Obamacare 2023 Rates for Saint Louis County

Obamacare > Rates > Missouri > Saint Louis County

ADVERTISEMENT

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 Saint Louis 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, 113 Plans and 2023 Rates for Saint Louis County, Missouri

Below, you’ll find a summary of the 113 plans for Saint Louis 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

Saint Louis County Resources

ADVERTISEMENT

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-738-6677 | Toll Free: 1-855-738-6677

Toc - Plan #1 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 3100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 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 		$324.74
$368.58
$415.02
$579.99
$881.34 		$573.17
$617.01
$663.45
$828.42 		$821.60
$865.44
$911.88
$1,076.85 		$1,070.03
$1,113.87
$1,160.31
$1,325.28 		$248.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.48
$737.16
$830.04
$1,159.98
$1,762.68 		$897.91
$985.59
$1,078.47
$1,408.41 		$1,146.34
$1,234.02
$1,326.90
$1,656.84 		$1,394.77
$1,482.45
$1,575.33
$1,905.27 		$248.43
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 6800 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$268.30
$304.52
$342.89
$479.18
$728.17 		$473.55
$509.77
$548.14
$684.43 		$678.80
$715.02
$753.39
$889.68 		$884.05
$920.27
$958.64
$1,094.93 		$205.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.60
$609.04
$685.78
$958.36
$1,456.34 		$741.85
$814.29
$891.03
$1,163.61 		$947.10
$1,019.54
$1,096.28
$1,368.86 		$1,152.35
$1,224.79
$1,301.53
$1,574.11 		$205.25
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$267.33
$303.42
$341.65
$477.45
$725.53 		$471.84
$507.93
$546.16
$681.96 		$676.35
$712.44
$750.67
$886.47 		$880.86
$916.95
$955.18
$1,090.98 		$204.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.66
$606.84
$683.30
$954.90
$1,451.06 		$739.17
$811.35
$887.81
$1,159.41 		$943.68
$1,015.86
$1,092.32
$1,363.92 		$1,148.19
$1,220.37
$1,296.83
$1,568.43 		$204.51
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 20% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$270.50
$307.02
$345.70
$483.11
$734.14 		$477.43
$513.95
$552.63
$690.04 		$684.36
$720.88
$759.56
$896.97 		$891.29
$927.81
$966.49
$1,103.90 		$206.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.00
$614.04
$691.40
$966.22
$1,468.28 		$747.93
$820.97
$898.33
$1,173.15 		$954.86
$1,027.90
$1,105.26
$1,380.08 		$1,161.79
$1,234.83
$1,312.19
$1,587.01 		$206.93
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 3900 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$3,900 $7,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323.10
$366.72
$412.92
$577.06
$876.89 		$570.27
$613.89
$660.09
$824.23 		$817.44
$861.06
$907.26
$1,071.40 		$1,064.61
$1,108.23
$1,154.43
$1,318.57 		$247.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.20
$733.44
$825.84
$1,154.12
$1,753.78 		$893.37
$980.61
$1,073.01
$1,401.29 		$1,140.54
$1,227.78
$1,320.18
$1,648.46 		$1,387.71
$1,474.95
$1,567.35
$1,895.63 		$247.17
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 3000 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,450 $12,900 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 		$324.13
$367.89
$414.24
$578.90
$879.69 		$572.09
$615.85
$662.20
$826.86 		$820.05
$863.81
$910.16
$1,074.82 		$1,068.01
$1,111.77
$1,158.12
$1,322.78 		$247.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.26
$735.78
$828.48
$1,157.80
$1,759.38 		$896.22
$983.74
$1,076.44
$1,405.76 		$1,144.18
$1,231.70
$1,324.40
$1,653.72 		$1,392.14
$1,479.66
$1,572.36
$1,901.68 		$247.96
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 6500 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$266.43
$302.40
$340.50
$475.84
$723.09 		$470.25
$506.22
$544.32
$679.66 		$674.07
$710.04
$748.14
$883.48 		$877.89
$913.86
$951.96
$1,087.30 		$203.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$532.86
$604.80
$681.00
$951.68
$1,446.18 		$736.68
$808.62
$884.82
$1,155.50 		$940.50
$1,012.44
$1,088.64
$1,359.32 		$1,144.32
$1,216.26
$1,292.46
$1,563.14 		$203.82
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 5400 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,300 $16,600 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 		$317.63
$360.51
$405.93
$567.29
$862.05 		$560.62
$603.50
$648.92
$810.28 		$803.61
$846.49
$891.91
$1,053.27 		$1,046.60
$1,089.48
$1,134.90
$1,296.26 		$242.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.26
$721.02
$811.86
$1,134.58
$1,724.10 		$878.25
$964.01
$1,054.85
$1,377.57 		$1,121.24
$1,207.00
$1,297.84
$1,620.56 		$1,364.23
$1,449.99
$1,540.83
$1,863.55 		$242.99
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 6500 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$315.57
$358.17
$403.30
$563.61
$856.46 		$556.98
$599.58
$644.71
$805.02 		$798.39
$840.99
$886.12
$1,046.43 		$1,039.80
$1,082.40
$1,127.53
$1,287.84 		$241.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.14
$716.34
$806.60
$1,127.22
$1,712.92 		$872.55
$957.75
$1,048.01
$1,368.63 		$1,113.96
$1,199.16
$1,289.42
$1,610.04 		$1,355.37
$1,440.57
$1,530.83
$1,851.45 		$241.41
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Catastrophic

