$679.07
$743.07
$970.39
$789.86
$850.24
$914.24
$1,141.56
$961.03
$1,021.41
$1,085.41
$1,312.73
$171.17
Toc - Plan #24 Ambetter from New Hampshire Healthy Families
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$286.35
$324.99
$365.94
$511.40
$777.12
$505.40
$544.04
$584.99
$730.45
$724.45
$763.09
$804.04
$949.50
$943.50
$982.14
$1,023.09
$1,168.55
$219.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.70
$649.98
$731.88
$1,022.80
$1,554.24
$791.75
$869.03
$950.93
$1,241.85
$1,010.80
$1,088.08
$1,169.98
$1,460.90
$1,229.85
$1,307.13
$1,389.03
$1,679.95
$219.05
Toc - Plan #25 Ambetter from New Hampshire Healthy Families
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$318.40
$361.38
$406.91
$568.65
$864.12
$561.97
$604.95
$650.48
$812.22
$805.54
$848.52
$894.05
$1,055.79
$1,049.11
$1,092.09
$1,137.62
$1,299.36
$243.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.80
$722.76
$813.82
$1,137.30
$1,728.24
$880.37
$966.33
$1,057.39
$1,380.87
$1,123.94
$1,209.90
$1,300.96
$1,624.44
$1,367.51
$1,453.47
$1,544.53
$1,868.01
$243.57
Toc - Plan #26 Ambetter from New Hampshire Healthy Families
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$271.91
$308.61
$347.49
$485.61
$737.94
$479.91
$516.61
$555.49
$693.61
$687.91
$724.61
$763.49
$901.61
$895.91
$932.61
$971.49
$1,109.61
$208.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$543.82
$617.22
$694.98
$971.22
$1,475.88
$751.82
$825.22
$902.98
$1,179.22
$959.82
$1,033.22
$1,110.98
$1,387.22
$1,167.82
$1,241.22
$1,318.98
$1,595.22
$208.00
Toc - Plan #27 Ambetter from New Hampshire Healthy Families
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$248.61
$282.16
$317.71
$444.00
$674.70
$438.79
$472.34
$507.89
$634.18
$628.97
$662.52
$698.07
$824.36
$819.15
$852.70
$888.25
$1,014.54
$190.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$497.22
$564.32
$635.42
$888.00
$1,349.40
$687.40
$754.50
$825.60
$1,078.18
$877.58
$944.68
$1,015.78
$1,268.36
$1,067.76
$1,134.86
$1,205.96
$1,458.54
$190.18
Toc - Plan #28 Ambetter from New Hampshire Healthy Families
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$260.57
$295.74
$333.00
$465.36
$707.16
$459.90
$495.07
$532.33
$664.69
$659.23
$694.40
$731.66
$864.02
$858.56
$893.73
$930.99
$1,063.35
$199.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$521.14
$591.48
$666.00
$930.72
$1,414.32
$720.47
$790.81
$865.33
$1,130.05
$919.80
$990.14
$1,064.66
$1,329.38
$1,119.13
$1,189.47
$1,263.99
$1,528.71
$199.33
Toc - Plan #29 Ambetter from New Hampshire Healthy Families
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$268.73
$305.00
$343.42
$479.93
$729.30
$474.30
$510.57
$548.99
$685.50
$679.87
$716.14
$754.56
$891.07
$885.44
$921.71
$960.13
$1,096.64
$205.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.46
$610.00
$686.84
$959.86
$1,458.60
$743.03
$815.57
$892.41
$1,165.43
$948.60
$1,021.14
$1,097.98
$1,371.00
$1,154.17
$1,226.71
$1,303.55
$1,576.57
$205.57
Toc - Plan #30 Ambetter from New Hampshire Healthy Families
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-265-1278

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
$299.43
$339.84
$382.65
$534.76
$812.62
$528.48
$568.89
$611.70
$763.81
$757.53
$797.94
$840.75
$992.86
$986.58
$1,026.99
$1,069.80
$1,221.91
$229.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.86
$679.68
$765.30
$1,069.52
$1,625.24
$827.91
$908.73
$994.35
$1,298.57
$1,056.96
$1,137.78
$1,223.40
$1,527.62
$1,286.01
$1,366.83
$1,452.45
$1,756.67
$229.05

