Obamacare 2023 Rates for Cherokee County

Obamacare > Rates > Georgia > Cherokee County

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Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Cherokee County, GA.

The health insurance rates listed below are for calendar year 2023.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 147 Plans and 2023 Rates for Cherokee County, Georgia

Below, you’ll find a summary of the 147 plans for Cherokee County, Georgia and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Cherokee County Resources

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Cigna HealthCare of Georgia, Inc

Local:  | Toll Free: 

Toc - Plan #1 Cigna HealthCare of Georgia, Inc
Bronze

(HMO) Cigna Connect 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$275.95
$313.20
$352.66
$492.84
$748.92 		$487.05
$524.30
$563.76
$703.94 		$698.15
$735.40
$774.86
$915.04 		$909.25
$946.50
$985.96
$1,126.14 		$211.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.90
$626.40
$705.32
$985.68
$1,497.84 		$763.00
$837.50
$916.42
$1,196.78 		$974.10
$1,048.60
$1,127.52
$1,407.88 		$1,185.20
$1,259.70
$1,338.62
$1,618.98 		$211.10
Toc - Plan #2 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 7800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 Annual Deductible
$9,100 $18,200 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 		$285.68
$324.25
$365.10
$510.23
$775.35 		$504.23
$542.80
$583.65
$728.78 		$722.78
$761.35
$802.20
$947.33 		$941.33
$979.90
$1,020.75
$1,165.88 		$218.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.36
$648.50
$730.20
$1,020.46
$1,550.70 		$789.91
$867.05
$948.75
$1,239.01 		$1,008.46
$1,085.60
$1,167.30
$1,457.56 		$1,227.01
$1,304.15
$1,385.85
$1,676.11 		$218.55
Toc - Plan #3 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 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 		$286.65
$325.35
$366.34
$511.96
$777.97 		$505.94
$544.64
$585.63
$731.25 		$725.23
$763.93
$804.92
$950.54 		$944.52
$983.22
$1,024.21
$1,169.83 		$219.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.30
$650.70
$732.68
$1,023.92
$1,555.94 		$792.59
$869.99
$951.97
$1,243.21 		$1,011.88
$1,089.28
$1,171.26
$1,462.50 		$1,231.17
$1,308.57
$1,390.55
$1,681.79 		$219.29
Toc - Plan #4 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect HSA 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$289.74
$328.86
$370.29
$517.48
$786.36 		$511.39
$550.51
$591.94
$739.13 		$733.04
$772.16
$813.59
$960.78 		$954.69
$993.81
$1,035.24
$1,182.43 		$221.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.48
$657.72
$740.58
$1,034.96
$1,572.72 		$801.13
$879.37
$962.23
$1,256.61 		$1,022.78
$1,101.02
$1,183.88
$1,478.26 		$1,244.43
$1,322.67
$1,405.53
$1,699.91 		$221.65
Toc - Plan #5 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$9,100 $18,200 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 		$289.47
$328.55
$369.94
$516.99
$785.62 		$510.92
$550.00
$591.39
$738.44 		$732.37
$771.45
$812.84
$959.89 		$953.82
$992.90
$1,034.29
$1,181.34 		$221.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$578.94
$657.10
$739.88
$1,033.98
$1,571.24 		$800.39
$878.55
$961.33
$1,255.43 		$1,021.84
$1,100.00
$1,182.78
$1,476.88 		$1,243.29
$1,321.45
$1,404.23
$1,698.33 		$221.45
Toc - Plan #6 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 3700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 Annual Deductible
$9,100 $18,200 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 		$334.53
$379.69
$427.53
$597.47
$907.91 		$590.44
$635.60
$683.44
$853.38 		$846.35
$891.51
$939.35
$1,109.29 		$1,102.26
$1,147.42
$1,195.26
$1,365.20 		$255.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.06
$759.38
$855.06
$1,194.94
$1,815.82 		$924.97
$1,015.29
$1,110.97
$1,450.85 		$1,180.88
$1,271.20
$1,366.88
$1,706.76 		$1,436.79
$1,527.11
$1,622.79
$1,962.67 		$255.91
Toc - Plan #7 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,000 $18,000 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 		$334.57
$379.73
$427.58
$597.54
$908.01 		$590.51
$635.67
$683.52
$853.48 		$846.45
$891.61
$939.46
$1,109.42 		$1,102.39
$1,147.55
$1,195.40
$1,365.36 		$255.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.14
$759.46
$855.16
$1,195.08
$1,816.02 		$925.08
$1,015.40
$1,111.10
$1,451.02 		$1,181.02
$1,271.34
$1,367.04
$1,706.96 		$1,436.96
$1,527.28
$1,622.98
$1,962.90 		$255.94
Toc - Plan #8 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 6000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 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 		$335.07
$380.30
$428.22
$598.43
$909.38 		$591.40
$636.63
$684.55
$854.76 		$847.73
$892.96
$940.88
$1,111.09 		$1,104.06
$1,149.29
$1,197.21
$1,367.42 		$256.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.14
$760.60
$856.44
$1,196.86
$1,818.76 		$926.47
$1,016.93
$1,112.77
$1,453.19 		$1,182.80
$1,273.26
$1,369.10
$1,709.52 		$1,439.13
$1,529.59
$1,625.43
$1,965.85 		$256.33
Toc - Plan #9 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 7200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$339.44
$385.26
$433.80
$606.23
$921.23 		$599.11
$644.93
$693.47
$865.90 		$858.78
$904.60
$953.14
$1,125.57 		$1,118.45
$1,164.27
$1,212.81
$1,385.24 		$259.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.88
$770.52
$867.60
$1,212.46
$1,842.46 		$938.55
$1,030.19
$1,127.27
$1,472.13 		$1,198.22
$1,289.86
$1,386.94
$1,731.80 		$1,457.89
$1,549.53
$1,646.61
$1,991.47 		$259.67
Toc - Plan #10 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 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 		$337.81
$383.42
$431.72
$603.33
$916.82 		$596.24
$641.85
$690.15
$861.76 		$854.67
$900.28
$948.58
$1,120.19 		$1,113.10
$1,158.71
$1,207.01
$1,378.62 		$258.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.62
$766.84
$863.44
$1,206.66
$1,833.64 		$934.05
$1,025.27
$1,121.87
$1,465.09 		$1,192.48
$1,283.70
$1,380.30
$1,723.52 		$1,450.91
$1,542.13
$1,638.73
$1,981.95 		$258.43
Toc - Plan #11 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$9,100 $18,200 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 		$336.23
$381.62
$429.70
$600.50
$912.52 		$593.44
$638.83
$686.91
$857.71 		$850.65
$896.04
$944.12
$1,114.92 		$1,107.86
$1,153.25
$1,201.33
$1,372.13 		$257.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.46
$763.24
$859.40
$1,201.00
$1,825.04 		$929.67
$1,020.45
$1,116.61
$1,458.21 		$1,186.88
$1,277.66
$1,373.82
$1,715.42 		$1,444.09
$1,534.87
$1,631.03
$1,972.63 		$257.21
Toc - Plan #12 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Cigna Connect 1600

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 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 		$423.75
$480.96
$541.56
$756.82
$1,150.07 		$747.92
$805.13
$865.73
$1,080.99 		$1,072.09
$1,129.30
$1,189.90
$1,405.16 		$1,396.26
$1,453.47
$1,514.07
$1,729.33 		$324.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847.50
$961.92
$1,083.12
$1,513.64
$2,300.14 		$1,171.67
$1,286.09
$1,407.29
$1,837.81 		$1,495.84
$1,610.26
$1,731.46
$2,161.98 		$1,820.01
$1,934.43
$2,055.63
$2,486.15 		$324.17
Toc - Plan #13 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 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 		$426.46
$484.03
$545.01
$761.65
$1,157.41 		$752.70
$810.27
$871.25
$1,087.89 		$1,078.94
$1,136.51
$1,197.49
$1,414.13 		$1,405.18
$1,462.75
$1,523.73
$1,740.37 		$326.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.92
$968.06
$1,090.02
$1,523.30
$2,314.82 		$1,179.16
$1,294.30
$1,416.26
$1,849.54 		$1,505.40
$1,620.54
$1,742.50
$2,175.78 		$1,831.64
$1,946.78
$2,068.74
$2,502.02 		$326.24
Toc - Plan #14 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,600 $15,200 Annual Deductible
$9,100 $18,200 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 		$290.20
$329.38
$370.88
$518.31
$787.62 		$512.21
$551.39
$592.89
$740.32 		$734.22
$773.40
$814.90
$962.33 		$956.23
$995.41
$1,036.91
$1,184.34 		$222.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.40
$658.76
$741.76
$1,036.62
$1,575.24 		$802.41
$880.77
$963.77
$1,258.63 		$1,024.42
$1,102.78
$1,185.78
$1,480.64 		$1,246.43
$1,324.79
$1,407.79
$1,702.65 		$222.01
Toc - Plan #15 Cigna HealthCare of Georgia, Inc
Bronze

(HMO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$275.95
$313.20
$352.66
$492.84
$748.92 		$487.05
$524.30
$563.76
$703.94 		$698.15
$735.40
$774.86
$915.04 		$909.25
$946.50
$985.96
$1,126.14 		$211.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.90
$626.40
$705.32
$985.68
$1,497.84 		$763.00
$837.50
$916.42
$1,196.78 		$974.10
$1,048.60
$1,127.52
$1,407.88 		$1,185.20
$1,259.70
$1,338.62
$1,618.98 		$211.10
Toc - Plan #16 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$287.54
$326.36
$367.47
$513.54
$780.38 		$507.51
$546.33
$587.44
$733.51 		$727.48
$766.30
$807.41
$953.48 		$947.45
$986.27
$1,027.38
$1,173.45 		$219.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.08
$652.72
$734.94
$1,027.08
$1,560.76 		$795.05
$872.69
$954.91
$1,247.05 		$1,015.02
$1,092.66
$1,174.88
$1,467.02 		$1,234.99
$1,312.63
$1,394.85
$1,686.99 		$219.97
Toc - Plan #17 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Cigna Connect 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$308.95
$350.65
$394.83
$551.78
$838.48 		$545.29
$586.99
$631.17
$788.12 		$781.63
$823.33
$867.51
$1,024.46 		$1,017.97
$1,059.67
$1,103.85
$1,260.80 		$236.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.90
$701.30
$789.66
$1,103.56
$1,676.96 		$854.24
$937.64
$1,026.00
$1,339.90 		$1,090.58
$1,173.98
$1,262.34
$1,576.24 		$1,326.92
$1,410.32
$1,498.68
$1,812.58 		$236.34
Toc - Plan #18 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Cigna Simple Choice 2000

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 		$421.78
$478.72
$539.04
$753.30
$1,144.72 		$744.44
$801.38
$861.70
$1,075.96 		$1,067.10
$1,124.04
$1,184.36
$1,398.62 		$1,389.76
$1,446.70
$1,507.02
$1,721.28 		$322.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.56
$957.44
$1,078.08
$1,506.60
$2,289.44 		$1,166.22
$1,280.10
$1,400.74
$1,829.26 		$1,488.88
$1,602.76
$1,723.40
$2,151.92 		$1,811.54
$1,925.42
$2,046.06
$2,474.58 		$322.66
Toc - Plan #19 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$335.07
$380.30
$428.22
$598.43
$909.38 		$591.40
$636.63
$684.55
$854.76 		$847.73
$892.96
$940.88
$1,111.09 		$1,104.06
$1,149.29
$1,197.21
$1,367.42 		$256.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.14
$760.60
$856.44
$1,196.86
$1,818.76 		$926.47
$1,016.93
$1,112.77
$1,453.19 		$1,182.80
$1,273.26
$1,369.10
$1,709.52 		$1,439.13
$1,529.59
$1,625.43
$1,965.85 		$256.33