(EPO) Anthem Catastrophic Pathway X 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$194.90
$221.21
$249.08
$348.09
$528.96 		$344.00
$370.31
$398.18
$497.19 		$493.10
$519.41
$547.28
$646.29 		$642.20
$668.51
$696.38
$795.39 		$149.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$389.80
$442.42
$498.16
$696.18
$1,057.92 		$538.90
$591.52
$647.26
$845.28 		$688.00
$740.62
$796.36
$994.38 		$837.10
$889.72
$945.46
$1,143.48 		$149.10
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 4350 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$4,350 $8,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277.23
$314.66
$354.30
$495.13
$752.40 		$489.31
$526.74
$566.38
$707.21 		$701.39
$738.82
$778.46
$919.29 		$913.47
$950.90
$990.54
$1,131.37 		$212.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.46
$629.32
$708.60
$990.26
$1,504.80 		$766.54
$841.40
$920.68
$1,202.34 		$978.62
$1,053.48
$1,132.76
$1,414.42 		$1,190.70
$1,265.56
$1,344.84
$1,626.50 		$212.08
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Bronze

(EPO) Anthem Bronze Pathway X 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$251.66
$285.63
$321.62
$449.46
$683.01 		$444.18
$478.15
$514.14
$641.98 		$636.70
$670.67
$706.66
$834.50 		$829.22
$863.19
$899.18
$1,027.02 		$192.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$503.32
$571.26
$643.24
$898.92
$1,366.02 		$695.84
$763.78
$835.76
$1,091.44 		$888.36
$956.30
$1,028.28
$1,283.96 		$1,080.88
$1,148.82
$1,220.80
$1,476.48 		$192.52
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$275.83
$313.07
$352.51
$492.63
$748.60 		$486.84
$524.08
$563.52
$703.64 		$697.85
$735.09
$774.53
$914.65 		$908.86
$946.10
$985.54
$1,125.66 		$211.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.66
$626.14
$705.02
$985.26
$1,497.20 		$762.67
$837.15
$916.03
$1,196.27 		$973.68
$1,048.16
$1,127.04
$1,407.28 		$1,184.69
$1,259.17
$1,338.05
$1,618.29 		$211.01
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

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 		$314.81
$357.31
$402.33
$562.25
$854.39 		$555.64
$598.14
$643.16
$803.08 		$796.47
$838.97
$883.99
$1,043.91 		$1,037.30
$1,079.80
$1,124.82
$1,284.74 		$240.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.62
$714.62
$804.66
$1,124.50
$1,708.78 		$870.45
$955.45
$1,045.49
$1,365.33 		$1,111.28
$1,196.28
$1,286.32
$1,606.16 		$1,352.11
$1,437.11
$1,527.15
$1,846.99 		$240.83
Toc - Plan #15 Anthem Blue Cross and Blue Shield
Gold

(EPO) Anthem Gold Pathway X 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$483.47
$548.74
$617.87
$863.48
$1,312.14 		$853.32
$918.59
$987.72
$1,233.33 		$1,223.17
$1,288.44
$1,357.57
$1,603.18 		$1,593.02
$1,658.29
$1,727.42
$1,973.03 		$369.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966.94
$1,097.48
$1,235.74
$1,726.96
$2,624.28 		$1,336.79
$1,467.33
$1,605.59
$2,096.81 		$1,706.64
$1,837.18
$1,975.44
$2,466.66 		$2,076.49
$2,207.03
$2,345.29
$2,836.51 		$369.85

