Obamacare 2023 Rates for Pike County

Obamacare > Rates > Georgia > Pike 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 Pike 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, 107 Plans and 2023 Rates for Pike County, Georgia

Below, you’ll find a summary of the 107 plans for Pike 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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Pike 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

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
Catastrophic

(HMO) Anthem Catastrophic Pathway X 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 		$309.05
$350.77
$394.97
$551.96
$838.76 		$545.47
$587.19
$631.39
$788.38 		$781.89
$823.61
$867.81
$1,024.80 		$1,018.31
$1,060.03
$1,104.23
$1,261.22 		$236.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.10
$701.54
$789.94
$1,103.92
$1,677.52 		$854.52
$937.96
$1,026.36
$1,340.34 		$1,090.94
$1,174.38
$1,262.78
$1,576.76 		$1,327.36
$1,410.80
$1,499.20
$1,813.18 		$236.42
Toc - Plan #21 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$449.24
$509.89
$574.13
$802.34
$1,219.24 		$792.91
$853.56
$917.80
$1,146.01 		$1,136.58
$1,197.23
$1,261.47
$1,489.68 		$1,480.25
$1,540.90
$1,605.14
$1,833.35 		$343.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.48
$1,019.78
$1,148.26
$1,604.68
$2,438.48 		$1,242.15
$1,363.45
$1,491.93
$1,948.35 		$1,585.82
$1,707.12
$1,835.60
$2,292.02 		$1,929.49
$2,050.79
$2,179.27
$2,635.69 		$343.67
Toc - Plan #22 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$435.12
$493.86
$556.08
$777.12
$1,180.92 		$767.99
$826.73
$888.95
$1,109.99 		$1,100.86
$1,159.60
$1,221.82
$1,442.86 		$1,433.73
$1,492.47
$1,554.69
$1,775.73 		$332.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.24
$987.72
$1,112.16
$1,554.24
$2,361.84 		$1,203.11
$1,320.59
$1,445.03
$1,887.11 		$1,535.98
$1,653.46
$1,777.90
$2,219.98 		$1,868.85
$1,986.33
$2,110.77
$2,552.85 		$332.87
Toc - Plan #23 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$427.70
$485.44
$546.60
$763.87
$1,160.78 		$754.89
$812.63
$873.79
$1,091.06 		$1,082.08
$1,139.82
$1,200.98
$1,418.25 		$1,409.27
$1,467.01
$1,528.17
$1,745.44 		$327.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.40
$970.88
$1,093.20
$1,527.74
$2,321.56 		$1,182.59
$1,298.07
$1,420.39
$1,854.93 		$1,509.78
$1,625.26
$1,747.58
$2,182.12 		$1,836.97
$1,952.45
$2,074.77
$2,509.31 		$327.19
Toc - Plan #24 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$536.83
$609.30
$686.07
$958.78
$1,456.96 		$947.50
$1,019.97
$1,096.74
$1,369.45 		$1,358.17
$1,430.64
$1,507.41
$1,780.12 		$1,768.84
$1,841.31
$1,918.08
$2,190.79 		$410.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,073.66
$1,218.60
$1,372.14
$1,917.56
$2,913.92 		$1,484.33
$1,629.27
$1,782.81
$2,328.23 		$1,895.00
$2,039.94
$2,193.48
$2,738.90 		$2,305.67
$2,450.61
$2,604.15
$3,149.57 		$410.67
Toc - Plan #25 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$540.89
$613.91
$691.26
$966.03
$1,467.98 		$954.67
$1,027.69
$1,105.04
$1,379.81 		$1,368.45
$1,441.47
$1,518.82
$1,793.59 		$1,782.23
$1,855.25
$1,932.60
$2,207.37 		$413.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,081.78
$1,227.82
$1,382.52
$1,932.06
$2,935.96 		$1,495.56
$1,641.60
$1,796.30
$2,345.84 		$1,909.34
$2,055.38
$2,210.08
$2,759.62 		$2,323.12
$2,469.16
$2,623.86
$3,173.40 		$413.78
Toc - Plan #26 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Bronze