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1804 | Toll Free: 1-855-748-1804

Toc - Plan #31 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X Enhanced HMO 35 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$218.03
$247.46
$278.64
$389.40
$591.73
$384.82
$414.25
$445.43
$556.19
$551.61
$581.04
$612.22
$722.98
$718.40
$747.83
$779.01
$889.77
$166.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$436.06
$494.92
$557.28
$778.80
$1,183.46
$602.85
$661.71
$724.07
$945.59
$769.64
$828.50
$890.86
$1,112.38
$936.43
$995.29
$1,057.65
$1,279.17
$166.79
Toc - Plan #32 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X Enhanced HMO 6000 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

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
$218.76
$248.29
$279.58
$390.71
$593.71
$386.11
$415.64
$446.93
$558.06
$553.46
$582.99
$614.28
$725.41
$720.81
$750.34
$781.63
$892.76
$167.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$437.52
$496.58
$559.16
$781.42
$1,187.42
$604.87
$663.93
$726.51
$948.77
$772.22
$831.28
$893.86
$1,116.12
$939.57
$998.63
$1,061.21
$1,283.47
$167.35
Toc - Plan #33 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X Enhanced HMO 10 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$264.35
$300.04
$337.84
$472.13
$717.45
$466.58
$502.27
$540.07
$674.36
$668.81
$704.50
$742.30
$876.59
$871.04
$906.73
$944.53
$1,078.82
$202.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$528.70
$600.08
$675.68
$944.26
$1,434.90
$730.93
$802.31
$877.91
$1,146.49
$933.16
$1,004.54
$1,080.14
$1,348.72
$1,135.39
$1,206.77
$1,282.37
$1,550.95
$202.23
Toc - Plan #34 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X Enhanced HMO 4000 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

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
$261.53
$296.84
$334.24
$467.09
$709.79
$461.60
$496.91
$534.31
$667.16
$661.67
$696.98
$734.38
$867.23
$861.74
$897.05
$934.45
$1,067.30
$200.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$523.06
$593.68
$668.48
$934.18
$1,419.58
$723.13
$793.75
$868.55
$1,134.25
$923.20
$993.82
$1,068.62
$1,334.32
$1,123.27
$1,193.89
$1,268.69
$1,534.39
$200.07
Toc - Plan #35 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway X Enhanced HMO 8700 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

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
$149.80
$170.02
$191.44
$267.54
$406.56
$264.40
$284.62
$306.04
$382.14
$379.00
$399.22
$420.64
$496.74
$493.60
$513.82
$535.24
$611.34
$114.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$299.60
$340.04
$382.88
$535.08
$813.12
$414.20
$454.64
$497.48
$649.68
$528.80
$569.24
$612.08
$764.28
$643.40
$683.84
$726.68
$878.88
$114.60
Toc - Plan #36 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X Enhanced HMO 3500 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

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
$269.63
$306.03
$344.59
$481.56
$731.78
$475.90
$512.30
$550.86
$687.83
$682.17
$718.57
$757.13
$894.10
$888.44
$924.84
$963.40
$1,100.37
$206.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$539.26
$612.06
$689.18
$963.12
$1,463.56
$745.53
$818.33
$895.45
$1,169.39
$951.80
$1,024.60
$1,101.72
$1,375.66
$1,158.07
$1,230.87
$1,307.99
$1,581.93
$206.27
Toc - Plan #37 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X Enhanced HMO 6500 40

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

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
$212.07
$240.70
$271.03
$378.76
$575.56
$374.30
$402.93
$433.26
$540.99
$536.53
$565.16
$595.49
$703.22
$698.76
$727.39
$757.72
$865.45
$162.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$424.14
$481.40
$542.06
$757.52
$1,151.12
$586.37
$643.63
$704.29
$919.75
$748.60
$805.86
$866.52
$1,081.98
$910.83
$968.09
$1,028.75
$1,244.21
$162.23
Toc - Plan #38 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X Enhanced HMO 6300 30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

Annual Out of Pocket Expenses:

Individual Family
$6,300 $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
$241.52
$274.13
$308.66
$431.35
$655.49
$426.28
$458.89
$493.42
$616.11
$611.04
$643.65
$678.18
$800.87
$795.80
$828.41
$862.94
$985.63
$184.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$483.04
$548.26
$617.32
$862.70
$1,310.98
$667.80
$733.02
$802.08
$1,047.46
$852.56
$917.78
$986.84
$1,232.22
$1,037.32
$1,102.54
$1,171.60
$1,416.98
$184.76
Toc - Plan #39 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X Enhanced HMO 1500 15

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.88
$327.88
$369.19
$515.94
$784.02
$509.87
$548.87
$590.18
$736.93
$730.86
$769.86
$811.17
$957.92
$951.85
$990.85
$1,032.16
$1,178.91
$220.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$577.76
$655.76
$738.38
$1,031.88
$1,568.04
$798.75
$876.75
$959.37
$1,252.87
$1,019.74
$1,097.74
$1,180.36
$1,473.86
$1,240.73
$1,318.73
$1,401.35
$1,694.85
$220.99
Toc - Plan #40 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X Enhanced HMO 4500 15

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$226.33
$256.88
$289.25
$404.23
$614.26
$399.47
$430.02
$462.39
$577.37
$572.61
$603.16
$635.53
$750.51
$745.75
$776.30
$808.67
$923.65
$173.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$452.66
$513.76
$578.50
$808.46
$1,228.52
$625.80
$686.90
$751.64
$981.60
$798.94
$860.04
$924.78
$1,154.74
$972.08
$1,033.18
$1,097.92
$1,327.88
$173.14
Toc - Plan #41 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X Enhanced HMO 5500 20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$250.52
$284.34
$320.16
$447.43
$679.91
$442.17
$475.99
$511.81
$639.08
$633.82
$667.64
$703.46
$830.73
$825.47
$859.29
$895.11
$1,022.38
$191.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$501.04
$568.68
$640.32
$894.86
$1,359.82
$692.69
$760.33
$831.97
$1,086.51
$884.34
$951.98
$1,023.62
$1,278.16
$1,075.99
$1,143.63
$1,215.27
$1,469.81
$191.65
Toc - Plan #42 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X Enhanced HMO 20 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

Annual Out of Pocket Expenses:

Individual Family
$4,600 $9,200 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
$238.39
$270.57
$304.66
$425.76
$646.99
$420.76
$452.94
$487.03
$608.13
$603.13
$635.31
$669.40
$790.50
$785.50
$817.68
$851.77
$972.87
$182.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$476.78
$541.14
$609.32
$851.52
$1,293.98
$659.15
$723.51
$791.69
$1,033.89
$841.52
$905.88
$974.06
$1,216.26
$1,023.89
$1,088.25
$1,156.43
$1,398.63
$182.37
Toc - Plan #43 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X Enhanced HMO 4000 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

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
$265.58
$301.43
$339.41
$474.33
$720.78
$468.75
$504.60
$542.58
$677.50
$671.92
$707.77
$745.75
$880.67
$875.09
$910.94
$948.92
$1,083.84
$203.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$531.16
$602.86
$678.82
$948.66
$1,441.56
$734.33
$806.03
$881.99
$1,151.83
$937.50
$1,009.20
$1,085.16
$1,355.00
$1,140.67
$1,212.37
$1,288.33
$1,558.17
$203.17
Toc - Plan #44 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X Enhanced HMO 8700 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1804

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
$211.55
$240.11
$270.36
$377.83
$574.15
$373.39
$401.95
$432.20
$539.67
$535.23
$563.79
$594.04
$701.51
$697.07
$725.63
$755.88
$863.35
$161.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$423.10
$480.22
$540.72
$755.66
$1,148.30
$584.94
$642.06
$702.56
$917.50
$746.78
$803.90
$864.40
$1,079.34
$908.62
$965.74
$1,026.24
$1,241.18
$161.84

‡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 Hillsborough County here.

Hillsborough County is in “Rating Area 1” of New Hampshire.

Currently, there are 44 plans offered in Rating Area 1.

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2022 Obamacare Plans for Hillsborough County, NH

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