ADVERTISEMENT

WellFirst Health

Local: 1-866-514-4194 | Toll Free: 1-866-514-4194 | TTY: 1-866-514-4194
Toc - Plan #16 WellFirst Health
Gold

(EPO) WellFirst Gold Copay Plus 1500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 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 		$434.70
$493.39
$555.55
$776.38
$1,179.78 		$767.25
$825.94
$888.10
$1,108.93 		$1,099.80
$1,158.49
$1,220.65
$1,441.48 		$1,432.35
$1,491.04
$1,553.20
$1,774.03 		$332.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.40
$986.78
$1,111.10
$1,552.76
$2,359.56 		$1,201.95
$1,319.33
$1,443.65
$1,885.31 		$1,534.50
$1,651.88
$1,776.20
$2,217.86 		$1,867.05
$1,984.43
$2,108.75
$2,550.41 		$332.55
Toc - Plan #17 WellFirst Health
Silver

(EPO) WellFirst Silver Copay Plus 4800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$404.72
$459.36
$517.24
$722.84
$1,098.42 		$714.33
$768.97
$826.85
$1,032.45 		$1,023.94
$1,078.58
$1,136.46
$1,342.06 		$1,333.55
$1,388.19
$1,446.07
$1,651.67 		$309.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.44
$918.72
$1,034.48
$1,445.68
$2,196.84 		$1,119.05
$1,228.33
$1,344.09
$1,755.29 		$1,428.66
$1,537.94
$1,653.70
$2,064.90 		$1,738.27
$1,847.55
$1,963.31
$2,374.51 		$309.61
Toc - Plan #18 WellFirst Health
Expanded Bronze

(EPO) WellFirst Bronze Copay Plus 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269.77
$306.19
$344.76
$481.80
$732.15 		$476.14
$512.56
$551.13
$688.17 		$682.51
$718.93
$757.50
$894.54 		$888.88
$925.30
$963.87
$1,100.91 		$206.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.54
$612.38
$689.52
$963.60
$1,464.30 		$745.91
$818.75
$895.89
$1,169.97 		$952.28
$1,025.12
$1,102.26
$1,376.34 		$1,158.65
$1,231.49
$1,308.63
$1,582.71 		$206.37
Toc - Plan #19 WellFirst Health
Gold

(EPO) WellFirst Gold Value Copay 4000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$4,000 $8,000 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 		$413.18
$468.96
$528.04
$737.94
$1,121.36 		$729.26
$785.04
$844.12
$1,054.02 		$1,045.34
$1,101.12
$1,160.20
$1,370.10 		$1,361.42
$1,417.20
$1,476.28
$1,686.18 		$316.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.36
$937.92
$1,056.08
$1,475.88
$2,242.72 		$1,142.44
$1,254.00
$1,372.16
$1,791.96 		$1,458.52
$1,570.08
$1,688.24
$2,108.04 		$1,774.60
$1,886.16
$2,004.32
$2,424.12 		$316.08
Toc - Plan #20 WellFirst Health
Silver

(EPO) WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.57
$458.05
$515.76
$720.78
$1,095.29 		$712.30
$766.78
$824.49
$1,029.51 		$1,021.03
$1,075.51
$1,133.22
$1,338.24 		$1,329.76
$1,384.24
$1,441.95
$1,646.97 		$308.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.14
$916.10
$1,031.52
$1,441.56
$2,190.58 		$1,115.87
$1,224.83
$1,340.25
$1,750.29 		$1,424.60
$1,533.56
$1,648.98
$2,059.02 		$1,733.33
$1,842.29
$1,957.71
$2,367.75 		$308.73
Toc - Plan #21 WellFirst Health
Bronze

(EPO) WellFirst Bronze Value Copay 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$264.11
$299.76
$337.53
$471.69
$716.78 		$466.15
$501.80
$539.57
$673.73 		$668.19
$703.84
$741.61
$875.77 		$870.23
$905.88
$943.65
$1,077.81 		$202.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528.22
$599.52
$675.06
$943.38
$1,433.56 		$730.26
$801.56
$877.10
$1,145.42 		$932.30
$1,003.60
$1,079.14
$1,347.46 		$1,134.34
$1,205.64
$1,281.18
$1,549.50 		$202.04
Toc - Plan #22 WellFirst Health
Silver

