Obamacare 2023 Rates for Jackson County

Obamacare > Rates > Missouri > Jackson 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 Jackson County, MO.

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, 101 Plans and 2023 Rates for Jackson County, Missouri

Below, you’ll find a summary of the 101 plans for Jackson County, Missouri 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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Jackson County Resources

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Blue Cross and Blue Shield of Kansas City

Local: 1-816-395-3558 | Toll Free: 1-888-800-4478

Toc - Plan #1 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$472.93
$536.78
$604.41
$844.65
$1,283.53 		$834.72
$898.57
$966.20
$1,206.44 		$1,196.51
$1,260.36
$1,327.99
$1,568.23 		$1,558.30
$1,622.15
$1,689.78
$1,930.02 		$361.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.86
$1,073.56
$1,208.82
$1,689.30
$2,567.06 		$1,307.65
$1,435.35
$1,570.61
$2,051.09 		$1,669.44
$1,797.14
$1,932.40
$2,412.88 		$2,031.23
$2,158.93
$2,294.19
$2,774.67 		$361.79
Toc - Plan #2 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$624.06
$708.30
$797.54
$1,114.57
$1,693.69 		$1,101.46
$1,185.70
$1,274.94
$1,591.97 		$1,578.86
$1,663.10
$1,752.34
$2,069.37 		$2,056.26
$2,140.50
$2,229.74
$2,546.77 		$477.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,248.12
$1,416.60
$1,595.08
$2,229.14
$3,387.38 		$1,725.52
$1,894.00
$2,072.48
$2,706.54 		$2,202.92
$2,371.40
$2,549.88
$3,183.94 		$2,680.32
$2,848.80
$3,027.28
$3,661.34 		$477.40
Toc - Plan #3 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$506.25
$574.60
$646.99
$904.17
$1,373.97 		$893.53
$961.88
$1,034.27
$1,291.45 		$1,280.81
$1,349.16
$1,421.55
$1,678.73 		$1,668.09
$1,736.44
$1,808.83
$2,066.01 		$387.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.50
$1,149.20
$1,293.98
$1,808.34
$2,747.94 		$1,399.78
$1,536.48
$1,681.26
$2,195.62 		$1,787.06
$1,923.76
$2,068.54
$2,582.90 		$2,174.34
$2,311.04
$2,455.82
$2,970.18 		$387.28
Toc - Plan #4 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$542.26
$615.47
$693.01
$968.48
$1,471.70 		$957.09
$1,030.30
$1,107.84
$1,383.31 		$1,371.92
$1,445.13
$1,522.67
$1,798.14 		$1,786.75
$1,859.96
$1,937.50
$2,212.97 		$414.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,084.52
$1,230.94
$1,386.02
$1,936.96
$2,943.40 		$1,499.35
$1,645.77
$1,800.85
$2,351.79 		$1,914.18
$2,060.60
$2,215.68
$2,766.62 		$2,329.01
$2,475.43
$2,630.51
$3,181.45 		$414.83
Toc - Plan #5 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.48
$467.03
$525.87
$734.90
$1,116.75 		$726.26
$781.81
$840.65
$1,049.68 		$1,041.04
$1,096.59
$1,155.43
$1,364.46 		$1,355.82
$1,411.37
$1,470.21
$1,679.24 		$314.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.96
$934.06
$1,051.74
$1,469.80
$2,233.50 		$1,137.74
$1,248.84
$1,366.52
$1,784.58 		$1,452.52
$1,563.62
$1,681.30
$2,099.36 		$1,767.30
$1,878.40
$1,996.08
$2,414.14 		$314.78
Toc - Plan #6 Blue Cross and Blue Shield of Kansas City
Gold

(EPO) Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$735.19
$834.44
$939.57
$1,313.05
$1,995.31 		$1,297.61
$1,396.86
$1,501.99
$1,875.47 		$1,860.03
$1,959.28
$2,064.41
$2,437.89 		$2,422.45
$2,521.70
$2,626.83
$3,000.31 		$562.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,470.38
$1,668.88
$1,879.14
$2,626.10
$3,990.62 		$2,032.80
$2,231.30
$2,441.56
$3,188.52 		$2,595.22
$2,793.72
$3,003.98
$3,750.94 		$3,157.64
$3,356.14
$3,566.40
$4,313.36 		$562.42
Toc - Plan #7 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 8700 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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 		$402.93
$457.33
$514.95
$719.63
$1,093.55 		$711.17
$765.57
$823.19
$1,027.87 		$1,019.41
$1,073.81
$1,131.43
$1,336.11 		$1,327.65
$1,382.05
$1,439.67
$1,644.35 		$308.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.86
$914.66
$1,029.90
$1,439.26
$2,187.10 		$1,114.10
$1,222.90
$1,338.14
$1,747.50 		$1,422.34
$1,531.14
$1,646.38
$2,055.74 		$1,730.58
$1,839.38
$1,954.62
$2,363.98 		$308.24
Toc - Plan #8 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$540.23
$613.16
$690.41
$964.84
$1,466.17 		$953.50
$1,026.43
$1,103.68
$1,378.11 		$1,366.77
$1,439.70
$1,516.95
$1,791.38 		$1,780.04
$1,852.97
$1,930.22
$2,204.65 		$413.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,080.46
$1,226.32
$1,380.82
$1,929.68
$2,932.34 		$1,493.73
$1,639.59
$1,794.09
$2,342.95 		$1,907.00
$2,052.86
$2,207.36
$2,756.22 		$2,320.27
$2,466.13
$2,620.63
$3,169.49 		$413.27
Toc - Plan #9 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$437.24
$496.26
$558.79
$780.90
$1,186.66 		$771.73
$830.75
$893.28
$1,115.39 		$1,106.22
$1,165.24
$1,227.77
$1,449.88 		$1,440.71
$1,499.73
$1,562.26
$1,784.37 		$334.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.48
$992.52
$1,117.58
$1,561.80
$2,373.32 		$1,208.97
$1,327.01
$1,452.07
$1,896.29 		$1,543.46
$1,661.50
$1,786.56
$2,230.78 		$1,877.95
$1,995.99
$2,121.05
$2,565.27 		$334.49
Toc - Plan #10 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Standard Bronze 7500 BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$405.73
$460.50
$518.52
$724.63
$1,101.15 		$716.11
$770.88
$828.90
$1,035.01 		$1,026.49
$1,081.26
$1,139.28
$1,345.39 		$1,336.87
$1,391.64
$1,449.66
$1,655.77 		$310.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.46
$921.00
$1,037.04
$1,449.26
$2,202.30 		$1,121.84
$1,231.38
$1,347.42
$1,759.64 		$1,432.22
$1,541.76
$1,657.80
$2,070.02 		$1,742.60
$1,852.14
$1,968.18
$2,380.40 		$310.38
Toc - Plan #11 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Standard Silver 5800 BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$552.27
$626.83
$705.80
$986.35
$1,498.86 		$974.76
$1,049.32
$1,128.29
$1,408.84 		$1,397.25
$1,471.81
$1,550.78
$1,831.33 		$1,819.74
$1,894.30
$1,973.27
$2,253.82 		$422.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,104.54
$1,253.66
$1,411.60
$1,972.70
$2,997.72 		$1,527.03
$1,676.15
$1,834.09
$2,395.19 		$1,949.52
$2,098.64
$2,256.58
$2,817.68 		$2,372.01
$2,521.13
$2,679.07
$3,240.17 		$422.49
Toc - Plan #12 Blue Cross and Blue Shield of Kansas City
Catastrophic

(EPO) Blue KC Catastrophic BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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 		$335.16
$380.41
$428.34
$598.60
$909.64 		$591.56
$636.81
$684.74
$855.00 		$847.96
$893.21
$941.14
$1,111.40 		$1,104.36
$1,149.61
$1,197.54
$1,367.80 		$256.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.32
$760.82
$856.68
$1,197.20
$1,819.28 		$926.72
$1,017.22
$1,113.08
$1,453.60 		$1,183.12
$1,273.62
$1,369.48
$1,710.00 		$1,439.52
$1,530.02
$1,625.88
$1,966.40 		$256.40

