Obamacare 2023 Rates for Tippah County

Obamacare > Rates > Mississippi > Tippah 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 Tippah County, MS.

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, 72 Plans and 2023 Rates for Tippah County, Mississippi

Below, you’ll find a summary of the 72 plans for Tippah County, Mississippi 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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Tippah County Resources

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Vantage Health Plan of Mississippi

Local: 1-318-361-0900 | Toll Free: 1-888-823-1910 | TTY: 1-866-524-5144
Toc - Plan #1 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Essential Bronze 6500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

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 		$329.37
$373.83
$420.93
$588.25
$893.91 		$538.52
$582.98
$630.08
$797.40 		$747.67
$792.13
$839.23
$1,006.55 		$956.82
$1,001.28
$1,048.38
$1,215.70 		$209.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.74
$747.66
$841.86
$1,176.50
$1,787.82 		$867.89
$956.81
$1,051.01
$1,385.65 		$1,077.04
$1,165.96
$1,260.16
$1,594.80 		$1,286.19
$1,375.11
$1,469.31
$1,803.95 		$209.15
Toc - Plan #2 Vantage Health Plan of Mississippi
Gold

(POS) Essential Gold 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 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 		$478.97
$543.64
$612.13
$855.45
$1,299.94 		$783.12
$847.79
$916.28
$1,159.60 		$1,087.27
$1,151.94
$1,220.43
$1,463.75 		$1,391.42
$1,456.09
$1,524.58
$1,767.90 		$304.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$957.94
$1,087.28
$1,224.26
$1,710.90
$2,599.88 		$1,262.09
$1,391.43
$1,528.41
$2,015.05 		$1,566.24
$1,695.58
$1,832.56
$2,319.20 		$1,870.39
$1,999.73
$2,136.71
$2,623.35 		$304.15
Toc - Plan #3 Vantage Health Plan of Mississippi
Silver

(POS) Freedom Silver 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

Individual Family
$4,000 $12,000 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$369.62
$419.52
$472.37
$660.14
$1,003.14 		$604.33
$654.23
$707.08
$894.85 		$839.04
$888.94
$941.79
$1,129.56 		$1,073.75
$1,123.65
$1,176.50
$1,364.27 		$234.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.24
$839.04
$944.74
$1,320.28
$2,006.28 		$973.95
$1,073.75
$1,179.45
$1,554.99 		$1,208.66
$1,308.46
$1,414.16
$1,789.70 		$1,443.37
$1,543.17
$1,648.87
$2,024.41 		$234.71
Toc - Plan #4 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Savings Bronze 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$324.54
$368.36
$414.77
$579.64
$880.81 		$530.63
$574.45
$620.86
$785.73 		$736.72
$780.54
$826.95
$991.82 		$942.81
$986.63
$1,033.04
$1,197.91 		$206.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.08
$736.72
$829.54
$1,159.28
$1,761.62 		$855.17
$942.81
$1,035.63
$1,365.37 		$1,061.26
$1,148.90
$1,241.72
$1,571.46 		$1,267.35
$1,354.99
$1,447.81
$1,777.55 		$206.09
Toc - Plan #5 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Savings Bronze 7200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

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 		$324.99
$368.86
$415.33
$580.43
$882.02 		$531.36
$575.23
$621.70
$786.80 		$737.73
$781.60
$828.07
$993.17 		$944.10
$987.97
$1,034.44
$1,199.54 		$206.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.98
$737.72
$830.66
$1,160.86
$1,764.04 		$856.35
$944.09
$1,037.03
$1,367.23 		$1,062.72
$1,150.46
$1,243.40
$1,573.60 		$1,269.09
$1,356.83
$1,449.77
$1,779.97 		$206.37
Toc - Plan #6 Vantage Health Plan of Mississippi
Gold

(POS) Standard Gold 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

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 		$483.92
$549.25
$618.46
$864.29
$1,313.37 		$791.21
$856.54
$925.75
$1,171.58 		$1,098.50
$1,163.83
$1,233.04
$1,478.87 		$1,405.79
$1,471.12
$1,540.33
$1,786.16 		$307.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$967.84
$1,098.50
$1,236.92
$1,728.58
$2,626.74 		$1,275.13
$1,405.79
$1,544.21
$2,035.87 		$1,582.42
$1,713.08
$1,851.50
$2,343.16 		$1,889.71
$2,020.37
$2,158.79
$2,650.45 		$307.29
Toc - Plan #7 Vantage Health Plan of Mississippi
Silver

(POS) Standard Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

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 		$361.62
$410.44
$462.15
$645.85
$981.43 		$591.25
$640.07
$691.78
$875.48 		$820.88
$869.70
$921.41
$1,105.11 		$1,050.51
$1,099.33
$1,151.04
$1,334.74 		$229.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.24
$820.88
$924.30
$1,291.70
$1,962.86 		$952.87
$1,050.51
$1,153.93
$1,521.33 		$1,182.50
$1,280.14
$1,383.56
$1,750.96 		$1,412.13
$1,509.77
$1,613.19
$1,980.59 		$229.63
Toc - Plan #8 Vantage Health Plan of Mississippi
Expanded Bronze

(POS) Standard Bronze 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-823-1910

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 		$335.85
$381.19
$429.22
$599.83
$911.50 		$549.12
$594.46
$642.49
$813.10 		$762.39
$807.73
$855.76
$1,026.37 		$975.66
$1,021.00
$1,069.03
$1,239.64 		$213.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.70
$762.38
$858.44
$1,199.66
$1,823.00 		$884.97
$975.65
$1,071.71
$1,412.93 		$1,098.24
$1,188.92
$1,284.98
$1,626.20 		$1,311.51
$1,402.19
$1,498.25
$1,839.47 		$213.27

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Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #9 Cigna Healthcare
Bronze