(EPO) WellFirst Silver HSA-E HDHP 3550X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 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 		$390.95
$443.72
$499.63
$698.23
$1,061.03 		$690.02
$742.79
$798.70
$997.30 		$989.09
$1,041.86
$1,097.77
$1,296.37 		$1,288.16
$1,340.93
$1,396.84
$1,595.44 		$299.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.90
$887.44
$999.26
$1,396.46
$2,122.06 		$1,080.97
$1,186.51
$1,298.33
$1,695.53 		$1,380.04
$1,485.58
$1,597.40
$1,994.60 		$1,679.11
$1,784.65
$1,896.47
$2,293.67 		$299.07
Toc - Plan #23 WellFirst Health
Expanded Bronze

(EPO) WellFirst Bronze HSA-E HDHP 7000X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$293.26
$332.86
$374.79
$523.77
$795.92 		$517.61
$557.21
$599.14
$748.12 		$741.96
$781.56
$823.49
$972.47 		$966.31
$1,005.91
$1,047.84
$1,196.82 		$224.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.52
$665.72
$749.58
$1,047.54
$1,591.84 		$810.87
$890.07
$973.93
$1,271.89 		$1,035.22
$1,114.42
$1,198.28
$1,496.24 		$1,259.57
$1,338.77
$1,422.63
$1,720.59 		$224.35
Toc - Plan #24 WellFirst Health
Catastrophic

(EPO) WellFirst Catastrophic Safety Net (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$214.58
$243.54
$274.23
$383.23
$582.36 		$378.73
$407.69
$438.38
$547.38 		$542.88
$571.84
$602.53
$711.53 		$707.03
$735.99
$766.68
$875.68 		$164.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$429.16
$487.08
$548.46
$766.46
$1,164.72 		$593.31
$651.23
$712.61
$930.61 		$757.46
$815.38
$876.76
$1,094.76 		$921.61
$979.53
$1,040.91
$1,258.91 		$164.15
Toc - Plan #25 WellFirst Health
Gold

(EPO) WellFirst Gold HSA HDHP 2000X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$384.99
$436.96
$492.01
$687.59
$1,044.86 		$679.51
$731.48
$786.53
$982.11 		$974.03
$1,026.00
$1,081.05
$1,276.63 		$1,268.55
$1,320.52
$1,375.57
$1,571.15 		$294.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.98
$873.92
$984.02
$1,375.18
$2,089.72 		$1,064.50
$1,168.44
$1,278.54
$1,669.70 		$1,359.02
$1,462.96
$1,573.06
$1,964.22 		$1,653.54
$1,757.48
$1,867.58
$2,258.74 		$294.52
Toc - Plan #26 WellFirst Health
Expanded Bronze

(EPO) WellFirst Bronze Copay PCP 8000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$262.77
$298.24
$335.81
$469.30
$713.15 		$463.79
$499.26
$536.83
$670.32 		$664.81
$700.28
$737.85
$871.34 		$865.83
$901.30
$938.87
$1,072.36 		$201.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$525.54
$596.48
$671.62
$938.60
$1,426.30 		$726.56
$797.50
$872.64
$1,139.62 		$927.58
$998.52
$1,073.66
$1,340.64 		$1,128.60
$1,199.54
$1,274.68
$1,541.66 		$201.02
Toc - Plan #27 WellFirst Health
Silver

(EPO) WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$377.54
$428.51
$482.49
$674.28
$1,024.64 		$666.36
$717.33
$771.31
$963.10 		$955.18
$1,006.15
$1,060.13
$1,251.92 		$1,244.00
$1,294.97
$1,348.95
$1,540.74 		$288.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.08
$857.02
$964.98
$1,348.56
$2,049.28 		$1,043.90
$1,145.84
$1,253.80
$1,637.38 		$1,332.72
$1,434.66
$1,542.62
$1,926.20 		$1,621.54
$1,723.48
$1,831.44
$2,215.02 		$288.82
Toc - Plan #28 WellFirst Health
Gold