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915 | TTY: 1-877-336-3915
Toc - Plan #13 Aetna CVS Health
Expanded Bronze

(EPO) Bronze: Aetna network of doctors & hospitals + Low-cost MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,100 $14,200 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 		$327.23
$371.41
$418.20
$584.44
$888.11 		$577.56
$621.74
$668.53
$834.77 		$827.89
$872.07
$918.86
$1,085.10 		$1,078.22
$1,122.40
$1,169.19
$1,335.43 		$250.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.46
$742.82
$836.40
$1,168.88
$1,776.22 		$904.79
$993.15
$1,086.73
$1,419.21 		$1,155.12
$1,243.48
$1,337.06
$1,669.54 		$1,405.45
$1,493.81
$1,587.39
$1,919.87 		$250.33
Toc - Plan #14 Aetna CVS Health
Expanded Bronze

(EPO) Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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 		$327.65
$371.88
$418.73
$585.18
$889.23 		$578.30
$622.53
$669.38
$835.83 		$828.95
$873.18
$920.03
$1,086.48 		$1,079.60
$1,123.83
$1,170.68
$1,337.13 		$250.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.30
$743.76
$837.46
$1,170.36
$1,778.46 		$905.95
$994.41
$1,088.11
$1,421.01 		$1,156.60
$1,245.06
$1,338.76
$1,671.66 		$1,407.25
$1,495.71
$1,589.41
$1,922.31 		$250.65
Toc - Plan #15 Aetna CVS Health
Gold

(EPO) Gold: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$504.98
$573.16
$645.37
$901.90
$1,370.52 		$891.29
$959.47
$1,031.68
$1,288.21 		$1,277.60
$1,345.78
$1,417.99
$1,674.52 		$1,663.91
$1,732.09
$1,804.30
$2,060.83 		$386.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,009.96
$1,146.32
$1,290.74
$1,803.80
$2,741.04 		$1,396.27
$1,532.63
$1,677.05
$2,190.11 		$1,782.58
$1,918.94
$2,063.36
$2,576.42 		$2,168.89
$2,305.25
$2,449.67
$2,962.73 		$386.31
Toc - Plan #16 Aetna CVS Health
Silver

(EPO) Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,700 $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 		$406.92
$461.85
$520.04
$726.75
$1,104.37 		$718.21
$773.14
$831.33
$1,038.04 		$1,029.50
$1,084.43
$1,142.62
$1,349.33 		$1,340.79
$1,395.72
$1,453.91
$1,660.62 		$311.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.84
$923.70
$1,040.08
$1,453.50
$2,208.74 		$1,125.13
$1,234.99
$1,351.37
$1,764.79 		$1,436.42
$1,546.28
$1,662.66
$2,076.08 		$1,747.71
$1,857.57
$1,973.95
$2,387.37 		$311.29
Toc - Plan #17 Aetna CVS Health
Silver

(EPO) Silver 1: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$4,425 $8,850 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.26
$464.51
$523.03
$730.94
$1,110.73 		$722.34
$777.59
$836.11
$1,044.02 		$1,035.42
$1,090.67
$1,149.19
$1,357.10 		$1,348.50
$1,403.75
$1,462.27
$1,670.18 		$313.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.52
$929.02
$1,046.06
$1,461.88
$2,221.46 		$1,131.60
$1,242.10
$1,359.14
$1,774.96 		$1,444.68
$1,555.18
$1,672.22
$2,088.04 		$1,757.76
$1,868.26
$1,985.30
$2,401.12 		$313.08
Toc - Plan #18 Aetna CVS Health
Expanded Bronze

(EPO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.87
$359.65
$404.96
$565.93
$859.98 		$559.28
$602.06
$647.37
$808.34 		$801.69
$844.47
$889.78
$1,050.75 		$1,044.10
$1,086.88
$1,132.19
$1,293.16 		$242.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.74
$719.30
$809.92
$1,131.86
$1,719.96 		$876.15
$961.71
$1,052.33
$1,374.27 		$1,118.56
$1,204.12
$1,294.74
$1,616.68 		$1,360.97
$1,446.53
$1,537.15
$1,859.09 		$242.41
Toc - Plan #19 Aetna CVS Health
Gold

(EPO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.80
$523.01
$588.90
$822.99
$1,250.61 		$813.31
$875.52
$941.41
$1,175.50 		$1,165.82
$1,228.03
$1,293.92
$1,528.01 		$1,518.33
$1,580.54
$1,646.43
$1,880.52 		$352.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.60
$1,046.02
$1,177.80
$1,645.98
$2,501.22 		$1,274.11
$1,398.53
$1,530.31
$1,998.49 		$1,626.62
$1,751.04
$1,882.82
$2,351.00 		$1,979.13
$2,103.55
$2,235.33
$2,703.51 		$352.51
Toc - Plan #20 Aetna CVS Health
Silver

(EPO) Silver 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$387.31
$439.60
$494.98
$691.73
$1,051.16 		$683.60
$735.89
$791.27
$988.02 		$979.89
$1,032.18
$1,087.56
$1,284.31 		$1,276.18
$1,328.47
$1,383.85
$1,580.60 		$296.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.62
$879.20
$989.96
$1,383.46
$2,102.32 		$1,070.91
$1,175.49
$1,286.25
$1,679.75 		$1,367.20
$1,471.78
$1,582.54
$1,976.04 		$1,663.49
$1,768.07
$1,878.83
$2,272.33 		$296.29
Toc - Plan #21 Aetna CVS Health
Silver

(EPO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$379.74
$431.00
$485.30
$678.21
$1,030.60 		$670.24
$721.50
$775.80
$968.71 		$960.74
$1,012.00
$1,066.30
$1,259.21 		$1,251.24
$1,302.50
$1,356.80
$1,549.71 		$290.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.48
$862.00
$970.60
$1,356.42
$2,061.20 		$1,049.98
$1,152.50
$1,261.10
$1,646.92 		$1,340.48
$1,443.00
$1,551.60
$1,937.42 		$1,630.98
$1,733.50
$1,842.10
$2,227.92 		$290.50

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777
Toc - Plan #22 Medica
Expanded Bronze

(EPO) Select by Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 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 		$448.49
$509.03
$573.16
$800.99
$1,217.18 		$791.58
$852.12
$916.25
$1,144.08 		$1,134.67
$1,195.21
$1,259.34
$1,487.17 		$1,477.76
$1,538.30
$1,602.43
$1,830.26 		$343.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.98
$1,018.06
$1,146.32
$1,601.98
$2,434.36 		$1,240.07
$1,361.15
$1,489.41
$1,945.07 		$1,583.16
$1,704.24
$1,832.50
$2,288.16 		$1,926.25
$2,047.33
$2,175.59
$2,631.25 		$343.09
Toc - Plan #23 Medica
Catastrophic

(EPO) Select by Medica Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$264.52
$300.22
$338.05
$472.42
$717.89 		$466.87
$502.57
$540.40
$674.77 		$669.22
$704.92
$742.75
$877.12 		$871.57
$907.27
$945.10
$1,079.47 		$202.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$529.04
$600.44
$676.10
$944.84
$1,435.78 		$731.39
$802.79
$878.45
$1,147.19 		$933.74
$1,005.14
$1,080.80
$1,349.54 		$1,136.09
$1,207.49
$1,283.15
$1,551.89 		$202.35
Toc - Plan #24 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$381.82
$433.35
$487.95
$681.91
$1,036.22 		$673.90
$725.43
$780.03
$973.99 		$965.98
$1,017.51
$1,072.11
$1,266.07 		$1,258.06
$1,309.59
$1,364.19
$1,558.15 		$292.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.64
$866.70
$975.90
$1,363.82
$2,072.44 		$1,055.72
$1,158.78
$1,267.98
$1,655.90 		$1,347.80
$1,450.86
$1,560.06
$1,947.98 		$1,639.88
$1,742.94
$1,852.14
$2,240.06 		$292.08
Toc - Plan #25 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.96
$421.03
$474.07
$662.51
$1,006.76 		$654.74
$704.81
$757.85
$946.29 		$938.52
$988.59
$1,041.63
$1,230.07 		$1,222.30
$1,272.37
$1,325.41
$1,513.85 		$283.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.92
$842.06
$948.14
$1,325.02
$2,013.52 		$1,025.70
$1,125.84
$1,231.92
$1,608.80 		$1,309.48
$1,409.62
$1,515.70
$1,892.58 		$1,593.26
$1,693.40
$1,799.48
$2,176.36 		$283.78
Toc - Plan #26 Medica
Gold