(EPO) Cigna Connect 8500A

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.71
$396.93
$446.93
$624.59
$949.12 		$571.78
$619.00
$669.00
$846.66 		$793.85
$841.07
$891.07
$1,068.73 		$1,015.92
$1,063.14
$1,113.14
$1,290.80 		$222.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.42
$793.86
$893.86
$1,249.18
$1,898.24 		$921.49
$1,015.93
$1,115.93
$1,471.25 		$1,143.56
$1,238.00
$1,338.00
$1,693.32 		$1,365.63
$1,460.07
$1,560.07
$1,915.39 		$222.07
Toc - Plan #10 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 8200

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.55
$409.22
$460.78
$643.94
$978.53 		$589.50
$638.17
$689.73
$872.89 		$818.45
$867.12
$918.68
$1,101.84 		$1,047.40
$1,096.07
$1,147.63
$1,330.79 		$228.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.10
$818.44
$921.56
$1,287.88
$1,957.06 		$950.05
$1,047.39
$1,150.51
$1,516.83 		$1,179.00
$1,276.34
$1,379.46
$1,745.78 		$1,407.95
$1,505.29
$1,608.41
$1,974.73 		$228.95
Toc - Plan #11 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6000

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,800 $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 		$363.21
$412.25
$464.19
$648.70
$985.76 		$593.85
$642.89
$694.83
$879.34 		$824.49
$873.53
$925.47
$1,109.98 		$1,055.13
$1,104.17
$1,156.11
$1,340.62 		$230.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.42
$824.50
$928.38
$1,297.40
$1,971.52 		$957.06
$1,055.14
$1,159.02
$1,528.04 		$1,187.70
$1,285.78
$1,389.66
$1,758.68 		$1,418.34
$1,516.42
$1,620.30
$1,989.32 		$230.64
Toc - Plan #12 Cigna Healthcare
Silver

(EPO) Cigna Connect 7250

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$388.88
$441.38
$496.99
$694.54
$1,055.43 		$635.82
$688.32
$743.93
$941.48 		$882.76
$935.26
$990.87
$1,188.42 		$1,129.70
$1,182.20
$1,237.81
$1,435.36 		$246.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.76
$882.76
$993.98
$1,389.08
$2,110.86 		$1,024.70
$1,129.70
$1,240.92
$1,636.02 		$1,271.64
$1,376.64
$1,487.86
$1,882.96 		$1,518.58
$1,623.58
$1,734.80
$2,129.90 		$246.94
Toc - Plan #13 Cigna Healthcare
Silver

(EPO) Cigna Connect 4450

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

Annual Out of Pocket Expenses:

Individual Family
$4,450 $8,900 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 		$387.06
$439.31
$494.66
$691.29
$1,050.48 		$632.84
$685.09
$740.44
$937.07 		$878.62
$930.87
$986.22
$1,182.85 		$1,124.40
$1,176.65
$1,232.00
$1,428.63 		$245.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.12
$878.62
$989.32
$1,382.58
$2,100.96 		$1,019.90
$1,124.40
$1,235.10
$1,628.36 		$1,265.68
$1,370.18
$1,480.88
$1,874.14 		$1,511.46
$1,615.96
$1,726.66
$2,119.92 		$245.78
Toc - Plan #14 Cigna Healthcare
Silver

(EPO) Cigna Connect 8500B

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$390.08
$442.74
$498.52
$696.69
$1,058.68 		$637.78
$690.44
$746.22
$944.39 		$885.48
$938.14
$993.92
$1,192.09 		$1,133.18
$1,185.84
$1,241.62
$1,439.79 		$247.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.16
$885.48
$997.04
$1,393.38
$2,117.36 		$1,027.86
$1,133.18
$1,244.74
$1,641.08 		$1,275.56
$1,380.88
$1,492.44
$1,888.78 		$1,523.26
$1,628.58
$1,740.14
$2,136.48 		$247.70
Toc - Plan #15 Cigna Healthcare
Silver

(EPO) Cigna Connect 0

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

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 		$397.10
$450.71
$507.49
$709.22
$1,077.72 		$649.26
$702.87
$759.65
$961.38 		$901.42
$955.03
$1,011.81
$1,213.54 		$1,153.58
$1,207.19
$1,263.97
$1,465.70 		$252.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.20
$901.42
$1,014.98
$1,418.44
$2,155.44 		$1,046.36
$1,153.58
$1,267.14
$1,670.60 		$1,298.52
$1,405.74
$1,519.30
$1,922.76 		$1,550.68
$1,657.90
$1,771.46
$2,174.92 		$252.16
Toc - Plan #16 Cigna Healthcare
Silver

(EPO) Cigna Connect 3800 Enhanced Diabetes Care

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

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 		$388.30
$440.73
$496.25
$693.51
$1,053.86 		$634.87
$687.30
$742.82
$940.08 		$881.44
$933.87
$989.39
$1,186.65 		$1,128.01
$1,180.44
$1,235.96
$1,433.22 		$246.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.60
$881.46
$992.50
$1,387.02
$2,107.72 		$1,023.17
$1,128.03
$1,239.07
$1,633.59 		$1,269.74
$1,374.60
$1,485.64
$1,880.16 		$1,516.31
$1,621.17
$1,732.21
$2,126.73 		$246.57
Toc - Plan #17 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$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 		$389.77
$442.39
$498.13
$696.13
$1,057.84 		$637.27
$689.89
$745.63
$943.63 		$884.77
$937.39
$993.13
$1,191.13 		$1,132.27
$1,184.89
$1,240.63
$1,438.63 		$247.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.54
$884.78
$996.26
$1,392.26
$2,115.68 		$1,027.04
$1,132.28
$1,243.76
$1,639.76 		$1,274.54
$1,379.78
$1,491.26
$1,887.26 		$1,522.04
$1,627.28
$1,738.76
$2,134.76 		$247.50
Toc - Plan #18 Cigna Healthcare
Gold