(HMO) Anthem Bronze Pathway X 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 		$410.76
$466.21
$524.95
$733.62
$1,114.80 		$724.99
$780.44
$839.18
$1,047.85 		$1,039.22
$1,094.67
$1,153.41
$1,362.08 		$1,353.45
$1,408.90
$1,467.64
$1,676.31 		$314.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.52
$932.42
$1,049.90
$1,467.24
$2,229.60 		$1,135.75
$1,246.65
$1,364.13
$1,781.47 		$1,449.98
$1,560.88
$1,678.36
$2,095.70 		$1,764.21
$1,875.11
$1,992.59
$2,409.93 		$314.23
Toc - Plan #27 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$544.26
$617.74
$695.56
$972.05
$1,477.12 		$960.62
$1,034.10
$1,111.92
$1,388.41 		$1,376.98
$1,450.46
$1,528.28
$1,804.77 		$1,793.34
$1,866.82
$1,944.64
$2,221.13 		$416.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,088.52
$1,235.48
$1,391.12
$1,944.10
$2,954.24 		$1,504.88
$1,651.84
$1,807.48
$2,360.46 		$1,921.24
$2,068.20
$2,223.84
$2,776.82 		$2,337.60
$2,484.56
$2,640.20
$3,193.18 		$416.36
Toc - Plan #28 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$534.53
$606.69
$683.13
$954.67
$1,450.71 		$943.45
$1,015.61
$1,092.05
$1,363.59 		$1,352.37
$1,424.53
$1,500.97
$1,772.51 		$1,761.29
$1,833.45
$1,909.89
$2,181.43 		$408.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,069.06
$1,213.38
$1,366.26
$1,909.34
$2,901.42 		$1,477.98
$1,622.30
$1,775.18
$2,318.26 		$1,886.90
$2,031.22
$2,184.10
$2,727.18 		$2,295.82
$2,440.14
$2,593.02
$3,136.10 		$408.92
Toc - Plan #29 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Gold

(HMO) Anthem Gold Pathway X 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 		$597.33
$677.97
$763.39
$1,066.83
$1,621.15 		$1,054.29
$1,134.93
$1,220.35
$1,523.79 		$1,511.25
$1,591.89
$1,677.31
$1,980.75 		$1,968.21
$2,048.85
$2,134.27
$2,437.71 		$456.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,194.66
$1,355.94
$1,526.78
$2,133.66
$3,242.30 		$1,651.62
$1,812.90
$1,983.74
$2,590.62 		$2,108.58
$2,269.86
$2,440.70
$3,047.58 		$2,565.54
$2,726.82
$2,897.66
$3,504.54 		$456.96
Toc - Plan #30 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$453.55
$514.78
$579.64
$810.04
$1,230.93 		$800.52
$861.75
$926.61
$1,157.01 		$1,147.49
$1,208.72
$1,273.58
$1,503.98 		$1,494.46
$1,555.69
$1,620.55
$1,850.95 		$346.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$907.10
$1,029.56
$1,159.28
$1,620.08
$2,461.86 		$1,254.07
$1,376.53
$1,506.25
$1,967.05 		$1,601.04
$1,723.50
$1,853.22
$2,314.02 		$1,948.01
$2,070.47
$2,200.19
$2,660.99 		$346.97
Toc - Plan #31 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$570.20
$647.18
$728.72
$1,018.38
$1,547.52 		$1,006.40
$1,083.38
$1,164.92
$1,454.58 		$1,442.60
$1,519.58
$1,601.12
$1,890.78 		$1,878.80
$1,955.78
$2,037.32
$2,326.98 		$436.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,140.40
$1,294.36
$1,457.44
$2,036.76
$3,095.04 		$1,576.60
$1,730.56
$1,893.64
$2,472.96 		$2,012.80
$2,166.76
$2,329.84
$2,909.16 		$2,449.00
$2,602.96
$2,766.04
$3,345.36 		$436.20
Toc - Plan #32 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Bronze

(HMO) Anthem Bronze Pathway X 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 		$423.05
$480.16
$540.66
$755.57
$1,148.16 		$746.68
$803.79
$864.29
$1,079.20 		$1,070.31
$1,127.42
$1,187.92
$1,402.83 		$1,393.94
$1,451.05
$1,511.55
$1,726.46 		$323.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.10
$960.32
$1,081.32
$1,511.14
$2,296.32 		$1,169.73
$1,283.95
$1,404.95
$1,834.77 		$1,493.36
$1,607.58
$1,728.58
$2,158.40 		$1,816.99
$1,931.21
$2,052.21
$2,482.03 		$323.63
Toc - Plan #33 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Expanded Bronze