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-609-9754 | Toll Free: 1-800-609-9754 | TTY: 1-800-609-9754
Toc - Plan #20 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$550.66
$624.99
$703.74
$983.47
$1,494.48 		$971.91
$1,046.24
$1,124.99
$1,404.72 		$1,393.16
$1,467.49
$1,546.24
$1,825.97 		$1,814.41
$1,888.74
$1,967.49
$2,247.22 		$421.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,101.32
$1,249.98
$1,407.48
$1,966.94
$2,988.96 		$1,522.57
$1,671.23
$1,828.73
$2,388.19 		$1,943.82
$2,092.48
$2,249.98
$2,809.44 		$2,365.07
$2,513.73
$2,671.23
$3,230.69 		$421.25
Toc - Plan #21 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$572.27
$649.53
$731.36
$1,022.08
$1,553.15 		$1,010.06
$1,087.32
$1,169.15
$1,459.87 		$1,447.85
$1,525.11
$1,606.94
$1,897.66 		$1,885.64
$1,962.90
$2,044.73
$2,335.45 		$437.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,144.54
$1,299.06
$1,462.72
$2,044.16
$3,106.30 		$1,582.33
$1,736.85
$1,900.51
$2,481.95 		$2,020.12
$2,174.64
$2,338.30
$2,919.74 		$2,457.91
$2,612.43
$2,776.09
$3,357.53 		$437.79
Toc - Plan #22 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 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 		$525.92
$596.92
$672.12
$939.29
$1,427.34 		$928.25
$999.25
$1,074.45
$1,341.62 		$1,330.58
$1,401.58
$1,476.78
$1,743.95 		$1,732.91
$1,803.91
$1,879.11
$2,146.28 		$402.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.84
$1,193.84
$1,344.24
$1,878.58
$2,854.68 		$1,454.17
$1,596.17
$1,746.57
$2,280.91 		$1,856.50
$1,998.50
$2,148.90
$2,683.24 		$2,258.83
$2,400.83
$2,551.23
$3,085.57 		$402.33
Toc - Plan #23 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,200 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 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 		$525.81
$596.79
$671.98
$939.09
$1,427.03 		$928.05
$999.03
$1,074.22
$1,341.33 		$1,330.29
$1,401.27
$1,476.46
$1,743.57 		$1,732.53
$1,803.51
$1,878.70
$2,145.81 		$402.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,051.62
$1,193.58
$1,343.96
$1,878.18
$2,854.06 		$1,453.86
$1,595.82
$1,746.20
$2,280.42 		$1,856.10
$1,998.06
$2,148.44
$2,682.66 		$2,258.34
$2,400.30
$2,550.68
$3,084.90 		$402.24
Toc - Plan #24 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 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 		$486.80
$552.52
$622.13
$869.42
$1,321.17 		$859.20
$924.92
$994.53
$1,241.82 		$1,231.60
$1,297.32
$1,366.93
$1,614.22 		$1,604.00
$1,669.72
$1,739.33
$1,986.62 		$372.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.60
$1,105.04
$1,244.26
$1,738.84
$2,642.34 		$1,346.00
$1,477.44
$1,616.66
$2,111.24 		$1,718.40
$1,849.84
$1,989.06
$2,483.64 		$2,090.80
$2,222.24
$2,361.46
$2,856.04 		$372.40
Toc - Plan #25 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 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 		$424.72
$482.05
$542.79
$758.55
$1,152.68 		$749.63
$806.96
$867.70
$1,083.46 		$1,074.54
$1,131.87
$1,192.61
$1,408.37 		$1,399.45
$1,456.78
$1,517.52
$1,733.28 		$324.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.44
$964.10
$1,085.58
$1,517.10
$2,305.36 		$1,174.35
$1,289.01
$1,410.49
$1,842.01 		$1,499.26
$1,613.92
$1,735.40
$2,166.92 		$1,824.17
$1,938.83
$2,060.31
$2,491.83 		$324.91
Toc - Plan #26 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $18,200 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 		$409.07
$464.30
$522.80
$730.60
$1,110.22 		$722.01
$777.24
$835.74
$1,043.54 		$1,034.95
$1,090.18
$1,148.68
$1,356.48 		$1,347.89
$1,403.12
$1,461.62
$1,669.42 		$312.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.14
$928.60
$1,045.60
$1,461.20
$2,220.44 		$1,131.08
$1,241.54
$1,358.54
$1,774.14 		$1,444.02
$1,554.48
$1,671.48
$2,087.08 		$1,756.96
$1,867.42
$1,984.42
$2,400.02 		$312.94
Toc - Plan #27 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

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 		$536.47
$608.89
$685.61
$958.13
$1,455.98 		$946.87
$1,019.29
$1,096.01
$1,368.53 		$1,357.27
$1,429.69
$1,506.41
$1,778.93 		$1,767.67
$1,840.09
$1,916.81
$2,189.33 		$410.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,072.94
$1,217.78
$1,371.22
$1,916.26
$2,911.96 		$1,483.34
$1,628.18
$1,781.62
$2,326.66 		$1,893.74
$2,038.58
$2,192.02
$2,737.06 		$2,304.14
$2,448.98
$2,602.42
$3,147.46 		$410.40
Toc - Plan #28 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$499.71
$567.18
$638.63
$892.49
$1,356.22 		$881.99
$949.46
$1,020.91
$1,274.77 		$1,264.27
$1,331.74
$1,403.19
$1,657.05 		$1,646.55
$1,714.02
$1,785.47
$2,039.33 		$382.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$999.42
$1,134.36
$1,277.26
$1,784.98
$2,712.44 		$1,381.70
$1,516.64
$1,659.54
$2,167.26 		$1,763.98
$1,898.92
$2,041.82
$2,549.54 		$2,146.26
$2,281.20
$2,424.10
$2,931.82 		$382.28
Toc - Plan #29 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 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 		$514.31
$583.75
$657.29
$918.57
$1,395.85 		$907.76
$977.20
$1,050.74
$1,312.02 		$1,301.21
$1,370.65
$1,444.19
$1,705.47 		$1,694.66
$1,764.10
$1,837.64
$2,098.92 		$393.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,028.62
$1,167.50
$1,314.58
$1,837.14
$2,791.70 		$1,422.07
$1,560.95
$1,708.03
$2,230.59 		$1,815.52
$1,954.40
$2,101.48
$2,624.04 		$2,208.97
$2,347.85
$2,494.93
$3,017.49 		$393.45
Toc - Plan #30 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 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 		$495.86
$562.80
$633.71
$885.61
$1,345.76 		$875.19
$942.13
$1,013.04
$1,264.94 		$1,254.52
$1,321.46
$1,392.37
$1,644.27 		$1,633.85
$1,700.79
$1,771.70
$2,023.60 		$379.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.72
$1,125.60
$1,267.42
$1,771.22
$2,691.52 		$1,371.05
$1,504.93
$1,646.75
$2,150.55 		$1,750.38
$1,884.26
$2,026.08
$2,529.88 		$2,129.71
$2,263.59
$2,405.41
$2,909.21 		$379.33
Toc - Plan #31 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 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 		$497.16
$564.28
$635.37
$887.93
$1,349.30 		$877.49
$944.61
$1,015.70
$1,268.26 		$1,257.82
$1,324.94
$1,396.03
$1,648.59 		$1,638.15
$1,705.27
$1,776.36
$2,028.92 		$380.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.32
$1,128.56
$1,270.74
$1,775.86
$2,698.60 		$1,374.65
$1,508.89
$1,651.07
$2,156.19 		$1,754.98
$1,889.22
$2,031.40
$2,536.52 		$2,135.31
$2,269.55
$2,411.73
$2,916.85 		$380.33
Toc - Plan #32 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 Annual Deductible
$9,100 $18,200 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 		$495.12
$561.96
$632.76
$884.28
$1,343.74 		$873.88
$940.72
$1,011.52
$1,263.04 		$1,252.64
$1,319.48
$1,390.28
$1,641.80 		$1,631.40
$1,698.24
$1,769.04
$2,020.56 		$378.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$990.24
$1,123.92
$1,265.52
$1,768.56
$2,687.48 		$1,369.00
$1,502.68
$1,644.28
$2,147.32 		$1,747.76
$1,881.44
$2,023.04
$2,526.08 		$2,126.52
$2,260.20
$2,401.80
$2,904.84 		$378.76
Toc - Plan #33 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$497.38
$564.53
$635.65
$888.32
$1,349.89 		$877.87
$945.02
$1,016.14
$1,268.81 		$1,258.36
$1,325.51
$1,396.63
$1,649.30 		$1,638.85
$1,706.00
$1,777.12
$2,029.79 		$380.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.76
$1,129.06
$1,271.30
$1,776.64
$2,699.78 		$1,375.25
$1,509.55
$1,651.79
$2,157.13 		$1,755.74
$1,890.04
$2,032.28
$2,537.62 		$2,136.23
$2,270.53
$2,412.77
$2,918.11 		$380.49
Toc - Plan #34 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$411.16
$466.67
$525.46
$734.33
$1,115.89 		$725.70
$781.21
$840.00
$1,048.87 		$1,040.24
$1,095.75
$1,154.54
$1,363.41 		$1,354.78
$1,410.29
$1,469.08
$1,677.95 		$314.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.32
$933.34
$1,050.92
$1,468.66
$2,231.78 		$1,136.86
$1,247.88
$1,365.46
$1,783.20 		$1,451.40
$1,562.42
$1,680.00
$2,097.74 		$1,765.94
$1,876.96
$1,994.54
$2,412.28 		$314.54
Toc - Plan #35 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $6,350 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,100 $18,200 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 		$409.50
$464.78
$523.34
$731.36
$1,111.37 		$722.77
$778.05
$836.61
$1,044.63 		$1,036.04
$1,091.32
$1,149.88
$1,357.90 		$1,349.31
$1,404.59
$1,463.15
$1,671.17 		$313.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.00
$929.56
$1,046.68
$1,462.72
$2,222.74 		$1,132.27
$1,242.83
$1,359.95
$1,775.99 		$1,445.54
$1,556.10
$1,673.22
$2,089.26 		$1,758.81
$1,869.37
$1,986.49
$2,402.53 		$313.27
Toc - Plan #36 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$422.36
$479.38
$539.78
$754.34
$1,146.29 		$745.47
$802.49
$862.89
$1,077.45 		$1,068.58
$1,125.60
$1,186.00
$1,400.56 		$1,391.69
$1,448.71
$1,509.11
$1,723.67 		$323.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.72
$958.76
$1,079.56
$1,508.68
$2,292.58 		$1,167.83
$1,281.87
$1,402.67
$1,831.79 		$1,490.94
$1,604.98
$1,725.78
$2,154.90 		$1,814.05
$1,928.09
$2,048.89
$2,478.01 		$323.11
Toc - Plan #37 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$400.99
$455.13
$512.47
$716.17
$1,088.29 		$707.75
$761.89
$819.23
$1,022.93 		$1,014.51
$1,068.65
$1,125.99
$1,329.69 		$1,321.27
$1,375.41
$1,432.75
$1,636.45 		$306.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.98
$910.26
$1,024.94
$1,432.34
$2,176.58 		$1,108.74
$1,217.02
$1,331.70
$1,739.10 		$1,415.50
$1,523.78
$1,638.46
$2,045.86 		$1,722.26
$1,830.54
$1,945.22
$2,352.62 		$306.76
Toc - Plan #38 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$525.17
$596.07
$671.17
$937.96
$1,425.32 		$926.93
$997.83
$1,072.93
$1,339.72 		$1,328.69
$1,399.59
$1,474.69
$1,741.48 		$1,730.45
$1,801.35
$1,876.45
$2,143.24 		$401.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,050.34
$1,192.14
$1,342.34
$1,875.92
$2,850.64 		$1,452.10
$1,593.90
$1,744.10
$2,277.68 		$1,853.86
$1,995.66
$2,145.86
$2,679.44 		$2,255.62
$2,397.42
$2,547.62
$3,081.20 		$401.76