(EPO) Select by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,350 $16,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$553.50
$628.21
$707.36
$988.54
$1,502.18 		$976.92
$1,051.63
$1,130.78
$1,411.96 		$1,400.34
$1,475.05
$1,554.20
$1,835.38 		$1,823.76
$1,898.47
$1,977.62
$2,258.80 		$423.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,107.00
$1,256.42
$1,414.72
$1,977.08
$3,004.36 		$1,530.42
$1,679.84
$1,838.14
$2,400.50 		$1,953.84
$2,103.26
$2,261.56
$2,823.92 		$2,377.26
$2,526.68
$2,684.98
$3,247.34 		$423.42
Toc - Plan #27 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Premier ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$372.28
$422.53
$475.77
$664.88
$1,010.35 		$657.07
$707.32
$760.56
$949.67 		$941.86
$992.11
$1,045.35
$1,234.46 		$1,226.65
$1,276.90
$1,330.14
$1,519.25 		$284.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.56
$845.06
$951.54
$1,329.76
$2,020.70 		$1,029.35
$1,129.85
$1,236.33
$1,614.55 		$1,314.14
$1,414.64
$1,521.12
$1,899.34 		$1,598.93
$1,699.43
$1,805.91
$2,184.13 		$284.79
Toc - Plan #28 Medica
Gold

(EPO) Select by Medica Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$526.43
$597.49
$672.77
$940.19
$1,428.72 		$929.14
$1,000.20
$1,075.48
$1,342.90 		$1,331.85
$1,402.91
$1,478.19
$1,745.61 		$1,734.56
$1,805.62
$1,880.90
$2,148.32 		$402.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,052.86
$1,194.98
$1,345.54
$1,880.38
$2,857.44 		$1,455.57
$1,597.69
$1,748.25
$2,283.09 		$1,858.28
$2,000.40
$2,150.96
$2,685.80 		$2,260.99
$2,403.11
$2,553.67
$3,088.51 		$402.71
Toc - Plan #29 Medica
Silver

(EPO) Select by Medica Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$500.84
$568.45
$640.07
$894.49
$1,359.27 		$883.98
$951.59
$1,023.21
$1,277.63 		$1,267.12
$1,334.73
$1,406.35
$1,660.77 		$1,650.26
$1,717.87
$1,789.49
$2,043.91 		$383.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,001.68
$1,136.90
$1,280.14
$1,788.98
$2,718.54 		$1,384.82
$1,520.04
$1,663.28
$2,172.12 		$1,767.96
$1,903.18
$2,046.42
$2,555.26 		$2,151.10
$2,286.32
$2,429.56
$2,938.40 		$383.14
Toc - Plan #30 Medica
Bronze

(EPO) Select by Medica Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$356.63
$404.77
$455.77
$636.93
$967.88 		$629.45
$677.59
$728.59
$909.75 		$902.27
$950.41
$1,001.41
$1,182.57 		$1,175.09
$1,223.23
$1,274.23
$1,455.39 		$272.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.26
$809.54
$911.54
$1,273.86
$1,935.76 		$986.08
$1,082.36
$1,184.36
$1,546.68 		$1,258.90
$1,355.18
$1,457.18
$1,819.50 		$1,531.72
$1,628.00
$1,730.00
$2,092.32 		$272.82

ADVERTISEMENT

Oscar Insurance Company

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755

Toc - Plan #31 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 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 		$313.43
$355.74
$400.55
$559.77
$850.63 		$553.20
$595.51
$640.32
$799.54 		$792.97
$835.28
$880.09
$1,039.31 		$1,032.74
$1,075.05
$1,119.86
$1,279.08 		$239.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.86
$711.48
$801.10
$1,119.54
$1,701.26 		$866.63
$951.25
$1,040.87
$1,359.31 		$1,106.40
$1,191.02
$1,280.64
$1,599.08 		$1,346.17
$1,430.79
$1,520.41
$1,838.85 		$239.77
Toc - Plan #32 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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 		$358.07
$406.40
$457.61
$639.50
$971.79 		$631.99
$680.32
$731.53
$913.42 		$905.91
$954.24
$1,005.45
$1,187.34 		$1,179.83
$1,228.16
$1,279.37
$1,461.26 		$273.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.14
$812.80
$915.22
$1,279.00
$1,943.58 		$990.06
$1,086.72
$1,189.14
$1,552.92 		$1,263.98
$1,360.64
$1,463.06
$1,826.84 		$1,537.90
$1,634.56
$1,736.98
$2,100.76 		$273.92
Toc - Plan #33 Oscar Insurance Company
Silver

(EPO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 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 		$392.80
$445.81
$501.98
$701.52
$1,066.02 		$693.28
$746.29
$802.46
$1,002.00 		$993.76
$1,046.77
$1,102.94
$1,302.48 		$1,294.24
$1,347.25
$1,403.42
$1,602.96 		$300.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.60
$891.62
$1,003.96
$1,403.04
$2,132.04 		$1,086.08
$1,192.10
$1,304.44
$1,703.52 		$1,386.56
$1,492.58
$1,604.92
$2,004.00 		$1,687.04
$1,793.06
$1,905.40
$2,304.48 		$300.48
Toc - Plan #34 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$387.22
$439.48
$494.85
$691.55
$1,050.88 		$683.43
$735.69
$791.06
$987.76 		$979.64
$1,031.90
$1,087.27
$1,283.97 		$1,275.85
$1,328.11
$1,383.48
$1,580.18 		$296.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.44
$878.96
$989.70
$1,383.10
$2,101.76 		$1,070.65
$1,175.17
$1,285.91
$1,679.31 		$1,366.86
$1,471.38
$1,582.12
$1,975.52 		$1,663.07
$1,767.59
$1,878.33
$2,271.73 		$296.21
Toc - Plan #35 Oscar Insurance Company
Catastrophic