(HMO) Anthem Bronze Pathway X 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 		$462.77
$525.24
$591.42
$826.51
$1,255.96 		$816.79
$879.26
$945.44
$1,180.53 		$1,170.81
$1,233.28
$1,299.46
$1,534.55 		$1,524.83
$1,587.30
$1,653.48
$1,888.57 		$354.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.54
$1,050.48
$1,182.84
$1,653.02
$2,511.92 		$1,279.56
$1,404.50
$1,536.86
$2,007.04 		$1,633.58
$1,758.52
$1,890.88
$2,361.06 		$1,987.60
$2,112.54
$2,244.90
$2,715.08 		$354.02
Toc - Plan #34 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Silver

(HMO) Anthem Silver Pathway X 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 		$542.85
$616.13
$693.76
$969.53
$1,473.29 		$958.13
$1,031.41
$1,109.04
$1,384.81 		$1,373.41
$1,446.69
$1,524.32
$1,800.09 		$1,788.69
$1,861.97
$1,939.60
$2,215.37 		$415.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,085.70
$1,232.26
$1,387.52
$1,939.06
$2,946.58 		$1,500.98
$1,647.54
$1,802.80
$2,354.34 		$1,916.26
$2,062.82
$2,218.08
$2,769.62 		$2,331.54
$2,478.10
$2,633.36
$3,184.90 		$415.28
Toc - Plan #35 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Gold

(HMO) Anthem Gold Pathway X 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 		$613.84
$696.71
$784.49
$1,096.32
$1,665.96 		$1,083.43
$1,166.30
$1,254.08
$1,565.91 		$1,553.02
$1,635.89
$1,723.67
$2,035.50 		$2,022.61
$2,105.48
$2,193.26
$2,505.09 		$469.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,227.68
$1,393.42
$1,568.98
$2,192.64
$3,331.92 		$1,697.27
$1,863.01
$2,038.57
$2,662.23 		$2,166.86
$2,332.60
$2,508.16
$3,131.82 		$2,636.45
$2,802.19
$2,977.75
$3,601.41 		$469.59

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

Alliant Health Plans

Local: 1-800-811-4793 | Toll Free: 1-800-811-4793

Toc - Plan #86 Alliant Health Plans
Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits) 40184

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$598.06
$678.78
$764.31
$1,068.11
$1,623.10 		$1,055.57
$1,136.29
$1,221.82
$1,525.62 		$1,513.08
$1,593.80
$1,679.33
$1,983.13 		$1,970.59
$2,051.31
$2,136.84
$2,440.64 		$457.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,196.12
$1,357.56
$1,528.62
$2,136.22
$3,246.20 		$1,653.63
$1,815.07
$1,986.13
$2,593.73 		$2,111.14
$2,272.58
$2,443.64
$3,051.24 		$2,568.65
$2,730.09
$2,901.15
$3,508.75 		$457.51
Toc - Plan #87 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40331

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,050 $18,100 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 		$447.35
$507.73
$571.70
$798.95
$1,214.09 		$789.57
$849.95
$913.92
$1,141.17 		$1,131.79
$1,192.17
$1,256.14
$1,483.39 		$1,474.01
$1,534.39
$1,598.36
$1,825.61 		$342.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.70
$1,015.46
$1,143.40
$1,597.90
$2,428.18 		$1,236.92
$1,357.68
$1,485.62
$1,940.12 		$1,579.14
$1,699.90
$1,827.84
$2,282.34 		$1,921.36
$2,042.12
$2,170.06
$2,624.56 		$342.22
Toc - Plan #88 Alliant Health Plans
Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits + Chiro + Dental) 40349

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$627.96
$712.72
$802.52
$1,121.52
$1,704.26 		$1,108.34
$1,193.10
$1,282.90
$1,601.90 		$1,588.72
$1,673.48
$1,763.28
$2,082.28 		$2,069.10
$2,153.86
$2,243.66
$2,562.66 		$480.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,255.92
$1,425.44
$1,605.04
$2,243.04
$3,408.52 		$1,736.30
$1,905.82
$2,085.42
$2,723.42 		$2,216.68
$2,386.20
$2,565.80
$3,203.80 		$2,697.06
$2,866.58
$3,046.18
$3,684.18 		$480.38
Toc - Plan #89 Alliant Health Plans
Platinum