ADVERTISEMENT

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Local: 1-855-738-6652 | Toll Free: 1-855-738-6652

Toc - Plan #39 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

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 		$354.57
$402.44
$453.14
$633.26
$962.30 		$625.82
$673.69
$724.39
$904.51 		$897.07
$944.94
$995.64
$1,175.76 		$1,168.32
$1,216.19
$1,266.89
$1,447.01 		$271.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.14
$804.88
$906.28
$1,266.52
$1,924.60 		$980.39
$1,076.13
$1,177.53
$1,537.77 		$1,251.64
$1,347.38
$1,448.78
$1,809.02 		$1,522.89
$1,618.63
$1,720.03
$2,080.27 		$271.25
Toc - Plan #40 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 3000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 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 		$423.73
$480.93
$541.53
$756.78
$1,150.00 		$747.88
$805.08
$865.68
$1,080.93 		$1,072.03
$1,129.23
$1,189.83
$1,405.08 		$1,396.18
$1,453.38
$1,513.98
$1,729.23 		$324.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847.46
$961.86
$1,083.06
$1,513.56
$2,300.00 		$1,171.61
$1,286.01
$1,407.21
$1,837.71 		$1,495.76
$1,610.16
$1,731.36
$2,161.86 		$1,819.91
$1,934.31
$2,055.51
$2,486.01 		$324.15
Toc - Plan #41 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 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 		$426.97
$484.61
$545.67
$762.57
$1,158.80 		$753.60
$811.24
$872.30
$1,089.20 		$1,080.23
$1,137.87
$1,198.93
$1,415.83 		$1,406.86
$1,464.50
$1,525.56
$1,742.46 		$326.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.94
$969.22
$1,091.34
$1,525.14
$2,317.60 		$1,180.57
$1,295.85
$1,417.97
$1,851.77 		$1,507.20
$1,622.48
$1,744.60
$2,178.40 		$1,833.83
$1,949.11
$2,071.23
$2,505.03 		$326.63
Toc - Plan #42 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5600($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,600 $11,200 Annual Deductible
$9,100 $18,200 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 		$343.48
$389.85
$438.97
$613.46
$932.20 		$606.24
$652.61
$701.73
$876.22 		$869.00
$915.37
$964.49
$1,138.98 		$1,131.76
$1,178.13
$1,227.25
$1,401.74 		$262.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.96
$779.70
$877.94
$1,226.92
$1,864.40 		$949.72
$1,042.46
$1,140.70
$1,489.68 		$1,212.48
$1,305.22
$1,403.46
$1,752.44 		$1,475.24
$1,567.98
$1,666.22
$2,015.20 		$262.76
Toc - Plan #43 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 6000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 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 		$337.55
$383.12
$431.39
$602.86
$916.11 		$595.78
$641.35
$689.62
$861.09 		$854.01
$899.58
$947.85
$1,119.32 		$1,112.24
$1,157.81
$1,206.08
$1,377.55 		$258.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.10
$766.24
$862.78
$1,205.72
$1,832.22 		$933.33
$1,024.47
$1,121.01
$1,463.95 		$1,191.56
$1,282.70
$1,379.24
$1,722.18 		$1,449.79
$1,540.93
$1,637.47
$1,980.41 		$258.23
Toc - Plan #44 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Catastrophic

(HMO) Anthem Catastrophic Pathway X Guided Access HMO 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$243.95
$276.88
$311.77
$435.69
$662.08 		$430.57
$463.50
$498.39
$622.31 		$617.19
$650.12
$685.01
$808.93 		$803.81
$836.74
$871.63
$995.55 		$186.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$487.90
$553.76
$623.54
$871.38
$1,324.16 		$674.52
$740.38
$810.16
$1,058.00 		$861.14
$927.00
$996.78
$1,244.62 		$1,047.76
$1,113.62
$1,183.40
$1,431.24 		$186.62
Toc - Plan #45 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 8000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 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 		$324.24
$368.01
$414.38
$579.09
$879.99 		$572.28
$616.05
$662.42
$827.13 		$820.32
$864.09
$910.46
$1,075.17 		$1,068.36
$1,112.13
$1,158.50
$1,323.21 		$248.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.48
$736.02
$828.76
$1,158.18
$1,759.98 		$896.52
$984.06
$1,076.80
$1,406.22 		$1,144.56
$1,232.10
$1,324.84
$1,654.26 		$1,392.60
$1,480.14
$1,572.88
$1,902.30 		$248.04
Toc - Plan #46 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 4950($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$4,950 $9,900 Annual Deductible
$9,100 $18,200 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 		$429.62
$487.62
$549.05
$767.30
$1,165.99 		$758.28
$816.28
$877.71
$1,095.96 		$1,086.94
$1,144.94
$1,206.37
$1,424.62 		$1,415.60
$1,473.60
$1,535.03
$1,753.28 		$328.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.24
$975.24
$1,098.10
$1,534.60
$2,331.98 		$1,187.90
$1,303.90
$1,426.76
$1,863.26 		$1,516.56
$1,632.56
$1,755.42
$2,191.92 		$1,845.22
$1,961.22
$2,084.08
$2,520.58 		$328.66
Toc - Plan #47 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Gold

(HMO) Anthem Gold Pathway X Guided Access HMO 1600($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$8,800 $17,600 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 		$471.51
$535.16
$602.59
$842.12
$1,279.68 		$832.22
$895.87
$963.30
$1,202.83 		$1,192.93
$1,256.58
$1,324.01
$1,563.54 		$1,553.64
$1,617.29
$1,684.72
$1,924.25 		$360.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$943.02
$1,070.32
$1,205.18
$1,684.24
$2,559.36 		$1,303.73
$1,431.03
$1,565.89
$2,044.95 		$1,664.44
$1,791.74
$1,926.60
$2,405.66 		$2,025.15
$2,152.45
$2,287.31
$2,766.37 		$360.71
Toc - Plan #48 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 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 		$357.99
$406.32
$457.51
$639.37
$971.58 		$631.85
$680.18
$731.37
$913.23 		$905.71
$954.04
$1,005.23
$1,187.09 		$1,179.57
$1,227.90
$1,279.09
$1,460.95 		$273.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.98
$812.64
$915.02
$1,278.74
$1,943.16 		$989.84
$1,086.50
$1,188.88
$1,552.60 		$1,263.70
$1,360.36
$1,462.74
$1,826.46 		$1,537.56
$1,634.22
$1,736.60
$2,100.32 		$273.86
Toc - Plan #49 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 2600($0 PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$2,600 $5,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$450.06
$510.82
$575.18
$803.81
$1,221.46 		$794.36
$855.12
$919.48
$1,148.11 		$1,138.66
$1,199.42
$1,263.78
$1,492.41 		$1,482.96
$1,543.72
$1,608.08
$1,836.71 		$344.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.12
$1,021.64
$1,150.36
$1,607.62
$2,442.92 		$1,244.42
$1,365.94
$1,494.66
$1,951.92 		$1,588.72
$1,710.24
$1,838.96
$2,296.22 		$1,933.02
$2,054.54
$2,183.26
$2,640.52 		$344.30
Toc - Plan #50 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 6500($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 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 		$421.94
$478.90
$539.24
$753.58
$1,145.15 		$744.72
$801.68
$862.02
$1,076.36 		$1,067.50
$1,124.46
$1,184.80
$1,399.14 		$1,390.28
$1,447.24
$1,507.58
$1,721.92 		$322.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.88
$957.80
$1,078.48
$1,507.16
$2,290.30 		$1,166.66
$1,280.58
$1,401.26
$1,829.94 		$1,489.44
$1,603.36
$1,724.04
$2,152.72 		$1,812.22
$1,926.14
$2,046.82
$2,475.50 		$322.78
Toc - Plan #51 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$333.93
$379.01
$426.76
$596.40
$906.29 		$589.39
$634.47
$682.22
$851.86 		$844.85
$889.93
$937.68
$1,107.32 		$1,100.31
$1,145.39
$1,193.14
$1,362.78 		$255.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.86
$758.02
$853.52
$1,192.80
$1,812.58 		$923.32
$1,013.48
$1,108.98
$1,448.26 		$1,178.78
$1,268.94
$1,364.44
$1,703.72 		$1,434.24
$1,524.40
$1,619.90
$1,959.18 		$255.46
Toc - Plan #52 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$365.28
$414.59
$466.83
$652.39
$991.37 		$644.72
$694.03
$746.27
$931.83 		$924.16
$973.47
$1,025.71
$1,211.27 		$1,203.60
$1,252.91
$1,305.15
$1,490.71 		$279.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.56
$829.18
$933.66
$1,304.78
$1,982.74 		$1,010.00
$1,108.62
$1,213.10
$1,584.22 		$1,289.44
$1,388.06
$1,492.54
$1,863.66 		$1,568.88
$1,667.50
$1,771.98
$2,143.10 		$279.44
Toc - Plan #53 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$428.51
$486.36
$547.64
$765.32
$1,162.98 		$756.32
$814.17
$875.45
$1,093.13 		$1,084.13
$1,141.98
$1,203.26
$1,420.94 		$1,411.94
$1,469.79
$1,531.07
$1,748.75 		$327.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.02
$972.72
$1,095.28
$1,530.64
$2,325.96 		$1,184.83
$1,300.53
$1,423.09
$1,858.45 		$1,512.64
$1,628.34
$1,750.90
$2,186.26 		$1,840.45
$1,956.15
$2,078.71
$2,514.07 		$327.81
Toc - Plan #54 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Gold

(HMO) Anthem Gold Pathway X Guided Access HMO 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

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 		$484.53
$549.94
$619.23
$865.37
$1,315.01 		$855.20
$920.61
$989.90
$1,236.04 		$1,225.87
$1,291.28
$1,360.57
$1,606.71 		$1,596.54
$1,661.95
$1,731.24
$1,977.38 		$370.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.06
$1,099.88
$1,238.46
$1,730.74
$2,630.02 		$1,339.73
$1,470.55
$1,609.13
$2,101.41 		$1,710.40
$1,841.22
$1,979.80
$2,472.08 		$2,081.07
$2,211.89
$2,350.47
$2,842.75 		$370.67