(EPO) Cigna Connect 2300

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

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$576.77
$654.64
$737.12
$1,030.12
$1,565.36 		$943.02
$1,020.89
$1,103.37
$1,396.37 		$1,309.27
$1,387.14
$1,469.62
$1,762.62 		$1,675.52
$1,753.39
$1,835.87
$2,128.87 		$366.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,153.54
$1,309.28
$1,474.24
$2,060.24
$3,130.72 		$1,519.79
$1,675.53
$1,840.49
$2,426.49 		$1,886.04
$2,041.78
$2,206.74
$2,792.74 		$2,252.29
$2,408.03
$2,572.99
$3,158.99 		$366.25
Toc - Plan #19 Cigna Healthcare
Silver

(EPO) Cigna Simple Choice 5800

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

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 		$387.55
$439.87
$495.29
$692.16
$1,051.81 		$633.64
$685.96
$741.38
$938.25 		$879.73
$932.05
$987.47
$1,184.34 		$1,125.82
$1,178.14
$1,233.56
$1,430.43 		$246.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.10
$879.74
$990.58
$1,384.32
$2,103.62 		$1,021.19
$1,125.83
$1,236.67
$1,630.41 		$1,267.28
$1,371.92
$1,482.76
$1,876.50 		$1,513.37
$1,618.01
$1,728.85
$2,122.59 		$246.09
Toc - Plan #20 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Simple Choice 7500

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$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 		$360.15
$408.77
$460.27
$643.23
$977.45 		$588.85
$637.47
$688.97
$871.93 		$817.55
$866.17
$917.67
$1,100.63 		$1,046.25
$1,094.87
$1,146.37
$1,329.33 		$228.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.30
$817.54
$920.54
$1,286.46
$1,954.90 		$949.00
$1,046.24
$1,149.24
$1,515.16 		$1,177.70
$1,274.94
$1,377.94
$1,743.86 		$1,406.40
$1,503.64
$1,606.64
$1,972.56 		$228.70
Toc - Plan #21 Cigna Healthcare
Bronze

(EPO) Cigna Simple Choice 9100

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

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 		$346.34
$393.10
$442.62
$618.56
$939.96 		$566.27
$613.03
$662.55
$838.49 		$786.20
$832.96
$882.48
$1,058.42 		$1,006.13
$1,052.89
$1,102.41
$1,278.35 		$219.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.68
$786.20
$885.24
$1,237.12
$1,879.92 		$912.61
$1,006.13
$1,105.17
$1,457.05 		$1,132.54
$1,226.06
$1,325.10
$1,676.98 		$1,352.47
$1,445.99
$1,545.03
$1,896.91 		$219.93
Toc - Plan #22 Cigna Healthcare
Gold

(EPO) Cigna Simple Choice 2000

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

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 		$565.54
$641.89
$722.76
$1,010.05
$1,534.87 		$924.66
$1,001.01
$1,081.88
$1,369.17 		$1,283.78
$1,360.13
$1,441.00
$1,728.29 		$1,642.90
$1,719.25
$1,800.12
$2,087.41 		$359.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,131.08
$1,283.78
$1,445.52
$2,020.10
$3,069.74 		$1,490.20
$1,642.90
$1,804.64
$2,379.22 		$1,849.32
$2,002.02
$2,163.76
$2,738.34 		$2,208.44
$2,361.14
$2,522.88
$3,097.46 		$359.12
Toc - Plan #23 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$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 		$362.24
$411.14
$462.94
$646.96
$983.11 		$592.26
$641.16
$692.96
$876.98 		$822.28
$871.18
$922.98
$1,107.00 		$1,052.30
$1,101.20
$1,153.00
$1,337.02 		$230.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.48
$822.28
$925.88
$1,293.92
$1,966.22 		$954.50
$1,052.30
$1,155.90
$1,523.94 		$1,184.52
$1,282.32
$1,385.92
$1,753.96 		$1,414.54
$1,512.34
$1,615.94
$1,983.98 		$230.02

ADVERTISEMENT

Molina Healthcare

Local: 1-866-472-9484 | Toll Free: 1-866-472-9484 | TTY: 1-800-659-8331
Toc - Plan #24 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

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 		$436.89
$495.87
$558.35
$780.29
$1,185.73 		$714.32
$773.30
$835.78
$1,057.72 		$991.75
$1,050.73
$1,113.21
$1,335.15 		$1,269.18
$1,328.16
$1,390.64
$1,612.58 		$277.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.78
$991.74
$1,116.70
$1,560.58
$2,371.46 		$1,151.21
$1,269.17
$1,394.13
$1,838.01 		$1,428.64
$1,546.60
$1,671.56
$2,115.44 		$1,706.07
$1,824.03
$1,948.99
$2,392.87 		$277.43
Toc - Plan #25 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$433.41
$491.92
$553.89
$774.06
$1,176.26 		$708.62
$767.13
$829.10
$1,049.27 		$983.83
$1,042.34
$1,104.31
$1,324.48 		$1,259.04
$1,317.55
$1,379.52
$1,599.69 		$275.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.82
$983.84
$1,107.78
$1,548.12
$2,352.52 		$1,142.03
$1,259.05
$1,382.99
$1,823.33 		$1,417.24
$1,534.26
$1,658.20
$2,098.54 		$1,692.45
$1,809.47
$1,933.41
$2,373.75 		$275.21
Toc - Plan #26 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 4

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$391.56
$444.42
$500.42
$699.33
$1,062.70 		$640.20
$693.06
$749.06
$947.97 		$888.84
$941.70
$997.70
$1,196.61 		$1,137.48
$1,190.34
$1,246.34
$1,445.25 		$248.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.12
$888.84
$1,000.84
$1,398.66
$2,125.40 		$1,031.76
$1,137.48
$1,249.48
$1,647.30 		$1,280.40
$1,386.12
$1,498.12
$1,895.94 		$1,529.04
$1,634.76
$1,746.76
$2,144.58 		$248.64
Toc - Plan #27 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

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 		$448.44
$508.98
$573.11
$800.92
$1,217.08 		$733.20
$793.74
$857.87
$1,085.68 		$1,017.96
$1,078.50
$1,142.63
$1,370.44 		$1,302.72
$1,363.26
$1,427.39
$1,655.20 		$284.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.88
$1,017.96
$1,146.22
$1,601.84
$2,434.16 		$1,181.64
$1,302.72
$1,430.98
$1,886.60 		$1,466.40
$1,587.48
$1,715.74
$2,171.36 		$1,751.16
$1,872.24
$2,000.50
$2,456.12 		$284.76
Toc - Plan #28 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