(EPO) Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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 		$260.59
$295.76
$333.02
$465.40
$707.22 		$459.93
$495.10
$532.36
$664.74 		$659.27
$694.44
$731.70
$864.08 		$858.61
$893.78
$931.04
$1,063.42 		$199.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.18
$591.52
$666.04
$930.80
$1,414.44 		$720.52
$790.86
$865.38
$1,130.14 		$919.86
$990.20
$1,064.72
$1,329.48 		$1,119.20
$1,189.54
$1,264.06
$1,528.82 		$199.34
Toc - Plan #36 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 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 		$334.10
$379.19
$426.97
$596.69
$906.72 		$589.68
$634.77
$682.55
$852.27 		$845.26
$890.35
$938.13
$1,107.85 		$1,100.84
$1,145.93
$1,193.71
$1,363.43 		$255.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.20
$758.38
$853.94
$1,193.38
$1,813.44 		$923.78
$1,013.96
$1,109.52
$1,448.96 		$1,179.36
$1,269.54
$1,365.10
$1,704.54 		$1,434.94
$1,525.12
$1,620.68
$1,960.12 		$255.58
Toc - Plan #37 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$334.14
$379.24
$427.02
$596.76
$906.84 		$589.75
$634.85
$682.63
$852.37 		$845.36
$890.46
$938.24
$1,107.98 		$1,100.97
$1,146.07
$1,193.85
$1,363.59 		$255.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$668.28
$758.48
$854.04
$1,193.52
$1,813.68 		$923.89
$1,014.09
$1,109.65
$1,449.13 		$1,179.50
$1,269.70
$1,365.26
$1,704.74 		$1,435.11
$1,525.31
$1,620.87
$1,960.35 		$255.61
Toc - Plan #38 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 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 		$340.28
$386.20
$434.86
$607.72
$923.49 		$600.59
$646.51
$695.17
$868.03 		$860.90
$906.82
$955.48
$1,128.34 		$1,121.21
$1,167.13
$1,215.79
$1,388.65 		$260.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.56
$772.40
$869.72
$1,215.44
$1,846.98 		$940.87
$1,032.71
$1,130.03
$1,475.75 		$1,201.18
$1,293.02
$1,390.34
$1,736.06 		$1,461.49
$1,553.33
$1,650.65
$1,996.37 		$260.31
Toc - Plan #39 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$377.08
$427.97
$481.90
$673.45
$1,023.37 		$665.54
$716.43
$770.36
$961.91 		$954.00
$1,004.89
$1,058.82
$1,250.37 		$1,242.46
$1,293.35
$1,347.28
$1,538.83 		$288.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.16
$855.94
$963.80
$1,346.90
$2,046.74 		$1,042.62
$1,144.40
$1,252.26
$1,635.36 		$1,331.08
$1,432.86
$1,540.72
$1,923.82 		$1,619.54
$1,721.32
$1,829.18
$2,212.28 		$288.46
Toc - Plan #40 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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 		$397.01
$450.60
$507.37
$709.05
$1,077.46 		$700.72
$754.31
$811.08
$1,012.76 		$1,004.43
$1,058.02
$1,114.79
$1,316.47 		$1,308.14
$1,361.73
$1,418.50
$1,620.18 		$303.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.02
$901.20
$1,014.74
$1,418.10
$2,154.92 		$1,097.73
$1,204.91
$1,318.45
$1,721.81 		$1,401.44
$1,508.62
$1,622.16
$2,025.52 		$1,705.15
$1,812.33
$1,925.87
$2,329.23 		$303.71
Toc - Plan #41 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 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 		$388.80
$441.28
$496.87
$694.38
$1,055.18 		$686.22
$738.70
$794.29
$991.80 		$983.64
$1,036.12
$1,091.71
$1,289.22 		$1,281.06
$1,333.54
$1,389.13
$1,586.64 		$297.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.60
$882.56
$993.74
$1,388.76
$2,110.36 		$1,075.02
$1,179.98
$1,291.16
$1,686.18 		$1,372.44
$1,477.40
$1,588.58
$1,983.60 		$1,669.86
$1,774.82
$1,886.00
$2,281.02 		$297.42
Toc - Plan #42 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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 		$332.14
$376.96
$424.46
$593.18
$901.39 		$586.22
$631.04
$678.54
$847.26 		$840.30
$885.12
$932.62
$1,101.34 		$1,094.38
$1,139.20
$1,186.70
$1,355.42 		$254.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.28
$753.92
$848.92
$1,186.36
$1,802.78 		$918.36
$1,008.00
$1,103.00
$1,440.44 		$1,172.44
$1,262.08
$1,357.08
$1,694.52 		$1,426.52
$1,516.16
$1,611.16
$1,948.60 		$254.08
Toc - Plan #43 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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 		$298.11
$338.34
$380.97
$532.40
$809.04 		$526.15
$566.38
$609.01
$760.44 		$754.19
$794.42
$837.05
$988.48 		$982.23
$1,022.46
$1,065.09
$1,216.52 		$228.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.22
$676.68
$761.94
$1,064.80
$1,618.08 		$824.26
$904.72
$989.98
$1,292.84 		$1,052.30
$1,132.76
$1,218.02
$1,520.88 		$1,280.34
$1,360.80
$1,446.06
$1,748.92 		$228.04
Toc - Plan #44 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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 		$380.71
$432.09
$486.53
$679.93
$1,033.21 		$671.94
$723.32
$777.76
$971.16 		$963.17
$1,014.55
$1,068.99
$1,262.39 		$1,254.40
$1,305.78
$1,360.22
$1,553.62 		$291.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.42
$864.18
$973.06
$1,359.86
$2,066.42 		$1,052.65
$1,155.41
$1,264.29
$1,651.09 		$1,343.88
$1,446.64
$1,555.52
$1,942.32 		$1,635.11
$1,737.87
$1,846.75
$2,233.55 		$291.23
Toc - Plan #45 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

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 		$445.63
$505.78
$569.50
$795.88
$1,209.42 		$786.53
$846.68
$910.40
$1,136.78 		$1,127.43
$1,187.58
$1,251.30
$1,477.68 		$1,468.33
$1,528.48
$1,592.20
$1,818.58 		$340.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891.26
$1,011.56
$1,139.00
$1,591.76
$2,418.84 		$1,232.16
$1,352.46
$1,479.90
$1,932.66 		$1,573.06
$1,693.36
$1,820.80
$2,273.56 		$1,913.96
$2,034.26
$2,161.70
$2,614.46 		$340.90

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #46 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6250

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

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 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 		$473.04
$536.90
$604.54
$844.84
$1,283.82 		$834.91
$898.77
$966.41
$1,206.71 		$1,196.78
$1,260.64
$1,328.28
$1,568.58 		$1,558.65
$1,622.51
$1,690.15
$1,930.45 		$361.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$946.08
$1,073.80
$1,209.08
$1,689.68
$2,567.64 		$1,307.95
$1,435.67
$1,570.95
$2,051.55 		$1,669.82
$1,797.54
$1,932.82
$2,413.42 		$2,031.69
$2,159.41
$2,294.69
$2,775.29 		$361.87
Toc - Plan #47 Cigna Healthcare
Silver

(EPO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$521.08
$591.43
$665.94
$930.65
$1,414.22 		$919.71
$990.06
$1,064.57
$1,329.28 		$1,318.34
$1,388.69
$1,463.20
$1,727.91 		$1,716.97
$1,787.32
$1,861.83
$2,126.54 		$398.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.16
$1,182.86
$1,331.88
$1,861.30
$2,828.44 		$1,440.79
$1,581.49
$1,730.51
$2,259.93 		$1,839.42
$1,980.12
$2,129.14
$2,658.56 		$2,238.05
$2,378.75
$2,527.77
$3,057.19 		$398.63
Toc - Plan #48 Cigna Healthcare
Silver

(EPO) Cigna Connect 2800

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

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$524.29
$595.07
$670.05
$936.39
$1,422.94 		$925.38
$996.16
$1,071.14
$1,337.48 		$1,326.47
$1,397.25
$1,472.23
$1,738.57 		$1,727.56
$1,798.34
$1,873.32
$2,139.66 		$401.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,048.58
$1,190.14
$1,340.10
$1,872.78
$2,845.88 		$1,449.67
$1,591.23
$1,741.19
$2,273.87 		$1,850.76
$1,992.32
$2,142.28
$2,674.96 		$2,251.85
$2,393.41
$2,543.37
$3,076.05 		$401.09
Toc - Plan #49 Cigna Healthcare
Gold

(EPO) Cigna Connect 1250

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

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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 		$742.11
$842.30
$948.42
$1,325.41
$2,014.09 		$1,309.82
$1,410.01
$1,516.13
$1,893.12 		$1,877.53
$1,977.72
$2,083.84
$2,460.83 		$2,445.24
$2,545.43
$2,651.55
$3,028.54 		$567.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,484.22
$1,684.60
$1,896.84
$2,650.82
$4,028.18 		$2,051.93
$2,252.31
$2,464.55
$3,218.53 		$2,619.64
$2,820.02
$3,032.26
$3,786.24 		$3,187.35
$3,387.73
$3,599.97
$4,353.95 		$567.71
Toc - Plan #50 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7150

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

Annual Out of Pocket Expenses:

Individual Family
$7,150 $14,300 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 		$478.14
$542.69
$611.06
$853.95
$1,297.66 		$843.91
$908.46
$976.83
$1,219.72 		$1,209.68
$1,274.23
$1,342.60
$1,585.49 		$1,575.45
$1,640.00
$1,708.37
$1,951.26 		$365.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.28
$1,085.38
$1,222.12
$1,707.90
$2,595.32 		$1,322.05
$1,451.15
$1,587.89
$2,073.67 		$1,687.82
$1,816.92
$1,953.66
$2,439.44 		$2,053.59
$2,182.69
$2,319.43
$2,805.21 		$365.77
Toc - Plan #51 Cigna Healthcare
Silver