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-255-0056
Toc - Plan #55 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 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 		$312.08
$354.20
$398.83
$557.36
$846.97 		$550.82
$592.94
$637.57
$796.10 		$789.56
$831.68
$876.31
$1,034.84 		$1,028.30
$1,070.42
$1,115.05
$1,273.58 		$238.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.16
$708.40
$797.66
$1,114.72
$1,693.94 		$862.90
$947.14
$1,036.40
$1,353.46 		$1,101.64
$1,185.88
$1,275.14
$1,592.20 		$1,340.38
$1,424.62
$1,513.88
$1,830.94 		$238.74
Toc - Plan #56 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424.86
$482.21
$542.97
$758.80
$1,153.06 		$749.88
$807.23
$867.99
$1,083.82 		$1,074.90
$1,132.25
$1,193.01
$1,408.84 		$1,399.92
$1,457.27
$1,518.03
$1,733.86 		$325.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.72
$964.42
$1,085.94
$1,517.60
$2,306.12 		$1,174.74
$1,289.44
$1,410.96
$1,842.62 		$1,499.76
$1,614.46
$1,735.98
$2,167.64 		$1,824.78
$1,939.48
$2,061.00
$2,492.66 		$325.02
Toc - Plan #57 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 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 		$424.53
$481.84
$542.54
$758.20
$1,152.16 		$749.29
$806.60
$867.30
$1,082.96 		$1,074.05
$1,131.36
$1,192.06
$1,407.72 		$1,398.81
$1,456.12
$1,516.82
$1,732.48 		$324.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.06
$963.68
$1,085.08
$1,516.40
$2,304.32 		$1,173.82
$1,288.44
$1,409.84
$1,841.16 		$1,498.58
$1,613.20
$1,734.60
$2,165.92 		$1,823.34
$1,937.96
$2,059.36
$2,490.68 		$324.76
Toc - Plan #58 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$434.49
$493.15
$555.28
$776.00
$1,179.20 		$766.87
$825.53
$887.66
$1,108.38 		$1,099.25
$1,157.91
$1,220.04
$1,440.76 		$1,431.63
$1,490.29
$1,552.42
$1,773.14 		$332.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.98
$986.30
$1,110.56
$1,552.00
$2,358.40 		$1,201.36
$1,318.68
$1,442.94
$1,884.38 		$1,533.74
$1,651.06
$1,775.32
$2,216.76 		$1,866.12
$1,983.44
$2,107.70
$2,549.14 		$332.38
Toc - Plan #59 CareSource
Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$344.08
$390.53
$439.73
$614.52
$933.82 		$607.30
$653.75
$702.95
$877.74 		$870.52
$916.97
$966.17
$1,140.96 		$1,133.74
$1,180.19
$1,229.39
$1,404.18 		$263.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.16
$781.06
$879.46
$1,229.04
$1,867.64 		$951.38
$1,044.28
$1,142.68
$1,492.26 		$1,214.60
$1,307.50
$1,405.90
$1,755.48 		$1,477.82
$1,570.72
$1,669.12
$2,018.70 		$263.22
Toc - Plan #60 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$294.89
$334.70
$376.87
$526.67
$800.33 		$520.48
$560.29
$602.46
$752.26 		$746.07
$785.88
$828.05
$977.85 		$971.66
$1,011.47
$1,053.64
$1,203.44 		$225.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.78
$669.40
$753.74
$1,053.34
$1,600.66 		$815.37
$894.99
$979.33
$1,278.93 		$1,040.96
$1,120.58
$1,204.92
$1,504.52 		$1,266.55
$1,346.17
$1,430.51
$1,730.11 		$225.59
Toc - Plan #61 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 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 		$462.91
$525.40
$591.59
$826.75
$1,256.33 		$817.03
$879.52
$945.71
$1,180.87 		$1,171.15
$1,233.64
$1,299.83
$1,534.99 		$1,525.27
$1,587.76
$1,653.95
$1,889.11 		$354.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.82
$1,050.80
$1,183.18
$1,653.50
$2,512.66 		$1,279.94
$1,404.92
$1,537.30
$2,007.62 		$1,634.06
$1,759.04
$1,891.42
$2,361.74 		$1,988.18
$2,113.16
$2,245.54
$2,715.86 		$354.12
Toc - Plan #62 CareSource
Silver

(HMO) CareSource Marketplace Federal Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$434.08
$492.67
$554.75
$775.26
$1,178.08 		$766.15
$824.74
$886.82
$1,107.33 		$1,098.22
$1,156.81
$1,218.89
$1,439.40 		$1,430.29
$1,488.88
$1,550.96
$1,771.47 		$332.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$868.16
$985.34
$1,109.50
$1,550.52
$2,356.16 		$1,200.23
$1,317.41
$1,441.57
$1,882.59 		$1,532.30
$1,649.48
$1,773.64
$2,214.66 		$1,864.37
$1,981.55
$2,105.71
$2,546.73 		$332.07
Toc - Plan #63 CareSource
Gold

(HMO) CareSource Marketplace Federal Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$433.07
$491.53
$553.46
$773.46
$1,175.34 		$764.37
$822.83
$884.76
$1,104.76 		$1,095.67
$1,154.13
$1,216.06
$1,436.06 		$1,426.97
$1,485.43
$1,547.36
$1,767.36 		$331.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.14
$983.06
$1,106.92
$1,546.92
$2,350.68 		$1,197.44
$1,314.36
$1,438.22
$1,878.22 		$1,528.74
$1,645.66
$1,769.52
$2,209.52 		$1,860.04
$1,976.96
$2,100.82
$2,540.82 		$331.30
Toc - Plan #64 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 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 		$322.34
$365.86
$411.95
$575.70
$874.83 		$568.93
$612.45
$658.54
$822.29 		$815.52
$859.04
$905.13
$1,068.88 		$1,062.11
$1,105.63
$1,151.72
$1,315.47 		$246.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.68
$731.72
$823.90
$1,151.40
$1,749.66 		$891.27
$978.31
$1,070.49
$1,397.99 		$1,137.86
$1,224.90
$1,317.08
$1,644.58 		$1,384.45
$1,471.49
$1,563.67
$1,891.17 		$246.59
Toc - Plan #65 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$435.50
$494.29
$556.56
$777.80
$1,181.94 		$768.66
$827.45
$889.72
$1,110.96 		$1,101.82
$1,160.61
$1,222.88
$1,444.12 		$1,434.98
$1,493.77
$1,556.04
$1,777.28 		$333.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.00
$988.58
$1,113.12
$1,555.60
$2,363.88 		$1,204.16
$1,321.74
$1,446.28
$1,888.76 		$1,537.32
$1,654.90
$1,779.44
$2,221.92 		$1,870.48
$1,988.06
$2,112.60
$2,555.08 		$333.16
Toc - Plan #66 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 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 		$434.66
$493.33
$555.49
$776.29
$1,179.65 		$767.17
$825.84
$888.00
$1,108.80 		$1,099.68
$1,158.35
$1,220.51
$1,441.31 		$1,432.19
$1,490.86
$1,553.02
$1,773.82 		$332.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.32
$986.66
$1,110.98
$1,552.58
$2,359.30 		$1,201.83
$1,319.17
$1,443.49
$1,885.09 		$1,534.34
$1,651.68
$1,776.00
$2,217.60 		$1,866.85
$1,984.19
$2,108.51
$2,550.11 		$332.51
Toc - Plan #67 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$444.62
$504.64
$568.22
$794.09
$1,206.70 		$784.75
$844.77
$908.35
$1,134.22 		$1,124.88
$1,184.90
$1,248.48
$1,474.35 		$1,465.01
$1,525.03
$1,588.61
$1,814.48 		$340.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.24
$1,009.28
$1,136.44
$1,588.18
$2,413.40 		$1,229.37
$1,349.41
$1,476.57
$1,928.31 		$1,569.50
$1,689.54
$1,816.70
$2,268.44 		$1,909.63
$2,029.67
$2,156.83
$2,608.57 		$340.13
Toc - Plan #68 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$304.33
$345.41
$388.92
$543.52
$825.93 		$537.14
$578.22
$621.73
$776.33 		$769.95
$811.03
$854.54
$1,009.14 		$1,002.76
$1,043.84
$1,087.35
$1,241.95 		$232.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.66
$690.82
$777.84
$1,087.04
$1,651.86 		$841.47
$923.63
$1,010.65
$1,319.85 		$1,074.28
$1,156.44
$1,243.46
$1,552.66 		$1,307.09
$1,389.25
$1,476.27
$1,785.47 		$232.81
Toc - Plan #69 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 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 		$472.54
$536.33
$603.90
$843.95
$1,282.47 		$834.03
$897.82
$965.39
$1,205.44 		$1,195.52
$1,259.31
$1,326.88
$1,566.93 		$1,557.01
$1,620.80
$1,688.37
$1,928.42 		$361.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.08
$1,072.66
$1,207.80
$1,687.90
$2,564.94 		$1,306.57
$1,434.15
$1,569.29
$2,049.39 		$1,668.06
$1,795.64
$1,930.78
$2,410.88 		$2,029.55
$2,157.13
$2,292.27
$2,772.37 		$361.49
Toc - Plan #70 CareSource
Silver

(HMO) CareSource Marketplace Federal Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$444.21
$504.17
$567.69
$793.35
$1,205.57 		$784.03
$843.99
$907.51
$1,133.17 		$1,123.85
$1,183.81
$1,247.33
$1,472.99 		$1,463.67
$1,523.63
$1,587.15
$1,812.81 		$339.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.42
$1,008.34
$1,135.38
$1,586.70
$2,411.14 		$1,228.24
$1,348.16
$1,475.20
$1,926.52 		$1,568.06
$1,687.98
$1,815.02
$2,266.34 		$1,907.88
$2,027.80
$2,154.84
$2,606.16 		$339.82
Toc - Plan #71 CareSource
Gold

(HMO) CareSource Marketplace Federal Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$443.71
$503.61
$567.05
$792.46
$1,204.22 		$783.14
$843.04
$906.48
$1,131.89 		$1,122.57
$1,182.47
$1,245.91
$1,471.32 		$1,462.00
$1,521.90
$1,585.34
$1,810.75 		$339.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.42
$1,007.22
$1,134.10
$1,584.92
$2,408.44 		$1,226.85
$1,346.65
$1,473.53
$1,924.35 		$1,566.28
$1,686.08
$1,812.96
$2,263.78 		$1,905.71
$2,025.51
$2,152.39
$2,603.21 		$339.43

ADVERTISEMENT

Ambetter from Peach State Health Plan

Local: 1-877-687-1180 | Toll Free: 1-877-687-1180 | TTY: 1-877-941-9231
Toc - Plan #72 Ambetter from Peach State Health Plan
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$328.58
$372.93
$419.92
$586.83
$891.75 		$579.94
$624.29
$671.28
$838.19 		$831.30
$875.65
$922.64
$1,089.55 		$1,082.66
$1,127.01
$1,174.00
$1,340.91 		$251.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.16
$745.86
$839.84
$1,173.66
$1,783.50 		$908.52
$997.22
$1,091.20
$1,425.02 		$1,159.88
$1,248.58
$1,342.56
$1,676.38 		$1,411.24
$1,499.94
$1,593.92
$1,927.74 		$251.36
Toc - Plan #73 Ambetter from Peach State Health Plan
Silver