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 		$445.24
$505.34
$569.01
$795.19
$1,208.37 		$727.96
$788.06
$851.73
$1,077.91 		$1,010.68
$1,070.78
$1,134.45
$1,360.63 		$1,293.40
$1,353.50
$1,417.17
$1,643.35 		$282.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.48
$1,010.68
$1,138.02
$1,590.38
$2,416.74 		$1,173.20
$1,293.40
$1,420.74
$1,873.10 		$1,455.92
$1,576.12
$1,703.46
$2,155.82 		$1,738.64
$1,858.84
$1,986.18
$2,438.54 		$282.72
Toc - Plan #29 Molina Healthcare
Expanded Bronze

(HMO) Core Care Bronze 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

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 		$400.71
$454.80
$512.11
$715.67
$1,087.52 		$655.16
$709.25
$766.56
$970.12 		$909.61
$963.70
$1,021.01
$1,224.57 		$1,164.06
$1,218.15
$1,275.46
$1,479.02 		$254.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.42
$909.60
$1,024.22
$1,431.34
$2,175.04 		$1,055.87
$1,164.05
$1,278.67
$1,685.79 		$1,310.32
$1,418.50
$1,533.12
$1,940.24 		$1,564.77
$1,672.95
$1,787.57
$2,194.69 		$254.45
Toc - Plan #30 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

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 		$441.79
$501.43
$564.61
$789.04
$1,199.02 		$722.33
$781.97
$845.15
$1,069.58 		$1,002.87
$1,062.51
$1,125.69
$1,350.12 		$1,283.41
$1,343.05
$1,406.23
$1,630.66 		$280.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.58
$1,002.86
$1,129.22
$1,578.08
$2,398.04 		$1,164.12
$1,283.40
$1,409.76
$1,858.62 		$1,444.66
$1,563.94
$1,690.30
$2,139.16 		$1,725.20
$1,844.48
$1,970.84
$2,419.70 		$280.54
Toc - Plan #31 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-472-9484

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$439.65
$499.00
$561.87
$785.22
$1,193.21 		$718.83
$778.18
$841.05
$1,064.40 		$998.01
$1,057.36
$1,120.23
$1,343.58 		$1,277.19
$1,336.54
$1,399.41
$1,622.76 		$279.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.30
$998.00
$1,123.74
$1,570.44
$2,386.42 		$1,158.48
$1,277.18
$1,402.92
$1,849.62 		$1,437.66
$1,556.36
$1,682.10
$2,128.80 		$1,716.84
$1,835.54
$1,961.28
$2,407.98 		$279.18

ADVERTISEMENT

Ambetter from Magnolia Health

Local: 1-877-687-1187 | Toll Free: 1-877-687-1187 | TTY: 1-877-687-1187
Toc - Plan #32 Ambetter from Magnolia Health
Silver

(HMO) Complete Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$388.33
$440.74
$496.27
$693.53
$1,053.89 		$634.91
$687.32
$742.85
$940.11 		$881.49
$933.90
$989.43
$1,186.69 		$1,128.07
$1,180.48
$1,236.01
$1,433.27 		$246.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$776.66
$881.48
$992.54
$1,387.06
$2,107.78 		$1,023.24
$1,128.06
$1,239.12
$1,633.64 		$1,269.82
$1,374.64
$1,485.70
$1,880.22 		$1,516.40
$1,621.22
$1,732.28
$2,126.80 		$246.58
Toc - Plan #33 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Everyday Bronze with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$362.93
$411.91
$463.81
$648.17
$984.96 		$593.38
$642.36
$694.26
$878.62 		$823.83
$872.81
$924.71
$1,109.07 		$1,054.28
$1,103.26
$1,155.16
$1,339.52 		$230.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.86
$823.82
$927.62
$1,296.34
$1,969.92 		$956.31
$1,054.27
$1,158.07
$1,526.79 		$1,186.76
$1,284.72
$1,388.52
$1,757.24 		$1,417.21
$1,515.17
$1,618.97
$1,987.69 		$230.45
Toc - Plan #34 Ambetter from Magnolia Health
Gold

(HMO) Complete Gold with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$492.63
$559.12
$629.56
$879.81
$1,336.96 		$805.44
$871.93
$942.37
$1,192.62 		$1,118.25
$1,184.74
$1,255.18
$1,505.43 		$1,431.06
$1,497.55
$1,567.99
$1,818.24 		$312.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.26
$1,118.24
$1,259.12
$1,759.62
$2,673.92 		$1,298.07
$1,431.05
$1,571.93
$2,072.43 		$1,610.88
$1,743.86
$1,884.74
$2,385.24 		$1,923.69
$2,056.67
$2,197.55
$2,698.05 		$312.81
Toc - Plan #35 Ambetter from Magnolia Health
Silver

(HMO) Everyday Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$383.98
$435.80
$490.71
$685.76
$1,042.08 		$627.80
$679.62
$734.53
$929.58 		$871.62
$923.44
$978.35
$1,173.40 		$1,115.44
$1,167.26
$1,222.17
$1,417.22 		$243.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.96
$871.60
$981.42
$1,371.52
$2,084.16 		$1,011.78
$1,115.42
$1,225.24
$1,615.34 		$1,255.60
$1,359.24
$1,469.06
$1,859.16 		$1,499.42
$1,603.06
$1,712.88
$2,102.98 		$243.82
Toc - Plan #36 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Choice Bronze HSA with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$369.26
$419.10
$471.90
$659.48
$1,002.14 		$603.73
$653.57
$706.37
$893.95 		$838.20
$888.04
$940.84
$1,128.42 		$1,072.67
$1,122.51
$1,175.31
$1,362.89 		$234.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.52
$838.20
$943.80
$1,318.96
$2,004.28 		$972.99
$1,072.67
$1,178.27
$1,553.43 		$1,207.46
$1,307.14
$1,412.74
$1,787.90 		$1,441.93
$1,541.61
$1,647.21
$2,022.37 		$234.47
Toc - Plan #37 Ambetter from Magnolia Health
Bronze