(EPO) WellFirst Gold Copay PCP 2000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.64
$449.05
$505.63
$706.61
$1,073.76 		$698.30
$751.71
$808.29
$1,009.27 		$1,000.96
$1,054.37
$1,110.95
$1,311.93 		$1,303.62
$1,357.03
$1,413.61
$1,614.59 		$302.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.28
$898.10
$1,011.26
$1,413.22
$2,147.52 		$1,093.94
$1,200.76
$1,313.92
$1,715.88 		$1,396.60
$1,503.42
$1,616.58
$2,018.54 		$1,699.26
$1,806.08
$1,919.24
$2,321.20 		$302.66
Toc - Plan #29 WellFirst Health
Gold

(EPO) WellFirst Gold Standard 2000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$416.60
$472.85
$532.42
$744.05
$1,130.66 		$735.30
$791.55
$851.12
$1,062.75 		$1,054.00
$1,110.25
$1,169.82
$1,381.45 		$1,372.70
$1,428.95
$1,488.52
$1,700.15 		$318.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$833.20
$945.70
$1,064.84
$1,488.10
$2,261.32 		$1,151.90
$1,264.40
$1,383.54
$1,806.80 		$1,470.60
$1,583.10
$1,702.24
$2,125.50 		$1,789.30
$1,901.80
$2,020.94
$2,444.20 		$318.70
Toc - Plan #30 WellFirst Health
Silver

(EPO) WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$384.47
$436.37
$491.35
$686.66
$1,043.44 		$678.59
$730.49
$785.47
$980.78 		$972.71
$1,024.61
$1,079.59
$1,274.90 		$1,266.83
$1,318.73
$1,373.71
$1,569.02 		$294.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.94
$872.74
$982.70
$1,373.32
$2,086.88 		$1,063.06
$1,166.86
$1,276.82
$1,667.44 		$1,357.18
$1,460.98
$1,570.94
$1,961.56 		$1,651.30
$1,755.10
$1,865.06
$2,255.68 		$294.12
Toc - Plan #31 WellFirst Health
Expanded Bronze

(EPO) WellFirst Bronze Standard 7500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$268.87
$305.17
$343.62
$480.21
$729.72 		$474.56
$510.86
$549.31
$685.90 		$680.25
$716.55
$755.00
$891.59 		$885.94
$922.24
$960.69
$1,097.28 		$205.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$537.74
$610.34
$687.24
$960.42
$1,459.44 		$743.43
$816.03
$892.93
$1,166.11 		$949.12
$1,021.72
$1,098.62
$1,371.80 		$1,154.81
$1,227.41
$1,304.31
$1,577.49 		$205.69
Toc - Plan #32 WellFirst Health
Bronze

(EPO) WellFirst Bronze Standard 9100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

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 		$249.95
$283.70
$319.44
$446.42
$678.38 		$441.17
$474.92
$510.66
$637.64 		$632.39
$666.14
$701.88
$828.86 		$823.61
$857.36
$893.10
$1,020.08 		$191.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.90
$567.40
$638.88
$892.84
$1,356.76 		$691.12
$758.62
$830.10
$1,084.06 		$882.34
$949.84
$1,021.32
$1,275.28 		$1,073.56
$1,141.06
$1,212.54
$1,466.50 		$191.22