(HMO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 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 		$394.60
$447.86
$504.28
$704.74
$1,070.91 		$696.46
$749.72
$806.14
$1,006.60 		$998.32
$1,051.58
$1,108.00
$1,308.46 		$1,300.18
$1,353.44
$1,409.86
$1,610.32 		$301.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.20
$895.72
$1,008.56
$1,409.48
$2,141.82 		$1,091.06
$1,197.58
$1,310.42
$1,711.34 		$1,392.92
$1,499.44
$1,612.28
$2,013.20 		$1,694.78
$1,801.30
$1,914.14
$2,315.06 		$301.86
Toc - Plan #74 Ambetter from Peach State Health Plan
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$390.22
$442.89
$498.69
$696.91
$1,059.03 		$688.73
$741.40
$797.20
$995.42 		$987.24
$1,039.91
$1,095.71
$1,293.93 		$1,285.75
$1,338.42
$1,394.22
$1,592.44 		$298.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.44
$885.78
$997.38
$1,393.82
$2,118.06 		$1,078.95
$1,184.29
$1,295.89
$1,692.33 		$1,377.46
$1,482.80
$1,594.40
$1,990.84 		$1,675.97
$1,781.31
$1,892.91
$2,289.35 		$298.51
Toc - Plan #75 Ambetter from Peach State Health Plan
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 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 		$412.87
$468.59
$527.63
$737.36
$1,120.50 		$728.71
$784.43
$843.47
$1,053.20 		$1,044.55
$1,100.27
$1,159.31
$1,369.04 		$1,360.39
$1,416.11
$1,475.15
$1,684.88 		$315.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.74
$937.18
$1,055.26
$1,474.72
$2,241.00 		$1,141.58
$1,253.02
$1,371.10
$1,790.56 		$1,457.42
$1,568.86
$1,686.94
$2,106.40 		$1,773.26
$1,884.70
$2,002.78
$2,422.24 		$315.84
Toc - Plan #76 Ambetter from Peach State Health Plan
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$386.15
$438.27
$493.49
$689.65
$1,048.00 		$681.55
$733.67
$788.89
$985.05 		$976.95
$1,029.07
$1,084.29
$1,280.45 		$1,272.35
$1,324.47
$1,379.69
$1,575.85 		$295.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.30
$876.54
$986.98
$1,379.30
$2,096.00 		$1,067.70
$1,171.94
$1,282.38
$1,674.70 		$1,363.10
$1,467.34
$1,577.78
$1,970.10 		$1,658.50
$1,762.74
$1,873.18
$2,265.50 		$295.40
Toc - Plan #77 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$361.06
$409.79
$461.42
$644.83
$979.89 		$637.26
$685.99
$737.62
$921.03 		$913.46
$962.19
$1,013.82
$1,197.23 		$1,189.66
$1,238.39
$1,290.02
$1,473.43 		$276.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.12
$819.58
$922.84
$1,289.66
$1,959.78 		$998.32
$1,095.78
$1,199.04
$1,565.86 		$1,274.52
$1,371.98
$1,475.24
$1,842.06 		$1,550.72
$1,648.18
$1,751.44
$2,118.26 		$276.20
Toc - Plan #78 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$353.52
$401.24
$451.79
$631.37
$959.43 		$623.96
$671.68
$722.23
$901.81 		$894.40
$942.12
$992.67
$1,172.25 		$1,164.84
$1,212.56
$1,263.11
$1,442.69 		$270.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.04
$802.48
$903.58
$1,262.74
$1,918.86 		$977.48
$1,072.92
$1,174.02
$1,533.18 		$1,247.92
$1,343.36
$1,444.46
$1,803.62 		$1,518.36
$1,613.80
$1,714.90
$2,074.06 		$270.44
Toc - Plan #79 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$400.00
$453.99
$511.19
$714.39
$1,085.58 		$706.00
$759.99
$817.19
$1,020.39 		$1,012.00
$1,065.99
$1,123.19
$1,326.39 		$1,318.00
$1,371.99
$1,429.19
$1,632.39 		$306.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$800.00
$907.98
$1,022.38
$1,428.78
$2,171.16 		$1,106.00
$1,213.98
$1,328.38
$1,734.78 		$1,412.00
$1,519.98
$1,634.38
$2,040.78 		$1,718.00
$1,825.98
$1,940.38
$2,346.78 		$306.00
Toc - Plan #80 Ambetter from Peach State Health Plan
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$380.39
$431.74
$486.13
$679.36
$1,032.36 		$671.38
$722.73
$777.12
$970.35 		$962.37
$1,013.72
$1,068.11
$1,261.34 		$1,253.36
$1,304.71
$1,359.10
$1,552.33 		$290.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.78
$863.48
$972.26
$1,358.72
$2,064.72 		$1,051.77
$1,154.47
$1,263.25
$1,649.71 		$1,342.76
$1,445.46
$1,554.24
$1,940.70 		$1,633.75
$1,736.45
$1,845.23
$2,231.69 		$290.99
Toc - Plan #81 Ambetter from Peach State Health Plan
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$384.69
$436.62
$491.63
$687.05
$1,044.03 		$678.97
$730.90
$785.91
$981.33 		$973.25
$1,025.18
$1,080.19
$1,275.61 		$1,267.53
$1,319.46
$1,374.47
$1,569.89 		$294.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.38
$873.24
$983.26
$1,374.10
$2,088.06 		$1,063.66
$1,167.52
$1,277.54
$1,668.38 		$1,357.94
$1,461.80
$1,571.82
$1,962.66 		$1,652.22
$1,756.08
$1,866.10
$2,256.94 		$294.28
Toc - Plan #82 Ambetter from Peach State Health Plan
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$394.64
$447.90
$504.33
$704.81
$1,071.02 		$696.53
$749.79
$806.22
$1,006.70 		$998.42
$1,051.68
$1,108.11
$1,308.59 		$1,300.31
$1,353.57
$1,410.00
$1,610.48 		$301.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.28
$895.80
$1,008.66
$1,409.62
$2,142.04 		$1,091.17
$1,197.69
$1,310.55
$1,711.51 		$1,393.06
$1,499.58
$1,612.44
$2,013.40 		$1,694.95
$1,801.47
$1,914.33
$2,315.29 		$301.89
Toc - Plan #83 Ambetter from Peach State Health Plan
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$390.06
$442.71
$498.48
$696.63
$1,058.60 		$688.45
$741.10
$796.87
$995.02 		$986.84
$1,039.49
$1,095.26
$1,293.41 		$1,285.23
$1,337.88
$1,393.65
$1,591.80 		$298.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.12
$885.42
$996.96
$1,393.26
$2,117.20 		$1,078.51
$1,183.81
$1,295.35
$1,691.65 		$1,376.90
$1,482.20
$1,593.74
$1,990.04 		$1,675.29
$1,780.59
$1,892.13
$2,288.43 		$298.39
Toc - Plan #84 Ambetter from Peach State Health Plan
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$455.48
$516.96
$582.10
$813.48
$1,236.16 		$803.92
$865.40
$930.54
$1,161.92 		$1,152.36
$1,213.84
$1,278.98
$1,510.36 		$1,500.80
$1,562.28
$1,627.42
$1,858.80 		$348.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.96
$1,033.92
$1,164.20
$1,626.96
$2,472.32 		$1,259.40
$1,382.36
$1,512.64
$1,975.40 		$1,607.84
$1,730.80
$1,861.08
$2,323.84 		$1,956.28
$2,079.24
$2,209.52
$2,672.28 		$348.44
Toc - Plan #85 Ambetter from Peach State Health Plan
Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$312.80
$355.02
$399.75
$558.64
$848.91 		$552.08
$594.30
$639.03
$797.92 		$791.36
$833.58
$878.31
$1,037.20 		$1,030.64
$1,072.86
$1,117.59
$1,276.48 		$239.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.60
$710.04
$799.50
$1,117.28
$1,697.82 		$864.88
$949.32
$1,038.78
$1,356.56 		$1,104.16
$1,188.60
$1,278.06
$1,595.84 		$1,343.44
$1,427.88
$1,517.34
$1,835.12 		$239.28
Toc - Plan #86 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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
$618.12
$939.30 		$610.86
$657.58
$707.07
$882.88 		$875.62
$922.34
$971.83
$1,147.64 		$1,140.38
$1,187.10
$1,236.59
$1,412.40 		$264.76
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
$1,236.24
$1,878.60 		$956.96
$1,050.40
$1,149.38
$1,501.00 		$1,221.72
$1,315.16
$1,414.14
$1,765.76 		$1,486.48
$1,579.92
$1,678.90
$2,030.52 		$264.76
Toc - Plan #87 Ambetter from Peach State Health Plan
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$381.22
$432.68
$487.19
$680.84
$1,034.61 		$672.85
$724.31
$778.82
$972.47 		$964.48
$1,015.94
$1,070.45
$1,264.10 		$1,256.11
$1,307.57
$1,362.08
$1,555.73 		$291.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.44
$865.36
$974.38
$1,361.68
$2,069.22 		$1,054.07
$1,156.99
$1,266.01
$1,653.31 		$1,345.70
$1,448.62
$1,557.64
$1,944.94 		$1,637.33
$1,740.25
$1,849.27
$2,236.57 		$291.63
Toc - Plan #88 Ambetter from Peach State Health Plan
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$390.93
$443.69
$499.59
$698.18
$1,060.95 		$689.98
$742.74
$798.64
$997.23 		$989.03
$1,041.79
$1,097.69
$1,296.28 		$1,288.08
$1,340.84
$1,396.74
$1,595.33 		$299.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.86
$887.38
$999.18
$1,396.36
$2,121.90 		$1,080.91
$1,186.43
$1,298.23
$1,695.41 		$1,379.96
$1,485.48
$1,597.28
$1,994.46 		$1,679.01
$1,784.53
$1,896.33
$2,293.51 		$299.05
Toc - Plan #89 Ambetter from Peach State Health Plan
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$401.45
$455.63
$513.04
$716.97
$1,089.51 		$708.55
$762.73
$820.14
$1,024.07 		$1,015.65
$1,069.83
$1,127.24
$1,331.17 		$1,322.75
$1,376.93
$1,434.34
$1,638.27 		$307.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.90
$911.26
$1,026.08
$1,433.94
$2,179.02 		$1,110.00
$1,218.36
$1,333.18
$1,741.04 		$1,417.10
$1,525.46
$1,640.28
$2,048.14 		$1,724.20
$1,832.56
$1,947.38
$2,355.24 		$307.10
Toc - Plan #90 Ambetter from Peach State Health Plan
Silver