(HMO) Clear Bronze with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$335.79
$381.11
$429.12
$599.70
$911.30 		$549.01
$594.33
$642.34
$812.92 		$762.23
$807.55
$855.56
$1,026.14 		$975.45
$1,020.77
$1,068.78
$1,239.36 		$213.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.58
$762.22
$858.24
$1,199.40
$1,822.60 		$884.80
$975.44
$1,071.46
$1,412.62 		$1,098.02
$1,188.66
$1,284.68
$1,625.84 		$1,311.24
$1,401.88
$1,497.90
$1,839.06 		$213.22
Toc - Plan #38 Ambetter from Magnolia Health
Silver

(HMO) Clear Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$376.48
$427.30
$481.13
$672.38
$1,021.74 		$615.54
$666.36
$720.19
$911.44 		$854.60
$905.42
$959.25
$1,150.50 		$1,093.66
$1,144.48
$1,198.31
$1,389.56 		$239.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.96
$854.60
$962.26
$1,344.76
$2,043.48 		$992.02
$1,093.66
$1,201.32
$1,583.82 		$1,231.08
$1,332.72
$1,440.38
$1,822.88 		$1,470.14
$1,571.78
$1,679.44
$2,061.94 		$239.06
Toc - Plan #39 Ambetter from Magnolia Health
Silver

(HMO) Focused Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$382.35
$433.95
$488.62
$682.85
$1,037.66 		$625.13
$676.73
$731.40
$925.63 		$867.91
$919.51
$974.18
$1,168.41 		$1,110.69
$1,162.29
$1,216.96
$1,411.19 		$242.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.70
$867.90
$977.24
$1,365.70
$2,075.32 		$1,007.48
$1,110.68
$1,220.02
$1,608.48 		$1,250.26
$1,353.46
$1,462.80
$1,851.26 		$1,493.04
$1,596.24
$1,705.58
$2,094.04 		$242.78
Toc - Plan #40 Ambetter from Magnolia Health
Gold

(HMO) Everyday Gold with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$469.83
$533.25
$600.43
$839.10
$1,275.10 		$768.17
$831.59
$898.77
$1,137.44 		$1,066.51
$1,129.93
$1,197.11
$1,435.78 		$1,364.85
$1,428.27
$1,495.45
$1,734.12 		$298.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.66
$1,066.50
$1,200.86
$1,678.20
$2,550.20 		$1,238.00
$1,364.84
$1,499.20
$1,976.54 		$1,536.34
$1,663.18
$1,797.54
$2,274.88 		$1,834.68
$1,961.52
$2,095.88
$2,573.22 		$298.34
Toc - Plan #41 Ambetter from Magnolia Health
Bronze

(HMO) CMS Standard Bronze with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$319.01
$362.07
$407.68
$569.74
$865.77 		$521.58
$564.64
$610.25
$772.31 		$724.15
$767.21
$812.82
$974.88 		$926.72
$969.78
$1,015.39
$1,177.45 		$202.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.02
$724.14
$815.36
$1,139.48
$1,731.54 		$840.59
$926.71
$1,017.93
$1,342.05 		$1,043.16
$1,129.28
$1,220.50
$1,544.62 		$1,245.73
$1,331.85
$1,423.07
$1,747.19 		$202.57
Toc - Plan #42 Ambetter from Magnolia Health
Expanded Bronze

(HMO) CMS Standard Expanded Bronze with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$354.89
$402.79
$453.54
$633.82
$963.15 		$580.24
$628.14
$678.89
$859.17 		$805.59
$853.49
$904.24
$1,084.52 		$1,030.94
$1,078.84
$1,129.59
$1,309.87 		$225.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.78
$805.58
$907.08
$1,267.64
$1,926.30 		$935.13
$1,030.93
$1,132.43
$1,492.99 		$1,160.48
$1,256.28
$1,357.78
$1,718.34 		$1,385.83
$1,481.63
$1,583.13
$1,943.69 		$225.35
Toc - Plan #43 Ambetter from Magnolia Health
Silver

(HMO) CMS Standard Silver with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$378.42
$429.50
$483.61
$675.85
$1,027.01 		$618.71
$669.79
$723.90
$916.14 		$859.00
$910.08
$964.19
$1,156.43 		$1,099.29
$1,150.37
$1,204.48
$1,396.72 		$240.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.84
$859.00
$967.22
$1,351.70
$2,054.02 		$997.13
$1,099.29
$1,207.51
$1,591.99 		$1,237.42
$1,339.58
$1,447.80
$1,832.28 		$1,477.71
$1,579.87
$1,688.09
$2,072.57 		$240.29
Toc - Plan #44 Ambetter from Magnolia Health
Gold

(HMO) CMS Standard Gold with Walgreens

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$463.19
$525.71
$591.95
$827.24
$1,257.08 		$757.31
$819.83
$886.07
$1,121.36 		$1,051.43
$1,113.95
$1,180.19
$1,415.48 		$1,345.55
$1,408.07
$1,474.31
$1,709.60 		$294.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.38
$1,051.42
$1,183.90
$1,654.48
$2,514.16 		$1,220.50
$1,345.54
$1,478.02
$1,948.60 		$1,514.62
$1,639.66
$1,772.14
$2,242.72 		$1,808.74
$1,933.78
$2,066.26
$2,536.84 		$294.12
Toc - Plan #45 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Everyday Bronze with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$378.78
$429.90
$484.06
$676.48
$1,027.97 		$619.30
$670.42
$724.58
$917.00 		$859.82
$910.94
$965.10
$1,157.52 		$1,100.34
$1,151.46
$1,205.62
$1,398.04 		$240.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.56
$859.80
$968.12
$1,352.96
$2,055.94 		$998.08
$1,100.32
$1,208.64
$1,593.48 		$1,238.60
$1,340.84
$1,449.16
$1,834.00 		$1,479.12
$1,581.36
$1,689.68
$2,074.52 		$240.52
Toc - Plan #46 Ambetter from Magnolia Health
Gold