(EPO) Cigna Connect 6100

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 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 		$522.47
$593.00
$667.71
$933.13
$1,417.98 		$922.16
$992.69
$1,067.40
$1,332.82 		$1,321.85
$1,392.38
$1,467.09
$1,732.51 		$1,721.54
$1,792.07
$1,866.78
$2,132.20 		$399.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.94
$1,186.00
$1,335.42
$1,866.26
$2,835.96 		$1,444.63
$1,585.69
$1,735.11
$2,265.95 		$1,844.32
$1,985.38
$2,134.80
$2,665.64 		$2,244.01
$2,385.07
$2,534.49
$3,065.33 		$399.69
Toc - Plan #52 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 		$525.43
$596.36
$671.50
$938.41
$1,426.01 		$927.38
$998.31
$1,073.45
$1,340.36 		$1,329.33
$1,400.26
$1,475.40
$1,742.31 		$1,731.28
$1,802.21
$1,877.35
$2,144.26 		$401.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,050.86
$1,192.72
$1,343.00
$1,876.82
$2,852.02 		$1,452.81
$1,594.67
$1,744.95
$2,278.77 		$1,854.76
$1,996.62
$2,146.90
$2,680.72 		$2,256.71
$2,398.57
$2,548.85
$3,082.67 		$401.95
Toc - Plan #53 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 		$475.74
$539.97
$608.00
$849.68
$1,291.17 		$839.68
$903.91
$971.94
$1,213.62 		$1,203.62
$1,267.85
$1,335.88
$1,577.56 		$1,567.56
$1,631.79
$1,699.82
$1,941.50 		$363.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$951.48
$1,079.94
$1,216.00
$1,699.36
$2,582.34 		$1,315.42
$1,443.88
$1,579.94
$2,063.30 		$1,679.36
$1,807.82
$1,943.88
$2,427.24 		$2,043.30
$2,171.76
$2,307.82
$2,791.18 		$363.94
Toc - Plan #54 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect HSA 7050

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

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 		$476.25
$540.54
$608.64
$850.58
$1,292.54 		$840.58
$904.87
$972.97
$1,214.91 		$1,204.91
$1,269.20
$1,337.30
$1,579.24 		$1,569.24
$1,633.53
$1,701.63
$1,943.57 		$364.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.50
$1,081.08
$1,217.28
$1,701.16
$2,585.08 		$1,316.83
$1,445.41
$1,581.61
$2,065.49 		$1,681.16
$1,809.74
$1,945.94
$2,429.82 		$2,045.49
$2,174.07
$2,310.27
$2,794.15 		$364.33
Toc - Plan #55 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 		$523.41
$594.07
$668.92
$934.82
$1,420.54 		$923.82
$994.48
$1,069.33
$1,335.23 		$1,324.23
$1,394.89
$1,469.74
$1,735.64 		$1,724.64
$1,795.30
$1,870.15
$2,136.05 		$400.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,046.82
$1,188.14
$1,337.84
$1,869.64
$2,841.08 		$1,447.23
$1,588.55
$1,738.25
$2,270.05 		$1,847.64
$1,988.96
$2,138.66
$2,670.46 		$2,248.05
$2,389.37
$2,539.07
$3,070.87 		$400.41
Toc - Plan #56 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 		$526.81
$597.93
$673.27
$940.89
$1,429.77 		$929.82
$1,000.94
$1,076.28
$1,343.90 		$1,332.83
$1,403.95
$1,479.29
$1,746.91 		$1,735.84
$1,806.96
$1,882.30
$2,149.92 		$403.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,053.62
$1,195.86
$1,346.54
$1,881.78
$2,859.54 		$1,456.63
$1,598.87
$1,749.55
$2,284.79 		$1,859.64
$2,001.88
$2,152.56
$2,687.80 		$2,262.65
$2,404.89
$2,555.57
$3,090.81 		$403.01
Toc - Plan #57 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 		$453.64
$514.88
$579.75
$810.20
$1,231.18 		$800.68
$861.92
$926.79
$1,157.24 		$1,147.72
$1,208.96
$1,273.83
$1,504.28 		$1,494.76
$1,556.00
$1,620.87
$1,851.32 		$347.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$907.28
$1,029.76
$1,159.50
$1,620.40
$2,462.36 		$1,254.32
$1,376.80
$1,506.54
$1,967.44 		$1,601.36
$1,723.84
$1,853.58
$2,314.48 		$1,948.40
$2,070.88
$2,200.62
$2,661.52 		$347.04
Toc - Plan #58 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 		$521.02
$591.36
$665.86
$930.54
$1,414.05 		$919.60
$989.94
$1,064.44
$1,329.12 		$1,318.18
$1,388.52
$1,463.02
$1,727.70 		$1,716.76
$1,787.10
$1,861.60
$2,126.28 		$398.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.04
$1,182.72
$1,331.72
$1,861.08
$2,828.10 		$1,440.62
$1,581.30
$1,730.30
$2,259.66 		$1,839.20
$1,979.88
$2,128.88
$2,658.24 		$2,237.78
$2,378.46
$2,527.46
$3,056.82 		$398.58
Toc - Plan #59 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 		$739.40
$839.22
$944.96
$1,320.57
$2,006.74 		$1,305.04
$1,404.86
$1,510.60
$1,886.21 		$1,870.68
$1,970.50
$2,076.24
$2,451.85 		$2,436.32
$2,536.14
$2,641.88
$3,017.49 		$565.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,478.80
$1,678.44
$1,889.92
$2,641.14
$4,013.48 		$2,044.44
$2,244.08
$2,455.56
$3,206.78 		$2,610.08
$2,809.72
$3,021.20
$3,772.42 		$3,175.72
$3,375.36
$3,586.84
$4,338.06 		$565.64

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-632-4195 | Toll Free: 1-877-632-4195 | TTY: 1-877-940-4172
Toc - Plan #60 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.27
$471.33
$530.72
$741.68
$1,127.05 		$732.95
$789.01
$848.40
$1,059.36 		$1,050.63
$1,106.69
$1,166.08
$1,377.04 		$1,368.31
$1,424.37
$1,483.76
$1,694.72 		$317.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.54
$942.66
$1,061.44
$1,483.36
$2,254.10 		$1,148.22
$1,260.34
$1,379.12
$1,801.04 		$1,465.90
$1,578.02
$1,696.80
$2,118.72 		$1,783.58
$1,895.70
$2,014.48
$2,436.40 		$317.68
Toc - Plan #61 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$437.14
$496.15
$558.66
$780.73
$1,186.39 		$771.55
$830.56
$893.07
$1,115.14 		$1,105.96
$1,164.97
$1,227.48
$1,449.55 		$1,440.37
$1,499.38
$1,561.89
$1,783.96 		$334.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.28
$992.30
$1,117.32
$1,561.46
$2,372.78 		$1,208.69
$1,326.71
$1,451.73
$1,895.87 		$1,543.10
$1,661.12
$1,786.14
$2,230.28 		$1,877.51
$1,995.53
$2,120.55
$2,564.69 		$334.41
Toc - Plan #62 UnitedHealthcare
Silver

(EPO) 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: 1-877-632-4195

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 		$385.62
$437.68
$492.82
$688.72
$1,046.57 		$680.62
$732.68
$787.82
$983.72 		$975.62
$1,027.68
$1,082.82
$1,278.72 		$1,270.62
$1,322.68
$1,377.82
$1,573.72 		$295.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.24
$875.36
$985.64
$1,377.44
$2,093.14 		$1,066.24
$1,170.36
$1,280.64
$1,672.44 		$1,361.24
$1,465.36
$1,575.64
$1,967.44 		$1,656.24
$1,760.36
$1,870.64
$2,262.44 		$295.00
Toc - Plan #63 UnitedHealthcare
Silver

(EPO) 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: 1-877-632-4195

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 		$381.31
$432.79
$487.32
$681.03
$1,034.89 		$673.02
$724.50
$779.03
$972.74 		$964.73
$1,016.21
$1,070.74
$1,264.45 		$1,256.44
$1,307.92
$1,362.45
$1,556.16 		$291.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.62
$865.58
$974.64
$1,362.06
$2,069.78 		$1,054.33
$1,157.29
$1,266.35
$1,653.77 		$1,346.04
$1,449.00
$1,558.06
$1,945.48 		$1,637.75
$1,740.71
$1,849.77
$2,237.19 		$291.71
Toc - Plan #64 UnitedHealthcare
Silver