(PPO) SoloCare PPO Platinum Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$617.79
$701.18
$789.52
$1,103.35
$1,676.65 		$1,090.39
$1,173.78
$1,262.12
$1,575.95 		$1,562.99
$1,646.38
$1,734.72
$2,048.55 		$2,035.59
$2,118.98
$2,207.32
$2,521.15 		$472.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,235.58
$1,402.36
$1,579.04
$2,206.70
$3,353.30 		$1,708.18
$1,874.96
$2,051.64
$2,679.30 		$2,180.78
$2,347.56
$2,524.24
$3,151.90 		$2,653.38
$2,820.16
$2,996.84
$3,624.50 		$472.60
Toc - Plan #90 Alliant Health Plans
Gold

(PPO) SoloCare PPO Gold Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$447.35
$507.73
$571.70
$798.95
$1,214.09 		$789.57
$849.95
$913.92
$1,141.17 		$1,131.79
$1,192.17
$1,256.14
$1,483.39 		$1,474.01
$1,534.39
$1,598.36
$1,825.61 		$342.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.70
$1,015.46
$1,143.40
$1,597.90
$2,428.18 		$1,236.92
$1,357.68
$1,485.62
$1,940.12 		$1,579.14
$1,699.90
$1,827.84
$2,282.34 		$1,921.36
$2,042.12
$2,170.06
$2,624.56 		$342.22
Toc - Plan #91 Alliant Health Plans
Silver

(PPO) SoloCare PPO Silver Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$424.63
$481.94
$542.66
$758.37
$1,152.42 		$749.46
$806.77
$867.49
$1,083.20 		$1,074.29
$1,131.60
$1,192.32
$1,408.03 		$1,399.12
$1,456.43
$1,517.15
$1,732.86 		$324.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.26
$963.88
$1,085.32
$1,516.74
$2,304.84 		$1,174.09
$1,288.71
$1,410.15
$1,841.57 		$1,498.92
$1,613.54
$1,734.98
$2,166.40 		$1,823.75
$1,938.37
$2,059.81
$2,491.23 		$324.83
Toc - Plan #92 Alliant Health Plans
Gold

(HMO) SoloCare Gold No Referral HMO (3 Free PCP Visits) 110003

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$454.53
$515.88
$580.88
$811.78
$1,233.57 		$802.24
$863.59
$928.59
$1,159.49 		$1,149.95
$1,211.30
$1,276.30
$1,507.20 		$1,497.66
$1,559.01
$1,624.01
$1,854.91 		$347.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.06
$1,031.76
$1,161.76
$1,623.56
$2,467.14 		$1,256.77
$1,379.47
$1,509.47
$1,971.27 		$1,604.48
$1,727.18
$1,857.18
$2,318.98 		$1,952.19
$2,074.89
$2,204.89
$2,666.69 		$347.71
Toc - Plan #93 Alliant Health Plans
Catastrophic

(HMO) SoloCare Catastropic No Referral HMO 110023

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$257.17
$291.88
$328.66
$459.29
$697.94 		$453.90
$488.61
$525.39
$656.02 		$650.63
$685.34
$722.12
$852.75 		$847.36
$882.07
$918.85
$1,049.48 		$196.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514.34
$583.76
$657.32
$918.58
$1,395.88 		$711.07
$780.49
$854.05
$1,115.31 		$907.80
$977.22
$1,050.78
$1,312.04 		$1,104.53
$1,173.95
$1,247.51
$1,508.77 		$196.73
Toc - Plan #94 Alliant Health Plans
Gold

(HMO) SoloCare HMO Gold Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-811-4793

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 		$444.96
$505.02
$568.65
$794.69
$1,207.60 		$785.35
$845.41
$909.04
$1,135.08 		$1,125.74
$1,185.80
$1,249.43
$1,475.47 		$1,466.13
$1,526.19
$1,589.82
$1,815.86 		$340.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.92
$1,010.04
$1,137.30
$1,589.38
$2,415.20 		$1,230.31
$1,350.43
$1,477.69
$1,929.77 		$1,570.70
$1,690.82
$1,818.08
$2,270.16 		$1,911.09
$2,031.21
$2,158.47
$2,610.55 		$340.39

ADVERTISEMENT

Kaiser Permanente

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

Toc - Plan #95 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 #96 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 #97 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 #98 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 #99 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 #100 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 #101 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 #102 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 #103 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 #104 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 #105 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 #106 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 #107 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

‡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 Pike County here.

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

Currently, there are 107 plans offered in Rating Area 3.

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2023 Obamacare Plans for Pike County, GA

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