(HMO) Complete Gold with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$514.14
$583.53
$657.05
$918.23
$1,395.34 		$840.61
$910.00
$983.52
$1,244.70 		$1,167.08
$1,236.47
$1,309.99
$1,571.17 		$1,493.55
$1,562.94
$1,636.46
$1,897.64 		$326.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,028.28
$1,167.06
$1,314.10
$1,836.46
$2,790.68 		$1,354.75
$1,493.53
$1,640.57
$2,162.93 		$1,681.22
$1,820.00
$1,967.04
$2,489.40 		$2,007.69
$2,146.47
$2,293.51
$2,815.87 		$326.47
Toc - Plan #47 Ambetter from Magnolia Health
Silver

(HMO) Complete Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$405.28
$459.98
$517.94
$723.81
$1,099.91 		$662.63
$717.33
$775.29
$981.16 		$919.98
$974.68
$1,032.64
$1,238.51 		$1,177.33
$1,232.03
$1,289.99
$1,495.86 		$257.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.56
$919.96
$1,035.88
$1,447.62
$2,199.82 		$1,067.91
$1,177.31
$1,293.23
$1,704.97 		$1,325.26
$1,434.66
$1,550.58
$1,962.32 		$1,582.61
$1,692.01
$1,807.93
$2,219.67 		$257.35
Toc - Plan #48 Ambetter from Magnolia Health
Expanded Bronze

(HMO) Choice Bronze HSA with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$385.38
$437.40
$492.51
$688.28
$1,045.90 		$630.09
$682.11
$737.22
$932.99 		$874.80
$926.82
$981.93
$1,177.70 		$1,119.51
$1,171.53
$1,226.64
$1,422.41 		$244.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.76
$874.80
$985.02
$1,376.56
$2,091.80 		$1,015.47
$1,119.51
$1,229.73
$1,621.27 		$1,260.18
$1,364.22
$1,474.44
$1,865.98 		$1,504.89
$1,608.93
$1,719.15
$2,110.69 		$244.71
Toc - Plan #49 Ambetter from Magnolia Health
Bronze

(HMO) Clear Bronze with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$350.45
$397.75
$447.86
$625.88
$951.09 		$572.98
$620.28
$670.39
$848.41 		$795.51
$842.81
$892.92
$1,070.94 		$1,018.04
$1,065.34
$1,115.45
$1,293.47 		$222.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.90
$795.50
$895.72
$1,251.76
$1,902.18 		$923.43
$1,018.03
$1,118.25
$1,474.29 		$1,145.96
$1,240.56
$1,340.78
$1,696.82 		$1,368.49
$1,463.09
$1,563.31
$1,919.35 		$222.53
Toc - Plan #50 Ambetter from Magnolia Health
Silver

(HMO) Focused Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$399.04
$452.90
$509.96
$712.67
$1,082.97 		$652.42
$706.28
$763.34
$966.05 		$905.80
$959.66
$1,016.72
$1,219.43 		$1,159.18
$1,213.04
$1,270.10
$1,472.81 		$253.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.08
$905.80
$1,019.92
$1,425.34
$2,165.94 		$1,051.46
$1,159.18
$1,273.30
$1,678.72 		$1,304.84
$1,412.56
$1,526.68
$1,932.10 		$1,558.22
$1,665.94
$1,780.06
$2,185.48 		$253.38
Toc - Plan #51 Ambetter from Magnolia Health
Gold

(HMO) Everyday Gold with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$490.35
$556.53
$626.65
$875.74
$1,330.78 		$801.71
$867.89
$938.01
$1,187.10 		$1,113.07
$1,179.25
$1,249.37
$1,498.46 		$1,424.43
$1,490.61
$1,560.73
$1,809.82 		$311.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$980.70
$1,113.06
$1,253.30
$1,751.48
$2,661.56 		$1,292.06
$1,424.42
$1,564.66
$2,062.84 		$1,603.42
$1,735.78
$1,876.02
$2,374.20 		$1,914.78
$2,047.14
$2,187.38
$2,685.56 		$311.36
Toc - Plan #52 Ambetter from Magnolia Health
Silver

(HMO) Everyday Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$400.74
$454.83
$512.14
$715.71
$1,087.59 		$655.20
$709.29
$766.60
$970.17 		$909.66
$963.75
$1,021.06
$1,224.63 		$1,164.12
$1,218.21
$1,275.52
$1,479.09 		$254.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.48
$909.66
$1,024.28
$1,431.42
$2,175.18 		$1,055.94
$1,164.12
$1,278.74
$1,685.88 		$1,310.40
$1,418.58
$1,533.20
$1,940.34 		$1,564.86
$1,673.04
$1,787.66
$2,194.80 		$254.46
Toc - Plan #53 Ambetter from Magnolia Health
Silver