(HMO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.23
$465.60
$524.26
$732.65
$1,113.33 		$724.05
$779.42
$838.08
$1,046.47 		$1,037.87
$1,093.24
$1,151.90
$1,360.29 		$1,351.69
$1,407.06
$1,465.72
$1,674.11 		$313.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.46
$931.20
$1,048.52
$1,465.30
$2,226.66 		$1,134.28
$1,245.02
$1,362.34
$1,779.12 		$1,448.10
$1,558.84
$1,676.16
$2,092.94 		$1,761.92
$1,872.66
$1,989.98
$2,406.76 		$313.82
Toc - Plan #91 Ambetter from Peach State Health Plan
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$405.67
$460.43
$518.44
$724.52
$1,100.97 		$716.00
$770.76
$828.77
$1,034.85 		$1,026.33
$1,081.09
$1,139.10
$1,345.18 		$1,336.66
$1,391.42
$1,449.43
$1,655.51 		$310.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.34
$920.86
$1,036.88
$1,449.04
$2,201.94 		$1,121.67
$1,231.19
$1,347.21
$1,759.37 		$1,432.00
$1,541.52
$1,657.54
$2,069.70 		$1,742.33
$1,851.85
$1,967.87
$2,380.03 		$310.33
Toc - Plan #92 Ambetter from Peach State Health Plan
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$341.60
$387.70
$436.55
$610.08
$927.07 		$602.92
$649.02
$697.87
$871.40 		$864.24
$910.34
$959.19
$1,132.72 		$1,125.56
$1,171.66
$1,220.51
$1,394.04 		$261.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.20
$775.40
$873.10
$1,220.16
$1,854.14 		$944.52
$1,036.72
$1,134.42
$1,481.48 		$1,205.84
$1,298.04
$1,395.74
$1,742.80 		$1,467.16
$1,559.36
$1,657.06
$2,004.12 		$261.32
Toc - Plan #93 Ambetter from Peach State Health Plan
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 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 		$429.22
$487.15
$548.53
$766.57
$1,164.88 		$757.57
$815.50
$876.88
$1,094.92 		$1,085.92
$1,143.85
$1,205.23
$1,423.27 		$1,414.27
$1,472.20
$1,533.58
$1,751.62 		$328.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.44
$974.30
$1,097.06
$1,533.14
$2,329.76 		$1,186.79
$1,302.65
$1,425.41
$1,861.49 		$1,515.14
$1,631.00
$1,753.76
$2,189.84 		$1,843.49
$1,959.35
$2,082.11
$2,518.19 		$328.35
Toc - Plan #94 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$375.36
$426.02
$479.70
$670.37
$1,018.70 		$662.50
$713.16
$766.84
$957.51 		$949.64
$1,000.30
$1,053.98
$1,244.65 		$1,236.78
$1,287.44
$1,341.12
$1,531.79 		$287.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.72
$852.04
$959.40
$1,340.74
$2,037.40 		$1,037.86
$1,139.18
$1,246.54
$1,627.88 		$1,325.00
$1,426.32
$1,533.68
$1,915.02 		$1,612.14
$1,713.46
$1,820.82
$2,202.16 		$287.14
Toc - Plan #95 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$367.52
$417.13
$469.68
$656.38
$997.43 		$648.67
$698.28
$750.83
$937.53 		$929.82
$979.43
$1,031.98
$1,218.68 		$1,210.97
$1,260.58
$1,313.13
$1,499.83 		$281.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.04
$834.26
$939.36
$1,312.76
$1,994.86 		$1,016.19
$1,115.41
$1,220.51
$1,593.91 		$1,297.34
$1,396.56
$1,501.66
$1,875.06 		$1,578.49
$1,677.71
$1,782.81
$2,156.21 		$281.15
Toc - Plan #96 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$415.85
$471.98
$531.44
$742.69
$1,128.58 		$733.97
$790.10
$849.56
$1,060.81 		$1,052.09
$1,108.22
$1,167.68
$1,378.93 		$1,370.21
$1,426.34
$1,485.80
$1,697.05 		$318.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.70
$943.96
$1,062.88
$1,485.38
$2,257.16 		$1,149.82
$1,262.08
$1,381.00
$1,803.50 		$1,467.94
$1,580.20
$1,699.12
$2,121.62 		$1,786.06
$1,898.32
$2,017.24
$2,439.74 		$318.12
Toc - Plan #97 Ambetter from Peach State Health Plan
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$399.93
$453.91
$511.10
$714.26
$1,085.39 		$705.87
$759.85
$817.04
$1,020.20 		$1,011.81
$1,065.79
$1,122.98
$1,326.14 		$1,317.75
$1,371.73
$1,428.92
$1,632.08 		$305.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.86
$907.82
$1,022.20
$1,428.52
$2,170.78 		$1,105.80
$1,213.76
$1,328.14
$1,734.46 		$1,411.74
$1,519.70
$1,634.08
$2,040.40 		$1,717.68
$1,825.64
$1,940.02
$2,346.34 		$305.94
Toc - Plan #98 Ambetter from Peach State Health Plan
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$410.27
$465.64
$524.31
$732.72
$1,113.44 		$724.12
$779.49
$838.16
$1,046.57 		$1,037.97
$1,093.34
$1,152.01
$1,360.42 		$1,351.82
$1,407.19
$1,465.86
$1,674.27 		$313.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.54
$931.28
$1,048.62
$1,465.44
$2,226.88 		$1,134.39
$1,245.13
$1,362.47
$1,779.29 		$1,448.24
$1,558.98
$1,676.32
$2,093.14 		$1,762.09
$1,872.83
$1,990.17
$2,406.99 		$313.85
Toc - Plan #99 Ambetter from Peach State Health Plan
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.46
$448.84
$505.39
$706.27
$1,073.25 		$697.98
$751.36
$807.91
$1,008.79 		$1,000.50
$1,053.88
$1,110.43
$1,311.31 		$1,303.02
$1,356.40
$1,412.95
$1,613.83 		$302.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.92
$897.68
$1,010.78
$1,412.54
$2,146.50 		$1,093.44
$1,200.20
$1,313.30
$1,715.06 		$1,395.96
$1,502.72
$1,615.82
$2,017.58 		$1,698.48
$1,805.24
$1,918.34
$2,320.10 		$302.52
Toc - Plan #100 Ambetter from Peach State Health Plan
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$405.51
$460.24
$518.23
$724.22
$1,100.53 		$715.72
$770.45
$828.44
$1,034.43 		$1,025.93
$1,080.66
$1,138.65
$1,344.64 		$1,336.14
$1,390.87
$1,448.86
$1,654.85 		$310.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.02
$920.48
$1,036.46
$1,448.44
$2,201.06 		$1,121.23
$1,230.69
$1,346.67
$1,758.65 		$1,431.44
$1,540.90
$1,656.88
$2,068.86 		$1,741.65
$1,851.11
$1,967.09
$2,379.07 		$310.21
Toc - Plan #101 Ambetter from Peach State Health Plan
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$473.52
$537.44
$605.15
$845.70
$1,285.12 		$835.76
$899.68
$967.39
$1,207.94 		$1,198.00
$1,261.92
$1,329.63
$1,570.18 		$1,560.24
$1,624.16
$1,691.87
$1,932.42 		$362.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.04
$1,074.88
$1,210.30
$1,691.40
$2,570.24 		$1,309.28
$1,437.12
$1,572.54
$2,053.64 		$1,671.52
$1,799.36
$1,934.78
$2,415.88 		$2,033.76
$2,161.60
$2,297.02
$2,778.12 		$362.24
Toc - Plan #102 Ambetter from Peach State Health Plan
Silver

(HMO) Complete Wellstar SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$372.07
$422.29
$475.49
$664.49
$1,009.76 		$656.69
$706.91
$760.11
$949.11 		$941.31
$991.53
$1,044.73
$1,233.73 		$1,225.93
$1,276.15
$1,329.35
$1,518.35 		$284.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.14
$844.58
$950.98
$1,328.98
$2,019.52 		$1,028.76
$1,129.20
$1,235.60
$1,613.60 		$1,313.38
$1,413.82
$1,520.22
$1,898.22 		$1,598.00
$1,698.44
$1,804.84
$2,182.84 		$284.62
Toc - Plan #103 Ambetter from Peach State Health Plan
Silver

(HMO) Clear Wellstar SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.72
$411.67
$463.54
$647.79
$984.38 		$640.19
$689.14
$741.01
$925.26 		$917.66
$966.61
$1,018.48
$1,202.73 		$1,195.13
$1,244.08
$1,295.95
$1,480.20 		$277.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.44
$823.34
$927.08
$1,295.58
$1,968.76 		$1,002.91
$1,100.81
$1,204.55
$1,573.05 		$1,280.38
$1,378.28
$1,482.02
$1,850.52 		$1,557.85
$1,655.75
$1,759.49
$2,127.99 		$277.47
Toc - Plan #104 Ambetter from Peach State Health Plan
Silver

(HMO) Focused Wellstar SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$366.82
$416.33
$468.78
$655.12
$995.52 		$647.43
$696.94
$749.39
$935.73 		$928.04
$977.55
$1,030.00
$1,216.34 		$1,208.65
$1,258.16
$1,310.61
$1,496.95 		$280.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.64
$832.66
$937.56
$1,310.24
$1,991.04 		$1,014.25
$1,113.27
$1,218.17
$1,590.85 		$1,294.86
$1,393.88
$1,498.78
$1,871.46 		$1,575.47
$1,674.49
$1,779.39
$2,152.07 		$280.61
Toc - Plan #105 Ambetter from Peach State Health Plan
Gold

(HMO) Everyday Wellstar SELECT Gold with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$376.33
$427.12
$480.94
$672.11
$1,021.33 		$664.21
$715.00
$768.82
$959.99 		$952.09
$1,002.88
$1,056.70
$1,247.87 		$1,239.97
$1,290.76
$1,344.58
$1,535.75 		$287.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.66
$854.24
$961.88
$1,344.22
$2,042.66 		$1,040.54
$1,142.12
$1,249.76
$1,632.10 		$1,328.42
$1,430.00
$1,537.64
$1,919.98 		$1,616.30
$1,717.88
$1,825.52
$2,207.86 		$287.88
Toc - Plan #106 Ambetter from Peach State Health Plan
Silver

(HMO) Enhanced Wellstar SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 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 		$367.02
$416.55
$469.03
$655.47
$996.06 		$647.78
$697.31
$749.79
$936.23 		$928.54
$978.07
$1,030.55
$1,216.99 		$1,209.30
$1,258.83
$1,311.31
$1,497.75 		$280.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.04
$833.10
$938.06
$1,310.94
$1,992.12 		$1,014.80
$1,113.86
$1,218.82
$1,591.70 		$1,295.56
$1,394.62
$1,499.58
$1,872.46 		$1,576.32
$1,675.38
$1,780.34
$2,153.22 		$280.76
Toc - Plan #107 Ambetter from Peach State Health Plan
Gold

(HMO) Clear Wellstar SELECT Gold with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$371.95
$422.15
$475.34
$664.28
$1,009.44 		$656.48
$706.68
$759.87
$948.81 		$941.01
$991.21
$1,044.40
$1,233.34 		$1,225.54
$1,275.74
$1,328.93
$1,517.87 		$284.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.90
$844.30
$950.68
$1,328.56
$2,018.88 		$1,028.43
$1,128.83
$1,235.21
$1,613.09 		$1,312.96
$1,413.36
$1,519.74
$1,897.62 		$1,597.49
$1,697.89
$1,804.27
$2,182.15 		$284.53
Toc - Plan #108 Ambetter from Peach State Health Plan
Silver

(HMO) CMS Standard Silver SELECT Wellstar

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$363.50
$412.57
$464.55
$649.20
$986.53 		$641.57
$690.64
$742.62
$927.27 		$919.64
$968.71
$1,020.69
$1,205.34 		$1,197.71
$1,246.78
$1,298.76
$1,483.41 		$278.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.00
$825.14
$929.10
$1,298.40
$1,973.06 		$1,005.07
$1,103.21
$1,207.17
$1,576.47 		$1,283.14
$1,381.28
$1,485.24
$1,854.54 		$1,561.21
$1,659.35
$1,763.31
$2,132.61 		$278.07
Toc - Plan #109 Ambetter from Peach State Health Plan
Gold

(HMO) CMS Standard Gold SELECT Wellstar

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

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 		$372.78
$423.09
$476.40
$665.76
$1,011.69 		$657.95
$708.26
$761.57
$950.93 		$943.12
$993.43
$1,046.74
$1,236.10 		$1,228.29
$1,278.60
$1,331.91
$1,521.27 		$285.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.56
$846.18
$952.80
$1,331.52
$2,023.38 		$1,030.73
$1,131.35
$1,237.97
$1,616.69 		$1,315.90
$1,416.52
$1,523.14
$1,901.86 		$1,601.07
$1,701.69
$1,808.31
$2,187.03 		$285.17
Toc - Plan #110 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$344.01
$390.44
$439.63
$614.39
$933.62 		$607.17
$653.60
$702.79
$877.55 		$870.33
$916.76
$965.95
$1,140.71 		$1,133.49
$1,179.92
$1,229.11
$1,403.87 		$263.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.02
$780.88
$879.26
$1,228.78
$1,867.24 		$951.18
$1,044.04
$1,142.42
$1,491.94 		$1,214.34
$1,307.20
$1,405.58
$1,755.10 		$1,477.50
$1,570.36
$1,668.74
$2,018.26 		$263.16
Toc - Plan #111 Ambetter from Peach State Health Plan
Silver

(HMO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.41
$427.21
$481.04
$672.25
$1,021.54 		$664.35
$715.15
$768.98
$960.19 		$952.29
$1,003.09
$1,056.92
$1,248.13 		$1,240.23
$1,291.03
$1,344.86
$1,536.07 		$287.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.82
$854.42
$962.08
$1,344.50
$2,043.08 		$1,040.76
$1,142.36
$1,250.02
$1,632.44 		$1,328.70
$1,430.30
$1,537.96
$1,920.38 		$1,616.64
$1,718.24
$1,825.90
$2,208.32 		$287.94
Toc - Plan #112 Ambetter from Peach State Health Plan
Gold