(EPO) 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: 1-877-632-4195

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 		$397.48
$451.14
$507.98
$709.90
$1,078.76 		$701.55
$755.21
$812.05
$1,013.97 		$1,005.62
$1,059.28
$1,116.12
$1,318.04 		$1,309.69
$1,363.35
$1,420.19
$1,622.11 		$304.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.96
$902.28
$1,015.96
$1,419.80
$2,157.52 		$1,099.03
$1,206.35
$1,320.03
$1,723.87 		$1,403.10
$1,510.42
$1,624.10
$2,027.94 		$1,707.17
$1,814.49
$1,928.17
$2,332.01 		$304.07
Toc - Plan #65 UnitedHealthcare
Silver

(EPO) 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: 1-877-632-4195

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 		$390.88
$443.65
$499.55
$698.11
$1,060.85 		$689.90
$742.67
$798.57
$997.13 		$988.92
$1,041.69
$1,097.59
$1,296.15 		$1,287.94
$1,340.71
$1,396.61
$1,595.17 		$299.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.76
$887.30
$999.10
$1,396.22
$2,121.70 		$1,080.78
$1,186.32
$1,298.12
$1,695.24 		$1,379.80
$1,485.34
$1,597.14
$1,994.26 		$1,678.82
$1,784.36
$1,896.16
$2,293.28 		$299.02
Toc - Plan #66 UnitedHealthcare
Silver

(EPO) UHC Silver Value HSA $5,400 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$388.67
$441.13
$496.71
$694.16
$1,054.84 		$686.00
$738.46
$794.04
$991.49 		$983.33
$1,035.79
$1,091.37
$1,288.82 		$1,280.66
$1,333.12
$1,388.70
$1,586.15 		$297.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.34
$882.26
$993.42
$1,388.32
$2,109.68 		$1,074.67
$1,179.59
$1,290.75
$1,685.65 		$1,372.00
$1,476.92
$1,588.08
$1,982.98 		$1,669.33
$1,774.25
$1,885.41
$2,280.31 		$297.33
Toc - Plan #67 UnitedHealthcare
Silver

(EPO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$387.61
$439.93
$495.36
$692.27
$1,051.96 		$684.13
$736.45
$791.88
$988.79 		$980.65
$1,032.97
$1,088.40
$1,285.31 		$1,277.17
$1,329.49
$1,384.92
$1,581.83 		$296.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.22
$879.86
$990.72
$1,384.54
$2,103.92 		$1,071.74
$1,176.38
$1,287.24
$1,681.06 		$1,368.26
$1,472.90
$1,583.76
$1,977.58 		$1,664.78
$1,769.42
$1,880.28
$2,274.10 		$296.52
Toc - Plan #68 UnitedHealthcare
Gold

(EPO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$425.33
$482.75
$543.57
$759.64
$1,154.34 		$750.71
$808.13
$868.95
$1,085.02 		$1,076.09
$1,133.51
$1,194.33
$1,410.40 		$1,401.47
$1,458.89
$1,519.71
$1,735.78 		$325.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.66
$965.50
$1,087.14
$1,519.28
$2,308.68 		$1,176.04
$1,290.88
$1,412.52
$1,844.66 		$1,501.42
$1,616.26
$1,737.90
$2,170.04 		$1,826.80
$1,941.64
$2,063.28
$2,495.42 		$325.38
Toc - Plan #69 UnitedHealthcare
Bronze

(EPO) UHC Bronze Essential ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$319.13
$362.21
$407.84
$569.96
$866.11 		$563.26
$606.34
$651.97
$814.09 		$807.39
$850.47
$896.10
$1,058.22 		$1,051.52
$1,094.60
$1,140.23
$1,302.35 		$244.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.26
$724.42
$815.68
$1,139.92
$1,732.22 		$882.39
$968.55
$1,059.81
$1,384.05 		$1,126.52
$1,212.68
$1,303.94
$1,628.18 		$1,370.65
$1,456.81
$1,548.07
$1,872.31 		$244.13
Toc - Plan #70 UnitedHealthcare
Expanded Bronze

(EPO) 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: 1-877-632-4195

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 		$332.33
$377.19
$424.71
$593.53
$901.93 		$586.56
$631.42
$678.94
$847.76 		$840.79
$885.65
$933.17
$1,101.99 		$1,095.02
$1,139.88
$1,187.40
$1,356.22 		$254.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$664.66
$754.38
$849.42
$1,187.06
$1,803.86 		$918.89
$1,008.61
$1,103.65
$1,441.29 		$1,173.12
$1,262.84
$1,357.88
$1,695.52 		$1,427.35
$1,517.07
$1,612.11
$1,949.75 		$254.23
Toc - Plan #71 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$330.80
$375.46
$422.77
$590.81
$897.80 		$583.86
$628.52
$675.83
$843.87 		$836.92
$881.58
$928.89
$1,096.93 		$1,089.98
$1,134.64
$1,181.95
$1,349.99 		$253.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$661.60
$750.92
$845.54
$1,181.62
$1,795.60 		$914.66
$1,003.98
$1,098.60
$1,434.68 		$1,167.72
$1,257.04
$1,351.66
$1,687.74 		$1,420.78
$1,510.10
$1,604.72
$1,940.80 		$253.06
Toc - Plan #72 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$334.53
$379.69
$427.53
$597.46
$907.91 		$590.44
$635.60
$683.44
$853.37 		$846.35
$891.51
$939.35
$1,109.28 		$1,102.26
$1,147.42
$1,195.26
$1,365.19 		$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
$1,194.92
$1,815.82 		$924.97
$1,015.29
$1,110.97
$1,450.83 		$1,180.88
$1,271.20
$1,366.88
$1,706.74 		$1,436.79
$1,527.11
$1,622.79
$1,962.65 		$255.91
Toc - Plan #73 UnitedHealthcare
Bronze

(EPO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$310.69
$352.64
$397.07
$554.90
$843.23 		$548.37
$590.32
$634.75
$792.58 		$786.05
$828.00
$872.43
$1,030.26 		$1,023.73
$1,065.68
$1,110.11
$1,267.94 		$237.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.38
$705.28
$794.14
$1,109.80
$1,686.46 		$859.06
$942.96
$1,031.82
$1,347.48 		$1,096.74
$1,180.64
$1,269.50
$1,585.16 		$1,334.42
$1,418.32
$1,507.18
$1,822.84 		$237.68

ADVERTISEMENT

Ambetter from Home State Health

Local: 1-855-650-3789 | Toll Free: 1-855-650-3789 | TTY: 1-855-650-3789
Toc - Plan #74 Ambetter from Home State Health
Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$328.64
$372.99
$419.99
$586.93
$891.90 		$580.04
$624.39
$671.39
$838.33 		$831.44
$875.79
$922.79
$1,089.73 		$1,082.84
$1,127.19
$1,174.19
$1,341.13 		$251.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.28
$745.98
$839.98
$1,173.86
$1,783.80 		$908.68
$997.38
$1,091.38
$1,425.26 		$1,160.08
$1,248.78
$1,342.78
$1,676.66 		$1,411.48
$1,500.18
$1,594.18
$1,928.06 		$251.40
Toc - Plan #75 Ambetter from Home State Health
Silver