(HMO) Clear Silver with Walgreens + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$392.92
$445.95
$502.14
$701.74
$1,066.36 		$642.42
$695.45
$751.64
$951.24 		$891.92
$944.95
$1,001.14
$1,200.74 		$1,141.42
$1,194.45
$1,250.64
$1,450.24 		$249.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.84
$891.90
$1,004.28
$1,403.48
$2,132.72 		$1,035.34
$1,141.40
$1,253.78
$1,652.98 		$1,284.84
$1,390.90
$1,503.28
$1,902.48 		$1,534.34
$1,640.40
$1,752.78
$2,151.98 		$249.50
Toc - Plan #54 Ambetter from Magnolia Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$352.52
$400.10
$450.51
$629.59
$956.72 		$576.37
$623.95
$674.36
$853.44 		$800.22
$847.80
$898.21
$1,077.29 		$1,024.07
$1,071.65
$1,122.06
$1,301.14 		$223.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.04
$800.20
$901.02
$1,259.18
$1,913.44 		$928.89
$1,024.05
$1,124.87
$1,483.03 		$1,152.74
$1,247.90
$1,348.72
$1,706.88 		$1,376.59
$1,471.75
$1,572.57
$1,930.73 		$223.85
Toc - Plan #55 Ambetter from Magnolia Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$374.23
$424.74
$478.25
$668.36
$1,015.63 		$611.86
$662.37
$715.88
$905.99 		$849.49
$900.00
$953.51
$1,143.62 		$1,087.12
$1,137.63
$1,191.14
$1,381.25 		$237.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.46
$849.48
$956.50
$1,336.72
$2,031.26 		$986.09
$1,087.11
$1,194.13
$1,574.35 		$1,223.72
$1,324.74
$1,431.76
$1,811.98 		$1,461.35
$1,562.37
$1,669.39
$2,049.61 		$237.63
Toc - Plan #56 Ambetter from Magnolia Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1187

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 		$478.22
$542.77
$611.15
$854.08
$1,297.86 		$781.88
$846.43
$914.81
$1,157.74 		$1,085.54
$1,150.09
$1,218.47
$1,461.40 		$1,389.20
$1,453.75
$1,522.13
$1,765.06 		$303.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.44
$1,085.54
$1,222.30
$1,708.16
$2,595.72 		$1,260.10
$1,389.20
$1,525.96
$2,011.82 		$1,563.76
$1,692.86
$1,829.62
$2,315.48 		$1,867.42
$1,996.52
$2,133.28
$2,619.14 		$303.66