(HMO) Ambetter Virtual Access Gold - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 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 		$401.07
$455.20
$512.55
$716.29
$1,088.48 		$707.88
$762.01
$819.36
$1,023.10 		$1,014.69
$1,068.82
$1,126.17
$1,329.91 		$1,321.50
$1,375.63
$1,432.98
$1,636.72 		$306.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.14
$910.40
$1,025.10
$1,432.58
$2,176.96 		$1,108.95
$1,217.21
$1,331.91
$1,739.39 		$1,415.76
$1,524.02
$1,638.72
$2,046.20 		$1,722.57
$1,830.83
$1,945.53
$2,353.01 		$306.81

ADVERTISEMENT

Kaiser Permanente

Local: 1-800-494-5314 | Toll Free: 1-800-494-5314

Toc - Plan #113 Kaiser Permanente
Gold

(HMO) KP GA Gold 500/20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$409.39
$464.66
$523.20
$731.17
$1,111.09 		$722.57
$777.84
$836.38
$1,044.35 		$1,035.75
$1,091.02
$1,149.56
$1,357.53 		$1,348.93
$1,404.20
$1,462.74
$1,670.71 		$313.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.78
$929.32
$1,046.40
$1,462.34
$2,222.18 		$1,131.96
$1,242.50
$1,359.58
$1,775.52 		$1,445.14
$1,555.68
$1,672.76
$2,088.70 		$1,758.32
$1,868.86
$1,985.94
$2,401.88 		$313.18
Toc - Plan #114 Kaiser Permanente
Silver

(HMO) KP GA Silver 3400/30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.58
$466.01
$524.73
$733.30
$1,114.33 		$724.68
$780.11
$838.83
$1,047.40 		$1,038.78
$1,094.21
$1,152.93
$1,361.50 		$1,352.88
$1,408.31
$1,467.03
$1,675.60 		$314.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.16
$932.02
$1,049.46
$1,466.60
$2,228.66 		$1,135.26
$1,246.12
$1,363.56
$1,780.70 		$1,449.36
$1,560.22
$1,677.66
$2,094.80 		$1,763.46
$1,874.32
$1,991.76
$2,408.90 		$314.10
Toc - Plan #115 Kaiser Permanente
Silver

(HMO) KP GA Silver 3500/20%/HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.61
$453.56
$510.70
$713.70
$1,084.54 		$705.31
$759.26
$816.40
$1,019.40 		$1,011.01
$1,064.96
$1,122.10
$1,325.10 		$1,316.71
$1,370.66
$1,427.80
$1,630.80 		$305.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.22
$907.12
$1,021.40
$1,427.40
$2,169.08 		$1,104.92
$1,212.82
$1,327.10
$1,733.10 		$1,410.62
$1,518.52
$1,632.80
$2,038.80 		$1,716.32
$1,824.22
$1,938.50
$2,344.50 		$305.70
Toc - Plan #116 Kaiser Permanente
Expanded Bronze

(HMO) KP GA Bronze Virtual Complete 5500/60

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 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 		$297.55
$337.72
$380.27
$531.42
$807.54 		$525.17
$565.34
$607.89
$759.04 		$752.79
$792.96
$835.51
$986.66 		$980.41
$1,020.58
$1,063.13
$1,214.28 		$227.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$595.10
$675.44
$760.54
$1,062.84
$1,615.08 		$822.72
$903.06
$988.16
$1,290.46 		$1,050.34
$1,130.68
$1,215.78
$1,518.08 		$1,277.96
$1,358.30
$1,443.40
$1,745.70 		$227.62
Toc - Plan #117 Kaiser Permanente
Expanded Bronze

(HMO) KP GA Bronze 6500/40%/HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$298.81
$339.15
$381.88
$533.68
$810.98 		$527.40
$567.74
$610.47
$762.27 		$755.99
$796.33
$839.06
$990.86 		$984.58
$1,024.92
$1,067.65
$1,219.45 		$228.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$597.62
$678.30
$763.76
$1,067.36
$1,621.96 		$826.21
$906.89
$992.35
$1,295.95 		$1,054.80
$1,135.48
$1,220.94
$1,524.54 		$1,283.39
$1,364.07
$1,449.53
$1,753.13 		$228.59
Toc - Plan #118 Kaiser Permanente
Catastrophic

(HMO) KP GA Catastrophic 9100/0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$258.76
$293.70
$330.70
$462.15
$702.28 		$456.71
$491.65
$528.65
$660.10 		$654.66
$689.60
$726.60
$858.05 		$852.61
$887.55
$924.55
$1,056.00 		$197.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.52
$587.40
$661.40
$924.30
$1,404.56 		$715.47
$785.35
$859.35
$1,122.25 		$913.42
$983.30
$1,057.30
$1,320.20 		$1,111.37
$1,181.25
$1,255.25
$1,518.15 		$197.95
Toc - Plan #119 Kaiser Permanente
Gold

(HMO) KP GA Gold 1500/20

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.35
$446.46
$502.71
$702.53
$1,067.56 		$694.27
$747.38
$803.63
$1,003.45 		$995.19
$1,048.30
$1,104.55
$1,304.37 		$1,296.11
$1,349.22
$1,405.47
$1,605.29 		$300.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.70
$892.92
$1,005.42
$1,405.06
$2,135.12 		$1,087.62
$1,193.84
$1,306.34
$1,705.98 		$1,388.54
$1,494.76
$1,607.26
$2,006.90 		$1,689.46
$1,795.68
$1,908.18
$2,307.82 		$300.92
Toc - Plan #120 Kaiser Permanente
Silver

(HMO) KP GA Silver 4500/35

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$398.11
$451.86
$508.79
$711.03
$1,080.48 		$702.67
$756.42
$813.35
$1,015.59 		$1,007.23
$1,060.98
$1,117.91
$1,320.15 		$1,311.79
$1,365.54
$1,422.47
$1,624.71 		$304.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.22
$903.72
$1,017.58
$1,422.06
$2,160.96 		$1,100.78
$1,208.28
$1,322.14
$1,726.62 		$1,405.34
$1,512.84
$1,626.70
$2,031.18 		$1,709.90
$1,817.40
$1,931.26
$2,335.74 		$304.56
Toc - Plan #121 Kaiser Permanente
Gold

(HMO) KP GA Gold 1800/25

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.63
$426.34
$480.05
$670.87
$1,019.45 		$662.99
$713.70
$767.41
$958.23 		$950.35
$1,001.06
$1,054.77
$1,245.59 		$1,237.71
$1,288.42
$1,342.13
$1,532.95 		$287.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.26
$852.68
$960.10
$1,341.74
$2,038.90 		$1,038.62
$1,140.04
$1,247.46
$1,629.10 		$1,325.98
$1,427.40
$1,534.82
$1,916.46 		$1,613.34
$1,714.76
$1,822.18
$2,203.82 		$287.36
Toc - Plan #122 Kaiser Permanente
Silver

(HMO) KP GA Silver Virtual Complete 4800/40

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.66
$427.51
$481.37
$672.71
$1,022.26 		$664.80
$715.65
$769.51
$960.85 		$952.94
$1,003.79
$1,057.65
$1,248.99 		$1,241.08
$1,291.93
$1,345.79
$1,537.13 		$288.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.32
$855.02
$962.74
$1,345.42
$2,044.52 		$1,041.46
$1,143.16
$1,250.88
$1,633.56 		$1,329.60
$1,431.30
$1,539.02
$1,921.70 		$1,617.74
$1,719.44
$1,827.16
$2,209.84 		$288.14
Toc - Plan #123 Kaiser Permanente
Gold

(HMO) KP GA Standard Gold 2000/30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

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 		$386.18
$438.31
$493.54
$689.72
$1,048.09 		$681.61
$733.74
$788.97
$985.15 		$977.04
$1,029.17
$1,084.40
$1,280.58 		$1,272.47
$1,324.60
$1,379.83
$1,576.01 		$295.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.36
$876.62
$987.08
$1,379.44
$2,096.18 		$1,067.79
$1,172.05
$1,282.51
$1,674.87 		$1,363.22
$1,467.48
$1,577.94
$1,970.30 		$1,658.65
$1,762.91
$1,873.37
$2,265.73 		$295.43
Toc - Plan #124 Kaiser Permanente
Silver

(HMO) KP GA Standard Silver 5800/40

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.64
$435.44
$490.30
$685.19
$1,041.21 		$677.13
$728.93
$783.79
$978.68 		$970.62
$1,022.42
$1,077.28
$1,272.17 		$1,264.11
$1,315.91
$1,370.77
$1,565.66 		$293.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.28
$870.88
$980.60
$1,370.38
$2,082.42 		$1,060.77
$1,164.37
$1,274.09
$1,663.87 		$1,354.26
$1,457.86
$1,567.58
$1,957.36 		$1,647.75
$1,751.35
$1,861.07
$2,250.85 		$293.49
Toc - Plan #125 Kaiser Permanente
Expanded Bronze

(HMO) KP GA Standard Bronze 7500/50

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$311.90
$354.00
$398.61
$557.05
$846.49 		$550.50
$592.60
$637.21
$795.65 		$789.10
$831.20
$875.81
$1,034.25 		$1,027.70
$1,069.80
$1,114.41
$1,272.85 		$238.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.80
$708.00
$797.22
$1,114.10
$1,692.98 		$862.40
$946.60
$1,035.82
$1,352.70 		$1,101.00
$1,185.20
$1,274.42
$1,591.30 		$1,339.60
$1,423.80
$1,513.02
$1,829.90 		$238.60

ADVERTISEMENT

Friday Health Plans

Local: 1-844-521-7999 | Toll Free: 1-844-521-7999 | TTY: 1-800-659-2656
Toc - Plan #126 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$247.75
$281.19
$316.62
$442.47
$672.38 		$437.27
$470.71
$506.14
$631.99 		$626.79
$660.23
$695.66
$821.51 		$816.31
$849.75
$885.18
$1,011.03 		$189.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$495.50
$562.38
$633.24
$884.94
$1,344.76 		$685.02
$751.90
$822.76
$1,074.46 		$874.54
$941.42
$1,012.28
$1,263.98 		$1,064.06
$1,130.94
$1,201.80
$1,453.50 		$189.52
Toc - Plan #127 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$318.53
$361.53
$407.08
$568.90
$864.49 		$562.21
$605.21
$650.76
$812.58 		$805.89
$848.89
$894.44
$1,056.26 		$1,049.57
$1,092.57
$1,138.12
$1,299.94 		$243.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.06
$723.06
$814.16
$1,137.80
$1,728.98 		$880.74
$966.74
$1,057.84
$1,381.48 		$1,124.42
$1,210.42
$1,301.52
$1,625.16 		$1,368.10
$1,454.10
$1,545.20
$1,868.84 		$243.68
Toc - Plan #128 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$320.89
$364.21
$410.10
$573.11
$870.90 		$566.37
$609.69
$655.58
$818.59 		$811.85
$855.17
$901.06
$1,064.07 		$1,057.33
$1,100.65
$1,146.54
$1,309.55 		$245.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.78
$728.42
$820.20
$1,146.22
$1,741.80 		$887.26
$973.90
$1,065.68
$1,391.70 		$1,132.74
$1,219.38
$1,311.16
$1,637.18 		$1,378.22
$1,464.86
$1,556.64
$1,882.66 		$245.48
Toc - Plan #129 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$339.37
$385.19
$433.72
$606.12
$921.06 		$598.99
$644.81
$693.34
$865.74 		$858.61
$904.43
$952.96
$1,125.36 		$1,118.23
$1,164.05
$1,212.58
$1,384.98 		$259.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.74
$770.38
$867.44
$1,212.24
$1,842.12 		$938.36
$1,030.00
$1,127.06
$1,471.86 		$1,197.98
$1,289.62
$1,386.68
$1,731.48 		$1,457.60
$1,549.24
$1,646.30
$1,991.10 		$259.62
Toc - Plan #130 Friday Health Plans
Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$344.53
$391.05
$440.32
$615.34
$935.07 		$608.10
$654.62
$703.89
$878.91 		$871.67
$918.19
$967.46
$1,142.48 		$1,135.24
$1,181.76
$1,231.03
$1,406.05 		$263.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.06
$782.10
$880.64
$1,230.68
$1,870.14 		$952.63
$1,045.67
$1,144.21
$1,494.25 		$1,216.20
$1,309.24
$1,407.78
$1,757.82 		$1,479.77
$1,572.81
$1,671.35
$2,021.39 		$263.57
Toc - Plan #131 Friday Health Plans
Gold