(EPO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$380.63
$432.01
$486.44
$679.79
$1,033.01 		$671.81
$723.19
$777.62
$970.97 		$962.99
$1,014.37
$1,068.80
$1,262.15 		$1,254.17
$1,305.55
$1,359.98
$1,553.33 		$291.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.26
$864.02
$972.88
$1,359.58
$2,066.02 		$1,052.44
$1,155.20
$1,264.06
$1,650.76 		$1,343.62
$1,446.38
$1,555.24
$1,941.94 		$1,634.80
$1,737.56
$1,846.42
$2,233.12 		$291.18
Toc - Plan #76 Ambetter from Home State Health
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$379.22
$430.41
$484.64
$677.28
$1,029.19 		$669.32
$720.51
$774.74
$967.38 		$959.42
$1,010.61
$1,064.84
$1,257.48 		$1,249.52
$1,300.71
$1,354.94
$1,547.58 		$290.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.44
$860.82
$969.28
$1,354.56
$2,058.38 		$1,048.54
$1,150.92
$1,259.38
$1,644.66 		$1,338.64
$1,441.02
$1,549.48
$1,934.76 		$1,628.74
$1,731.12
$1,839.58
$2,224.86 		$290.10
Toc - Plan #77 Ambetter from Home State Health
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,700 $15,400 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 		$471.52
$535.17
$602.60
$842.13
$1,279.69 		$832.23
$895.88
$963.31
$1,202.84 		$1,192.94
$1,256.59
$1,324.02
$1,563.55 		$1,553.65
$1,617.30
$1,684.73
$1,924.26 		$360.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$943.04
$1,070.34
$1,205.20
$1,684.26
$2,559.38 		$1,303.75
$1,431.05
$1,565.91
$2,044.97 		$1,664.46
$1,791.76
$1,926.62
$2,405.68 		$2,025.17
$2,152.47
$2,287.33
$2,766.39 		$360.71
Toc - Plan #78 Ambetter from Home State Health
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$355.85
$403.88
$454.77
$635.54
$965.76 		$628.07
$676.10
$726.99
$907.76 		$900.29
$948.32
$999.21
$1,179.98 		$1,172.51
$1,220.54
$1,271.43
$1,452.20 		$272.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.70
$807.76
$909.54
$1,271.08
$1,931.52 		$983.92
$1,079.98
$1,181.76
$1,543.30 		$1,256.14
$1,352.20
$1,453.98
$1,815.52 		$1,528.36
$1,624.42
$1,726.20
$2,087.74 		$272.22
Toc - Plan #79 Ambetter from Home State Health
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$361.22
$409.97
$461.63
$645.12
$980.33 		$637.55
$686.30
$737.96
$921.45 		$913.88
$962.63
$1,014.29
$1,197.78 		$1,190.21
$1,238.96
$1,290.62
$1,474.11 		$276.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.44
$819.94
$923.26
$1,290.24
$1,960.66 		$998.77
$1,096.27
$1,199.59
$1,566.57 		$1,275.10
$1,372.60
$1,475.92
$1,842.90 		$1,551.43
$1,648.93
$1,752.25
$2,119.23 		$276.33
Toc - Plan #80 Ambetter from Home State Health
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$398.56
$452.35
$509.35
$711.81
$1,081.66 		$703.45
$757.24
$814.24
$1,016.70 		$1,008.34
$1,062.13
$1,119.13
$1,321.59 		$1,313.23
$1,367.02
$1,424.02
$1,626.48 		$304.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.12
$904.70
$1,018.70
$1,423.62
$2,163.32 		$1,102.01
$1,209.59
$1,323.59
$1,728.51 		$1,406.90
$1,514.48
$1,628.48
$2,033.40 		$1,711.79
$1,819.37
$1,933.37
$2,338.29 		$304.89
Toc - Plan #81 Ambetter from Home State Health
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$366.97
$416.50
$468.97
$655.39
$995.92 		$647.69
$697.22
$749.69
$936.11 		$928.41
$977.94
$1,030.41
$1,216.83 		$1,209.13
$1,258.66
$1,311.13
$1,497.55 		$280.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.94
$833.00
$937.94
$1,310.78
$1,991.84 		$1,014.66
$1,113.72
$1,218.66
$1,591.50 		$1,295.38
$1,394.44
$1,499.38
$1,872.22 		$1,576.10
$1,675.16
$1,780.10
$2,152.94 		$280.72
Toc - Plan #82 Ambetter from Home State Health
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$373.86
$424.32
$477.78
$667.69
$1,014.62 		$659.85
$710.31
$763.77
$953.68 		$945.84
$996.30
$1,049.76
$1,239.67 		$1,231.83
$1,282.29
$1,335.75
$1,525.66 		$285.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.72
$848.64
$955.56
$1,335.38
$2,029.24 		$1,033.71
$1,134.63
$1,241.55
$1,621.37 		$1,319.70
$1,420.62
$1,527.54
$1,907.36 		$1,605.69
$1,706.61
$1,813.53
$2,193.35 		$285.99
Toc - Plan #83 Ambetter from Home State Health
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$451.62
$512.58
$577.16
$806.57
$1,225.67 		$797.10
$858.06
$922.64
$1,152.05 		$1,142.58
$1,203.54
$1,268.12
$1,497.53 		$1,488.06
$1,549.02
$1,613.60
$1,843.01 		$345.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.24
$1,025.16
$1,154.32
$1,613.14
$2,451.34 		$1,248.72
$1,370.64
$1,499.80
$1,958.62 		$1,594.20
$1,716.12
$1,845.28
$2,304.10 		$1,939.68
$2,061.60
$2,190.76
$2,649.58 		$345.48
Toc - Plan #84 Ambetter from Home State Health
Gold

(EPO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$444.92
$504.97
$568.59
$794.61
$1,207.48 		$785.28
$845.33
$908.95
$1,134.97 		$1,125.64
$1,185.69
$1,249.31
$1,475.33 		$1,466.00
$1,526.05
$1,589.67
$1,815.69 		$340.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$889.84
$1,009.94
$1,137.18
$1,589.22
$2,414.96 		$1,230.20
$1,350.30
$1,477.54
$1,929.58 		$1,570.56
$1,690.66
$1,817.90
$2,269.94 		$1,910.92
$2,031.02
$2,158.26
$2,610.30 		$340.36
Toc - Plan #85 Ambetter from Home State Health
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,300 $10,600 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 		$516.10
$585.76
$659.56
$921.73
$1,400.66 		$910.91
$980.57
$1,054.37
$1,316.54 		$1,305.72
$1,375.38
$1,449.18
$1,711.35 		$1,700.53
$1,770.19
$1,843.99
$2,106.16 		$394.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,032.20
$1,171.52
$1,319.12
$1,843.46
$2,801.32 		$1,427.01
$1,566.33
$1,713.93
$2,238.27 		$1,821.82
$1,961.14
$2,108.74
$2,633.08 		$2,216.63
$2,355.95
$2,503.55
$3,027.89 		$394.81
Toc - Plan #86 Ambetter from Home State Health
Bronze