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-561-2831 | Toll Free: 1-877-561-2831 | TTY: 1-888-239-1451
Toc - Plan #57 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$665.50
$755.34
$850.51
$1,188.58
$1,806.16 		$1,088.09
$1,177.93
$1,273.10
$1,611.17 		$1,510.68
$1,600.52
$1,695.69
$2,033.76 		$1,933.27
$2,023.11
$2,118.28
$2,456.35 		$422.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,331.00
$1,510.68
$1,701.02
$2,377.16
$3,612.32 		$1,753.59
$1,933.27
$2,123.61
$2,799.75 		$2,176.18
$2,355.86
$2,546.20
$3,222.34 		$2,598.77
$2,778.45
$2,968.79
$3,644.93 		$422.59
Toc - Plan #58 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$658.86
$747.80
$842.02
$1,176.72
$1,788.14 		$1,077.23
$1,166.17
$1,260.39
$1,595.09 		$1,495.60
$1,584.54
$1,678.76
$2,013.46 		$1,913.97
$2,002.91
$2,097.13
$2,431.83 		$418.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,317.72
$1,495.60
$1,684.04
$2,353.44
$3,576.28 		$1,736.09
$1,913.97
$2,102.41
$2,771.81 		$2,154.46
$2,332.34
$2,520.78
$3,190.18 		$2,572.83
$2,750.71
$2,939.15
$3,608.55 		$418.37
Toc - Plan #59 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$675.68
$766.90
$863.52
$1,206.76
$1,833.79 		$1,104.74
$1,195.96
$1,292.58
$1,635.82 		$1,533.80
$1,625.02
$1,721.64
$2,064.88 		$1,962.86
$2,054.08
$2,150.70
$2,493.94 		$429.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,351.36
$1,533.80
$1,727.04
$2,413.52
$3,667.58 		$1,780.42
$1,962.86
$2,156.10
$2,842.58 		$2,209.48
$2,391.92
$2,585.16
$3,271.64 		$2,638.54
$2,820.98
$3,014.22
$3,700.70 		$429.06
Toc - Plan #60 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,400 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$512.50
$581.69
$654.98
$915.33
$1,390.93 		$837.94
$907.13
$980.42
$1,240.77 		$1,163.38
$1,232.57
$1,305.86
$1,566.21 		$1,488.82
$1,558.01
$1,631.30
$1,891.65 		$325.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,025.00
$1,163.38
$1,309.96
$1,830.66
$2,781.86 		$1,350.44
$1,488.82
$1,635.40
$2,156.10 		$1,675.88
$1,814.26
$1,960.84
$2,481.54 		$2,001.32
$2,139.70
$2,286.28
$2,806.98 		$325.44
Toc - Plan #61 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$510.52
$579.44
$652.45
$911.80
$1,385.56 		$834.70
$903.62
$976.63
$1,235.98 		$1,158.88
$1,227.80
$1,300.81
$1,560.16 		$1,483.06
$1,551.98
$1,624.99
$1,884.34 		$324.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.04
$1,158.88
$1,304.90
$1,823.60
$2,771.12 		$1,345.22
$1,483.06
$1,629.08
$2,147.78 		$1,669.40
$1,807.24
$1,953.26
$2,471.96 		$1,993.58
$2,131.42
$2,277.44
$2,796.14 		$324.18
Toc - Plan #62 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$507.26
$575.74
$648.28
$905.96
$1,376.70 		$829.37
$897.85
$970.39
$1,228.07 		$1,151.48
$1,219.96
$1,292.50
$1,550.18 		$1,473.59
$1,542.07
$1,614.61
$1,872.29 		$322.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,014.52
$1,151.48
$1,296.56
$1,811.92
$2,753.40 		$1,336.63
$1,473.59
$1,618.67
$2,134.03 		$1,658.74
$1,795.70
$1,940.78
$2,456.14 		$1,980.85
$2,117.81
$2,262.89
$2,778.25 		$322.11
Toc - Plan #63 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$528.91
$600.31
$675.95
$944.64
$1,435.47 		$864.77
$936.17
$1,011.81
$1,280.50 		$1,200.63
$1,272.03
$1,347.67
$1,616.36 		$1,536.49
$1,607.89
$1,683.53
$1,952.22 		$335.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,057.82
$1,200.62
$1,351.90
$1,889.28
$2,870.94 		$1,393.68
$1,536.48
$1,687.76
$2,225.14 		$1,729.54
$1,872.34
$2,023.62
$2,561.00 		$2,065.40
$2,208.20
$2,359.48
$2,896.86 		$335.86
Toc - Plan #64 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$507.57
$576.09
$648.67
$906.52
$1,377.54 		$829.88
$898.40
$970.98
$1,228.83 		$1,152.19
$1,220.71
$1,293.29
$1,551.14 		$1,474.50
$1,543.02
$1,615.60
$1,873.45 		$322.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,015.14
$1,152.18
$1,297.34
$1,813.04
$2,755.08 		$1,337.45
$1,474.49
$1,619.65
$2,135.35 		$1,659.76
$1,796.80
$1,941.96
$2,457.66 		$1,982.07
$2,119.11
$2,264.27
$2,779.97 		$322.31
Toc - Plan #65 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$526.16
$597.19
$672.43
$939.72
$1,427.99 		$860.27
$931.30
$1,006.54
$1,273.83 		$1,194.38
$1,265.41
$1,340.65
$1,607.94 		$1,528.49
$1,599.52
$1,674.76
$1,942.05 		$334.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,052.32
$1,194.38
$1,344.86
$1,879.44
$2,855.98 		$1,386.43
$1,528.49
$1,678.97
$2,213.55 		$1,720.54
$1,862.60
$2,013.08
$2,547.66 		$2,054.65
$2,196.71
$2,347.19
$2,881.77 		$334.11
Toc - Plan #66 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$514.85
$584.36
$657.98
$919.53
$1,397.31 		$841.78
$911.29
$984.91
$1,246.46 		$1,168.71
$1,238.22
$1,311.84
$1,573.39 		$1,495.64
$1,565.15
$1,638.77
$1,900.32 		$326.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,029.70
$1,168.72
$1,315.96
$1,839.06
$2,794.62 		$1,356.63
$1,495.65
$1,642.89
$2,165.99 		$1,683.56
$1,822.58
$1,969.82
$2,492.92 		$2,010.49
$2,149.51
$2,296.75
$2,819.85 		$326.93
Toc - Plan #67 UnitedHealthcare
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$428.74
$486.62
$547.93
$765.72
$1,163.59 		$700.99
$758.87
$820.18
$1,037.97 		$973.24
$1,031.12
$1,092.43
$1,310.22 		$1,245.49
$1,303.37
$1,364.68
$1,582.47 		$272.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.48
$973.24
$1,095.86
$1,531.44
$2,327.18 		$1,129.73
$1,245.49
$1,368.11
$1,803.69 		$1,401.98
$1,517.74
$1,640.36
$2,075.94 		$1,674.23
$1,789.99
$1,912.61
$2,348.19 		$272.25
Toc - Plan #68 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $6,500 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$456.67
$518.33
$583.63
$815.62
$1,239.42 		$746.66
$808.32
$873.62
$1,105.61 		$1,036.65
$1,098.31
$1,163.61
$1,395.60 		$1,326.64
$1,388.30
$1,453.60
$1,685.59 		$289.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$913.34
$1,036.66
$1,167.26
$1,631.24
$2,478.84 		$1,203.33
$1,326.65
$1,457.25
$1,921.23 		$1,493.32
$1,616.64
$1,747.24
$2,211.22 		$1,783.31
$1,906.63
$2,037.23
$2,501.21 		$289.99
Toc - Plan #69 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA $6,700 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$480.01
$544.81
$613.45
$857.29
$1,302.74 		$784.81
$849.61
$918.25
$1,162.09 		$1,089.61
$1,154.41
$1,223.05
$1,466.89 		$1,394.41
$1,459.21
$1,527.85
$1,771.69 		$304.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$960.02
$1,089.62
$1,226.90
$1,714.58
$2,605.48 		$1,264.82
$1,394.42
$1,531.70
$2,019.38 		$1,569.62
$1,699.22
$1,836.50
$2,324.18 		$1,874.42
$2,004.02
$2,141.30
$2,628.98 		$304.80
Toc - Plan #70 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$460.42
$522.58
$588.42
$822.31
$1,249.58 		$752.79
$814.95
$880.79
$1,114.68 		$1,045.16
$1,107.32
$1,173.16
$1,407.05 		$1,337.53
$1,399.69
$1,465.53
$1,699.42 		$292.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$920.84
$1,045.16
$1,176.84
$1,644.62
$2,499.16 		$1,213.21
$1,337.53
$1,469.21
$1,936.99 		$1,505.58
$1,629.90
$1,761.58
$2,229.36 		$1,797.95
$1,922.27
$2,053.95
$2,521.73 		$292.37
Toc - Plan #71 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

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 		$428.79
$486.67
$547.99
$765.81
$1,163.72 		$701.07
$758.95
$820.27
$1,038.09 		$973.35
$1,031.23
$1,092.55
$1,310.37 		$1,245.63
$1,303.51
$1,364.83
$1,582.65 		$272.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.58
$973.34
$1,095.98
$1,531.62
$2,327.44 		$1,129.86
$1,245.62
$1,368.26
$1,803.90 		$1,402.14
$1,517.90
$1,640.54
$2,076.18 		$1,674.42
$1,790.18
$1,912.82
$2,348.46 		$272.28
Toc - Plan #72 UnitedHealthcare
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-561-2831

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.22
$500.79
$563.88
$788.03
$1,197.48 		$721.40
$780.97
$844.06
$1,068.21 		$1,001.58
$1,061.15
$1,124.24
$1,348.39 		$1,281.76
$1,341.33
$1,404.42
$1,628.57 		$280.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.44
$1,001.58
$1,127.76
$1,576.06
$2,394.96 		$1,162.62
$1,281.76
$1,407.94
$1,856.24 		$1,442.80
$1,561.94
$1,688.12
$2,136.42 		$1,722.98
$1,842.12
$1,968.30
$2,416.60 		$280.18

‡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 Tippah County here.

Tippah County is in “Rating Area 2” of Mississippi.

Currently, there are 72 plans offered in Rating Area 2.

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2023 Obamacare Plans for Tippah County, MS

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