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915 | TTY: 1-877-336-3915
Toc - Plan #33 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 		$296.56
$336.60
$379.01
$529.66
$804.87 		$523.43
$563.47
$605.88
$756.53 		$750.30
$790.34
$832.75
$983.40 		$977.17
$1,017.21
$1,059.62
$1,210.27 		$226.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$593.12
$673.20
$758.02
$1,059.32
$1,609.74 		$819.99
$900.07
$984.89
$1,286.19 		$1,046.86
$1,126.94
$1,211.76
$1,513.06 		$1,273.73
$1,353.81
$1,438.63
$1,739.93 		$226.87
Toc - Plan #34 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 		$296.94
$337.02
$379.49
$530.33
$805.89 		$524.10
$564.18
$606.65
$757.49 		$751.26
$791.34
$833.81
$984.65 		$978.42
$1,018.50
$1,060.97
$1,211.81 		$227.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$593.88
$674.04
$758.98
$1,060.66
$1,611.78 		$821.04
$901.20
$986.14
$1,287.82 		$1,048.20
$1,128.36
$1,213.30
$1,514.98 		$1,275.36
$1,355.52
$1,440.46
$1,742.14 		$227.16
Toc - Plan #35 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 		$457.65
$519.44
$584.88
$817.37
$1,242.07 		$807.75
$869.54
$934.98
$1,167.47 		$1,157.85
$1,219.64
$1,285.08
$1,517.57 		$1,507.95
$1,569.74
$1,635.18
$1,867.67 		$350.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.30
$1,038.88
$1,169.76
$1,634.74
$2,484.14 		$1,265.40
$1,388.98
$1,519.86
$1,984.84 		$1,615.50
$1,739.08
$1,869.96
$2,334.94 		$1,965.60
$2,089.18
$2,220.06
$2,685.04 		$350.10
Toc - Plan #36 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 		$368.78
$418.56
$471.30
$658.64
$1,000.86 		$650.89
$700.67
$753.41
$940.75 		$933.00
$982.78
$1,035.52
$1,222.86 		$1,215.11
$1,264.89
$1,317.63
$1,504.97 		$282.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.56
$837.12
$942.60
$1,317.28
$2,001.72 		$1,019.67
$1,119.23
$1,224.71
$1,599.39 		$1,301.78
$1,401.34
$1,506.82
$1,881.50 		$1,583.89
$1,683.45
$1,788.93
$2,163.61 		$282.11
Toc - Plan #37 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 		$370.90
$420.97
$474.01
$662.43
$1,006.63 		$654.64
$704.71
$757.75
$946.17 		$938.38
$988.45
$1,041.49
$1,229.91 		$1,222.12
$1,272.19
$1,325.23
$1,513.65 		$283.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.80
$841.94
$948.02
$1,324.86
$2,013.26 		$1,025.54
$1,125.68
$1,231.76
$1,608.60 		$1,309.28
$1,409.42
$1,515.50
$1,892.34 		$1,593.02
$1,693.16
$1,799.24
$2,176.08 		$283.74
Toc - Plan #38 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 		$287.17
$325.94
$367.00
$512.89
$779.38 		$506.86
$545.63
$586.69
$732.58 		$726.55
$765.32
$806.38
$952.27 		$946.24
$985.01
$1,026.07
$1,171.96 		$219.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.34
$651.88
$734.00
$1,025.78
$1,558.76 		$794.03
$871.57
$953.69
$1,245.47 		$1,013.72
$1,091.26
$1,173.38
$1,465.16 		$1,233.41
$1,310.95
$1,393.07
$1,684.85 		$219.69
Toc - Plan #39 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 		$417.61
$473.99
$533.71
$745.85
$1,133.40 		$737.08
$793.46
$853.18
$1,065.32 		$1,056.55
$1,112.93
$1,172.65
$1,384.79 		$1,376.02
$1,432.40
$1,492.12
$1,704.26 		$319.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.22
$947.98
$1,067.42
$1,491.70
$2,266.80 		$1,154.69
$1,267.45
$1,386.89
$1,811.17 		$1,474.16
$1,586.92
$1,706.36
$2,130.64 		$1,793.63
$1,906.39
$2,025.83
$2,450.11 		$319.47
Toc - Plan #40 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 		$351.01
$398.39
$448.59
$626.90
$952.63 		$619.53
$666.91
$717.11
$895.42 		$888.05
$935.43
$985.63
$1,163.94 		$1,156.57
$1,203.95
$1,254.15
$1,432.46 		$268.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.02
$796.78
$897.18
$1,253.80
$1,905.26 		$970.54
$1,065.30
$1,165.70
$1,522.32 		$1,239.06
$1,333.82
$1,434.22
$1,790.84 		$1,507.58
$1,602.34
$1,702.74
$2,059.36 		$268.52
Toc - Plan #41 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 		$344.14
$390.60
$439.82
$614.64
$934.01 		$607.41
$653.87
$703.09
$877.91 		$870.68
$917.14
$966.36
$1,141.18 		$1,133.95
$1,180.41
$1,229.63
$1,404.45 		$263.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.28
$781.20
$879.64
$1,229.28
$1,868.02 		$951.55
$1,044.47
$1,142.91
$1,492.55 		$1,214.82
$1,307.74
$1,406.18
$1,755.82 		$1,478.09
$1,571.01
$1,669.45
$2,019.09 		$263.27

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777
Toc - Plan #42 Medica
Catastrophic

(EPO) Balance 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 		$205.33
$233.04
$262.40
$366.71
$557.25 		$362.40
$390.11
$419.47
$523.78 		$519.47
$547.18
$576.54
$680.85 		$676.54
$704.25
$733.61
$837.92 		$157.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$410.66
$466.08
$524.80
$733.42
$1,114.50 		$567.73
$623.15
$681.87
$890.49 		$724.80
$780.22
$838.94
$1,047.56 		$881.87
$937.29
$996.01
$1,204.63 		$157.07
Toc - Plan #43 Medica
Silver

