Obamacare 2023 Rates for Jasper County

Obamacare > Rates > Georgia > Jasper 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 Jasper 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, 92 Plans and 2023 Rates for Jasper County, Georgia

Below, you’ll find a summary of the 92 plans for Jasper 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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Jasper County, GA Consumer Law 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

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

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

Toc - Plan #20 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 #21 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 #22 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 #23 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 #24 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 #25 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 #26 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 #27 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 #28 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 #29 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 #30 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 #31 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 #32 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 #33 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 #34 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 #35 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 #36 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 #37 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 #38 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 #39 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 #40 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 #41 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 #42 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 #43 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 #44 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 #45 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 #46 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 #47 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 #48 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 #49 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 #50 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 #51 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 #52 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 #53 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 #54 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 #55 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 #56 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 #57 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 #58 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 #59 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 #60 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 #61 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 #62 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 #63 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 #64 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 #65 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 #66 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 #67 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 #68 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 #69 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 #70 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 #71 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 #72 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 #73 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 #74 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 #75 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 #76 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 #77 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 #78 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 #79 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 #80 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 #81 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 #82 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 #83 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 #84 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 #85 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

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #86 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$419.52
$476.16
$536.15
$749.27
$1,138.59 		$740.46
$797.10
$857.09
$1,070.21 		$1,061.40
$1,118.04
$1,178.03
$1,391.15 		$1,382.34
$1,438.98
$1,498.97
$1,712.09 		$320.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.04
$952.32
$1,072.30
$1,498.54
$2,277.18 		$1,159.98
$1,273.26
$1,393.24
$1,819.48 		$1,480.92
$1,594.20
$1,714.18
$2,140.42 		$1,801.86
$1,915.14
$2,035.12
$2,461.36 		$320.94
Toc - Plan #87 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.47
$406.87
$458.13
$640.23
$972.89 		$632.70
$681.10
$732.36
$914.46 		$906.93
$955.33
$1,006.59
$1,188.69 		$1,181.16
$1,229.56
$1,280.82
$1,462.92 		$274.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.94
$813.74
$916.26
$1,280.46
$1,945.78 		$991.17
$1,087.97
$1,190.49
$1,554.69 		$1,265.40
$1,362.20
$1,464.72
$1,828.92 		$1,539.63
$1,636.43
$1,738.95
$2,103.15 		$274.23
Toc - Plan #88 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.44
$422.72
$475.98
$665.17
$1,010.80 		$657.35
$707.63
$760.89
$950.08 		$942.26
$992.54
$1,045.80
$1,234.99 		$1,227.17
$1,277.45
$1,330.71
$1,519.90 		$284.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.88
$845.44
$951.96
$1,330.34
$2,021.60 		$1,029.79
$1,130.35
$1,236.87
$1,615.25 		$1,314.70
$1,415.26
$1,521.78
$1,900.16 		$1,599.61
$1,700.17
$1,806.69
$2,185.07 		$284.91
Toc - Plan #89 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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 		$317.36
$360.21
$405.59
$566.81
$861.32 		$560.14
$602.99
$648.37
$809.59 		$802.92
$845.77
$891.15
$1,052.37 		$1,045.70
$1,088.55
$1,133.93
$1,295.15 		$242.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.72
$720.42
$811.18
$1,133.62
$1,722.64 		$877.50
$963.20
$1,053.96
$1,376.40 		$1,120.28
$1,205.98
$1,296.74
$1,619.18 		$1,363.06
$1,448.76
$1,539.52
$1,861.96 		$242.78
Toc - Plan #90 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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 		$411.41
$466.95
$525.78
$734.78
$1,116.57 		$726.14
$781.68
$840.51
$1,049.51 		$1,040.87
$1,096.41
$1,155.24
$1,364.24 		$1,355.60
$1,411.14
$1,469.97
$1,678.97 		$314.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.82
$933.90
$1,051.56
$1,469.56
$2,233.14 		$1,137.55
$1,248.63
$1,366.29
$1,784.29 		$1,452.28
$1,563.36
$1,681.02
$2,099.02 		$1,767.01
$1,878.09
$1,995.75
$2,413.75 		$314.73
Toc - Plan #91 Aetna CVS Health
Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$387.86
$440.22
$495.69
$692.72
$1,052.66 		$684.57
$736.93
$792.40
$989.43 		$981.28
$1,033.64
$1,089.11
$1,286.14 		$1,277.99
$1,330.35
$1,385.82
$1,582.85 		$296.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.72
$880.44
$991.38
$1,385.44
$2,105.32 		$1,072.43
$1,177.15
$1,288.09
$1,682.15 		$1,369.14
$1,473.86
$1,584.80
$1,978.86 		$1,665.85
$1,770.57
$1,881.51
$2,275.57 		$296.71
Toc - Plan #92 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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 		$350.09
$397.35
$447.42
$625.26
$950.15 		$617.91
$665.17
$715.24
$893.08 		$885.73
$932.99
$983.06
$1,160.90 		$1,153.55
$1,200.81
$1,250.88
$1,428.72 		$267.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.18
$794.70
$894.84
$1,250.52
$1,900.30 		$968.00
$1,062.52
$1,162.66
$1,518.34 		$1,235.82
$1,330.34
$1,430.48
$1,786.16 		$1,503.64
$1,598.16
$1,698.30
$2,053.98 		$267.82

‡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 Jasper County here.

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

Currently, there are 92 plans offered in Rating Area 3.

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2023 Obamacare Plans for Jasper County, GA

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