(EPO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$313.30
$355.58
$400.38
$559.54
$850.27 		$552.97
$595.25
$640.05
$799.21 		$792.64
$834.92
$879.72
$1,038.88 		$1,032.31
$1,074.59
$1,119.39
$1,278.55 		$239.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.60
$711.16
$800.76
$1,119.08
$1,700.54 		$866.27
$950.83
$1,040.43
$1,358.75 		$1,105.94
$1,190.50
$1,280.10
$1,598.42 		$1,345.61
$1,430.17
$1,519.77
$1,838.09 		$239.67
Toc - Plan #87 Ambetter from Home State Health
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$344.66
$391.18
$440.47
$615.55
$935.39 		$608.32
$654.84
$704.13
$879.21 		$871.98
$918.50
$967.79
$1,142.87 		$1,135.64
$1,182.16
$1,231.45
$1,406.53 		$263.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.32
$782.36
$880.94
$1,231.10
$1,870.78 		$952.98
$1,046.02
$1,144.60
$1,494.76 		$1,216.64
$1,309.68
$1,408.26
$1,758.42 		$1,480.30
$1,573.34
$1,671.92
$2,022.08 		$263.66
Toc - Plan #88 Ambetter from Home State Health
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$366.28
$415.72
$468.10
$654.16
$994.06 		$646.48
$695.92
$748.30
$934.36 		$926.68
$976.12
$1,028.50
$1,214.56 		$1,206.88
$1,256.32
$1,308.70
$1,494.76 		$280.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.56
$831.44
$936.20
$1,308.32
$1,988.12 		$1,012.76
$1,111.64
$1,216.40
$1,588.52 		$1,292.96
$1,391.84
$1,496.60
$1,868.72 		$1,573.16
$1,672.04
$1,776.80
$2,148.92 		$280.20
Toc - Plan #89 Ambetter from Home State Health
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$445.22
$505.32
$568.98
$795.15
$1,208.31 		$785.81
$845.91
$909.57
$1,135.74 		$1,126.40
$1,186.50
$1,250.16
$1,476.33 		$1,466.99
$1,527.09
$1,590.75
$1,816.92 		$340.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.44
$1,010.64
$1,137.96
$1,590.30
$2,416.62 		$1,231.03
$1,351.23
$1,478.55
$1,930.89 		$1,571.62
$1,691.82
$1,819.14
$2,271.48 		$1,912.21
$2,032.41
$2,159.73
$2,612.07 		$340.59
Toc - Plan #90 Ambetter from Home State Health
Expanded Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$339.34
$385.14
$433.66
$606.04
$920.94 		$598.93
$644.73
$693.25
$865.63 		$858.52
$904.32
$952.84
$1,125.22 		$1,118.11
$1,163.91
$1,212.43
$1,384.81 		$259.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.68
$770.28
$867.32
$1,212.08
$1,841.88 		$938.27
$1,029.87
$1,126.91
$1,471.67 		$1,197.86
$1,289.46
$1,386.50
$1,731.26 		$1,457.45
$1,549.05
$1,646.09
$1,990.85 		$259.59
Toc - Plan #91 Ambetter from Home State Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$367.44
$417.03
$469.57
$656.23
$997.20 		$648.52
$698.11
$750.65
$937.31 		$929.60
$979.19
$1,031.73
$1,218.39 		$1,210.68
$1,260.27
$1,312.81
$1,499.47 		$281.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.88
$834.06
$939.14
$1,312.46
$1,994.40 		$1,015.96
$1,115.14
$1,220.22
$1,593.54 		$1,297.04
$1,396.22
$1,501.30
$1,874.62 		$1,578.12
$1,677.30
$1,782.38
$2,155.70 		$281.08
Toc - Plan #92 Ambetter from Home State Health
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,700 $15,400 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 		$486.88
$552.59
$622.21
$869.54
$1,321.35 		$859.33
$925.04
$994.66
$1,241.99 		$1,231.78
$1,297.49
$1,367.11
$1,614.44 		$1,604.23
$1,669.94
$1,739.56
$1,986.89 		$372.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$973.76
$1,105.18
$1,244.42
$1,739.08
$2,642.70 		$1,346.21
$1,477.63
$1,616.87
$2,111.53 		$1,718.66
$1,850.08
$1,989.32
$2,483.98 		$2,091.11
$2,222.53
$2,361.77
$2,856.43 		$372.45
Toc - Plan #93 Ambetter from Home State Health
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$391.57
$444.42
$500.41
$699.33
$1,062.69 		$691.11
$743.96
$799.95
$998.87 		$990.65
$1,043.50
$1,099.49
$1,298.41 		$1,290.19
$1,343.04
$1,399.03
$1,597.95 		$299.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.14
$888.84
$1,000.82
$1,398.66
$2,125.38 		$1,082.68
$1,188.38
$1,300.36
$1,698.20 		$1,382.22
$1,487.92
$1,599.90
$1,997.74 		$1,681.76
$1,787.46
$1,899.44
$2,297.28 		$299.54
Toc - Plan #94 Ambetter from Home State Health
Silver

(EPO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.02
$446.07
$502.27
$701.92
$1,066.64 		$693.68
$746.73
$802.93
$1,002.58 		$994.34
$1,047.39
$1,103.59
$1,303.24 		$1,295.00
$1,348.05
$1,404.25
$1,603.90 		$300.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.04
$892.14
$1,004.54
$1,403.84
$2,133.28 		$1,086.70
$1,192.80
$1,305.20
$1,704.50 		$1,387.36
$1,493.46
$1,605.86
$2,005.16 		$1,688.02
$1,794.12
$1,906.52
$2,305.82 		$300.66
Toc - Plan #95 Ambetter from Home State Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$372.98
$423.32
$476.66
$666.12
$1,012.24 		$658.30
$708.64
$761.98
$951.44 		$943.62
$993.96
$1,047.30
$1,236.76 		$1,228.94
$1,279.28
$1,332.62
$1,522.08 		$285.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.96
$846.64
$953.32
$1,332.24
$2,024.48 		$1,031.28
$1,131.96
$1,238.64
$1,617.56 		$1,316.60
$1,417.28
$1,523.96
$1,902.88 		$1,601.92
$1,702.60
$1,809.28
$2,188.20 		$285.32
Toc - Plan #96 Ambetter from Home State Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$411.53
$467.08
$525.93
$734.98
$1,116.88 		$726.35
$781.90
$840.75
$1,049.80 		$1,041.17
$1,096.72
$1,155.57
$1,364.62 		$1,355.99
$1,411.54
$1,470.39
$1,679.44 		$314.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.06
$934.16
$1,051.86
$1,469.96
$2,233.76 		$1,137.88
$1,248.98
$1,366.68
$1,784.78 		$1,452.70
$1,563.80
$1,681.50
$2,099.60 		$1,767.52
$1,878.62
$1,996.32
$2,414.42 		$314.82
Toc - Plan #97 Ambetter from Home State Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$386.03
$438.13
$493.33
$689.43
$1,047.65 		$681.33
$733.43
$788.63
$984.73 		$976.63
$1,028.73
$1,083.93
$1,280.03 		$1,271.93
$1,324.03
$1,379.23
$1,575.33 		$295.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.06
$876.26
$986.66
$1,378.86
$2,095.30 		$1,067.36
$1,171.56
$1,281.96
$1,674.16 		$1,362.66
$1,466.86
$1,577.26
$1,969.46 		$1,657.96
$1,762.16
$1,872.56
$2,264.76 		$295.30
Toc - Plan #98 Ambetter from Home State Health
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$466.32
$529.26
$595.95
$832.83
$1,265.57 		$823.05
$885.99
$952.68
$1,189.56 		$1,179.78
$1,242.72
$1,309.41
$1,546.29 		$1,536.51
$1,599.45
$1,666.14
$1,903.02 		$356.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$932.64
$1,058.52
$1,191.90
$1,665.66
$2,531.14 		$1,289.37
$1,415.25
$1,548.63
$2,022.39 		$1,646.10
$1,771.98
$1,905.36
$2,379.12 		$2,002.83
$2,128.71
$2,262.09
$2,735.85 		$356.73
Toc - Plan #99 Ambetter from Home State Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$378.91
$430.06
$484.24
$676.72
$1,028.35 		$668.77
$719.92
$774.10
$966.58 		$958.63
$1,009.78
$1,063.96
$1,256.44 		$1,248.49
$1,299.64
$1,353.82
$1,546.30 		$289.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.82
$860.12
$968.48
$1,353.44
$2,056.70 		$1,047.68
$1,149.98
$1,258.34
$1,643.30 		$1,337.54
$1,439.84
$1,548.20
$1,933.16 		$1,627.40
$1,729.70
$1,838.06
$2,223.02 		$289.86
Toc - Plan #100 Ambetter from Home State Health
Gold

(EPO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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 		$459.40
$521.41
$587.11
$820.48
$1,246.80 		$810.84
$872.85
$938.55
$1,171.92 		$1,162.28
$1,224.29
$1,289.99
$1,523.36 		$1,513.72
$1,575.73
$1,641.43
$1,874.80 		$351.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.80
$1,042.82
$1,174.22
$1,640.96
$2,493.60 		$1,270.24
$1,394.26
$1,525.66
$1,992.40 		$1,621.68
$1,745.70
$1,877.10
$2,343.84 		$1,973.12
$2,097.14
$2,228.54
$2,695.28 		$351.44
Toc - Plan #101 Ambetter from Home State Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,300 $10,600 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 		$532.90
$604.83
$681.03
$951.74
$1,446.26 		$940.56
$1,012.49
$1,088.69
$1,359.40 		$1,348.22
$1,420.15
$1,496.35
$1,767.06 		$1,755.88
$1,827.81
$1,904.01
$2,174.72 		$407.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,065.80
$1,209.66
$1,362.06
$1,903.48
$2,892.52 		$1,473.46
$1,617.32
$1,769.72
$2,311.14 		$1,881.12
$2,024.98
$2,177.38
$2,718.80 		$2,288.78
$2,432.64
$2,585.04
$3,126.46 		$407.66

‡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 Jackson County here.

Jackson County is in “Rating Area 3” of Missouri.

Currently, there are 101 plans offered in Rating Area 3.

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2023 Obamacare Plans for Jackson County, MO

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