(HMO) Friday Gold + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.73
$468.45
$527.48
$737.14
$1,120.16 		$728.47
$784.19
$843.22
$1,052.88 		$1,044.21
$1,099.93
$1,158.96
$1,368.62 		$1,359.95
$1,415.67
$1,474.70
$1,684.36 		$315.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.46
$936.90
$1,054.96
$1,474.28
$2,240.32 		$1,141.20
$1,252.64
$1,370.70
$1,790.02 		$1,456.94
$1,568.38
$1,686.44
$2,105.76 		$1,772.68
$1,884.12
$2,002.18
$2,421.50 		$315.74
Toc - Plan #132 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$317.03
$359.82
$405.16
$566.21
$860.41 		$559.55
$602.34
$647.68
$808.73 		$802.07
$844.86
$890.20
$1,051.25 		$1,044.59
$1,087.38
$1,132.72
$1,293.77 		$242.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.06
$719.64
$810.32
$1,132.42
$1,720.82 		$876.58
$962.16
$1,052.84
$1,374.94 		$1,119.10
$1,204.68
$1,295.36
$1,617.46 		$1,361.62
$1,447.20
$1,537.88
$1,859.98 		$242.52
Toc - Plan #133 Friday Health Plans
Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$366.01
$415.42
$467.76
$653.69
$993.35 		$646.01
$695.42
$747.76
$933.69 		$926.01
$975.42
$1,027.76
$1,213.69 		$1,206.01
$1,255.42
$1,307.76
$1,493.69 		$280.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.02
$830.84
$935.52
$1,307.38
$1,986.70 		$1,012.02
$1,110.84
$1,215.52
$1,587.38 		$1,292.02
$1,390.84
$1,495.52
$1,867.38 		$1,572.02
$1,670.84
$1,775.52
$2,147.38 		$280.00
Toc - Plan #134 Friday Health Plans
Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.21
$483.75
$544.69
$761.21
$1,156.73 		$752.26
$809.80
$870.74
$1,087.26 		$1,078.31
$1,135.85
$1,196.79
$1,413.31 		$1,404.36
$1,461.90
$1,522.84
$1,739.36 		$326.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.42
$967.50
$1,089.38
$1,522.42
$2,313.46 		$1,178.47
$1,293.55
$1,415.43
$1,848.47 		$1,504.52
$1,619.60
$1,741.48
$2,174.52 		$1,830.57
$1,945.65
$2,067.53
$2,500.57 		$326.05
Toc - Plan #135 Friday Health Plans
Bronze

(HMO) Friday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$318.18
$361.14
$406.64
$568.28
$863.55 		$561.59
$604.55
$650.05
$811.69 		$805.00
$847.96
$893.46
$1,055.10 		$1,048.41
$1,091.37
$1,136.87
$1,298.51 		$243.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.36
$722.28
$813.28
$1,136.56
$1,727.10 		$879.77
$965.69
$1,056.69
$1,379.97 		$1,123.18
$1,209.10
$1,300.10
$1,623.38 		$1,366.59
$1,452.51
$1,543.51
$1,866.79 		$243.41
Toc - Plan #136 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$320.54
$363.82
$409.65
$572.49
$869.95 		$565.76
$609.04
$654.87
$817.71 		$810.98
$854.26
$900.09
$1,062.93 		$1,056.20
$1,099.48
$1,145.31
$1,308.15 		$245.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.08
$727.64
$819.30
$1,144.98
$1,739.90 		$886.30
$972.86
$1,064.52
$1,390.20 		$1,131.52
$1,218.08
$1,309.74
$1,635.42 		$1,376.74
$1,463.30
$1,554.96
$1,880.64 		$245.22
Toc - Plan #137 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$316.68
$359.43
$404.71
$565.59
$859.46 		$558.94
$601.69
$646.97
$807.85 		$801.20
$843.95
$889.23
$1,050.11 		$1,043.46
$1,086.21
$1,131.49
$1,292.37 		$242.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.36
$718.86
$809.42
$1,131.18
$1,718.92 		$875.62
$961.12
$1,051.68
$1,373.44 		$1,117.88
$1,203.38
$1,293.94
$1,615.70 		$1,360.14
$1,445.64
$1,536.20
$1,857.96 		$242.26
Toc - Plan #138 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$344.19
$390.65
$439.87
$614.72
$934.12 		$607.49
$653.95
$703.17
$878.02 		$870.79
$917.25
$966.47
$1,141.32 		$1,134.09
$1,180.55
$1,229.77
$1,404.62 		$263.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.38
$781.30
$879.74
$1,229.44
$1,868.24 		$951.68
$1,044.60
$1,143.04
$1,492.74 		$1,214.98
$1,307.90
$1,406.34
$1,756.04 		$1,478.28
$1,571.20
$1,669.64
$2,019.34 		$263.30
Toc - Plan #139 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$365.66
$415.02
$467.31
$653.07
$992.40 		$645.39
$694.75
$747.04
$932.80 		$925.12
$974.48
$1,026.77
$1,212.53 		$1,204.85
$1,254.21
$1,306.50
$1,492.26 		$279.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.32
$830.04
$934.62
$1,306.14
$1,984.80 		$1,011.05
$1,109.77
$1,214.35
$1,585.87 		$1,290.78
$1,389.50
$1,494.08
$1,865.60 		$1,570.51
$1,669.23
$1,773.81
$2,145.33 		$279.73
Toc - Plan #140 Friday Health Plans
Silver

(HMO) Friday Silver Zero Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 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 		$372.37
$422.64
$475.89
$665.05
$1,010.61 		$657.23
$707.50
$760.75
$949.91 		$942.09
$992.36
$1,045.61
$1,234.77 		$1,226.95
$1,277.22
$1,330.47
$1,519.63 		$284.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.74
$845.28
$951.78
$1,330.10
$2,021.22 		$1,029.60
$1,130.14
$1,236.64
$1,614.96 		$1,314.46
$1,415.00
$1,521.50
$1,899.82 		$1,599.32
$1,699.86
$1,806.36
$2,184.68 		$284.86
Toc - Plan #141 Friday Health Plans
Silver

(HMO) Friday Silver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$360.54
$409.21
$460.77
$643.92
$978.51 		$636.35
$685.02
$736.58
$919.73 		$912.16
$960.83
$1,012.39
$1,195.54 		$1,187.97
$1,236.64
$1,288.20
$1,471.35 		$275.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.08
$818.42
$921.54
$1,287.84
$1,957.02 		$996.89
$1,094.23
$1,197.35
$1,563.65 		$1,272.70
$1,370.04
$1,473.16
$1,839.46 		$1,548.51
$1,645.85
$1,748.97
$2,115.27 		$275.81
Toc - Plan #142 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.39
$468.06
$527.03
$736.52
$1,119.22 		$727.87
$783.54
$842.51
$1,052.00 		$1,043.35
$1,099.02
$1,157.99
$1,367.48 		$1,358.83
$1,414.50
$1,473.47
$1,682.96 		$315.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.78
$936.12
$1,054.06
$1,473.04
$2,238.44 		$1,140.26
$1,251.60
$1,369.54
$1,788.52 		$1,455.74
$1,567.08
$1,685.02
$2,104.00 		$1,771.22
$1,882.56
$2,000.50
$2,419.48 		$315.48
Toc - Plan #143 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$425.86
$483.35
$544.25
$760.59
$1,155.79 		$751.64
$809.13
$870.03
$1,086.37 		$1,077.42
$1,134.91
$1,195.81
$1,412.15 		$1,403.20
$1,460.69
$1,521.59
$1,737.93 		$325.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.72
$966.70
$1,088.50
$1,521.18
$2,311.58 		$1,177.50
$1,292.48
$1,414.28
$1,846.96 		$1,503.28
$1,618.26
$1,740.06
$2,172.74 		$1,829.06
$1,944.04
$2,065.84
$2,498.52 		$325.78
Toc - Plan #144 Friday Health Plans
Bronze

(HMO) Friday Standard Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 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 		$318.18
$361.14
$406.64
$568.28
$863.55 		$561.59
$604.55
$650.05
$811.69 		$805.00
$847.96
$893.46
$1,055.10 		$1,048.41
$1,091.37
$1,136.87
$1,298.51 		$243.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.36
$722.28
$813.28
$1,136.56
$1,727.10 		$879.77
$965.69
$1,056.69
$1,379.97 		$1,123.18
$1,209.10
$1,300.10
$1,623.38 		$1,366.59
$1,452.51
$1,543.51
$1,866.79 		$243.41
Toc - Plan #145 Friday Health Plans
Expanded Bronze

(HMO) Friday Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 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 		$317.31
$360.15
$405.52
$566.72
$861.18 		$560.05
$602.89
$648.26
$809.46 		$802.79
$845.63
$891.00
$1,052.20 		$1,045.53
$1,088.37
$1,133.74
$1,294.94 		$242.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.62
$720.30
$811.04
$1,133.44
$1,722.36 		$877.36
$963.04
$1,053.78
$1,376.18 		$1,120.10
$1,205.78
$1,296.52
$1,618.92 		$1,362.84
$1,448.52
$1,539.26
$1,861.66 		$242.74
Toc - Plan #146 Friday Health Plans
Silver

(HMO) Friday Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 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 		$335.86
$381.20
$429.23
$599.84
$911.52 		$592.79
$638.13
$686.16
$856.77 		$849.72
$895.06
$943.09
$1,113.70 		$1,106.65
$1,151.99
$1,200.02
$1,370.63 		$256.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.72
$762.40
$858.46
$1,199.68
$1,823.04 		$928.65
$1,019.33
$1,115.39
$1,456.61 		$1,185.58
$1,276.26
$1,372.32
$1,713.54 		$1,442.51
$1,533.19
$1,629.25
$1,970.47 		$256.93
Toc - Plan #147 Friday Health Plans
Gold

(HMO) Friday Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-521-7999

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 		$424.10
$481.36
$542.01
$757.45
$1,151.02 		$748.54
$805.80
$866.45
$1,081.89 		$1,072.98
$1,130.24
$1,190.89
$1,406.33 		$1,397.42
$1,454.68
$1,515.33
$1,730.77 		$324.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.20
$962.72
$1,084.02
$1,514.90
$2,302.04 		$1,172.64
$1,287.16
$1,408.46
$1,839.34 		$1,497.08
$1,611.60
$1,732.90
$2,163.78 		$1,821.52
$1,936.04
$2,057.34
$2,488.22 		$324.44

‡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 Cherokee County here.

Cherokee County is in “Rating Area 3” of Georgia.

Currently, there are 147 plans offered in Rating Area 3.

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2023 Obamacare Plans for Cherokee County, GA

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