(EPO) Balance by Medica Silver Share ($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
$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 		$405.99
$460.78
$518.84
$725.07
$1,101.82 		$716.56
$771.35
$829.41
$1,035.64 		$1,027.13
$1,081.92
$1,139.98
$1,346.21 		$1,337.70
$1,392.49
$1,450.55
$1,656.78 		$310.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.98
$921.56
$1,037.68
$1,450.14
$2,203.64 		$1,122.55
$1,232.13
$1,348.25
$1,760.71 		$1,433.12
$1,542.70
$1,658.82
$2,071.28 		$1,743.69
$1,853.27
$1,969.39
$2,381.85 		$310.57
Toc - Plan #44 Medica
Expanded Bronze

(EPO) Balance 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 		$296.38
$336.38
$378.76
$529.32
$804.35 		$523.10
$563.10
$605.48
$756.04 		$749.82
$789.82
$832.20
$982.76 		$976.54
$1,016.54
$1,058.92
$1,209.48 		$226.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.76
$672.76
$757.52
$1,058.64
$1,608.70 		$819.48
$899.48
$984.24
$1,285.36 		$1,046.20
$1,126.20
$1,210.96
$1,512.08 		$1,272.92
$1,352.92
$1,437.68
$1,738.80 		$226.72
Toc - Plan #45 Medica
Expanded Bronze

(EPO) Balance 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 		$287.95
$326.81
$367.99
$514.26
$781.47 		$508.23
$547.09
$588.27
$734.54 		$728.51
$767.37
$808.55
$954.82 		$948.79
$987.65
$1,028.83
$1,175.10 		$220.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.90
$653.62
$735.98
$1,028.52
$1,562.94 		$796.18
$873.90
$956.26
$1,248.80 		$1,016.46
$1,094.18
$1,176.54
$1,469.08 		$1,236.74
$1,314.46
$1,396.82
$1,689.36 		$220.28
Toc - Plan #46 Medica
Gold

(EPO) Balance 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 		$429.65
$487.64
$549.08
$767.33
$1,166.04 		$758.32
$816.31
$877.75
$1,096.00 		$1,086.99
$1,144.98
$1,206.42
$1,424.67 		$1,415.66
$1,473.65
$1,535.09
$1,753.34 		$328.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.30
$975.28
$1,098.16
$1,534.66
$2,332.08 		$1,187.97
$1,303.95
$1,426.83
$1,863.33 		$1,516.64
$1,632.62
$1,755.50
$2,192.00 		$1,845.31
$1,961.29
$2,084.17
$2,520.67 		$328.67
Toc - Plan #47 Medica
Expanded Bronze

(EPO) Balance 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 		$288.98
$327.98
$369.30
$516.10
$784.27 		$510.04
$549.04
$590.36
$737.16 		$731.10
$770.10
$811.42
$958.22 		$952.16
$991.16
$1,032.48
$1,179.28 		$221.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.96
$655.96
$738.60
$1,032.20
$1,568.54 		$799.02
$877.02
$959.66
$1,253.26 		$1,020.08
$1,098.08
$1,180.72
$1,474.32 		$1,241.14
$1,319.14
$1,401.78
$1,695.38 		$221.06
Toc - Plan #48 Medica
Gold

(EPO) Balance 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 		$408.64
$463.79
$522.22
$729.81
$1,109.01 		$721.24
$776.39
$834.82
$1,042.41 		$1,033.84
$1,088.99
$1,147.42
$1,355.01 		$1,346.44
$1,401.59
$1,460.02
$1,667.61 		$312.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.28
$927.58
$1,044.44
$1,459.62
$2,218.02 		$1,129.88
$1,240.18
$1,357.04
$1,772.22 		$1,442.48
$1,552.78
$1,669.64
$2,084.82 		$1,755.08
$1,865.38
$1,982.24
$2,397.42 		$312.60
Toc - Plan #49 Medica
Silver

(EPO) Balance 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 		$388.77
$441.25
$496.84
$694.33
$1,055.10 		$686.17
$738.65
$794.24
$991.73 		$983.57
$1,036.05
$1,091.64
$1,289.13 		$1,280.97
$1,333.45
$1,389.04
$1,586.53 		$297.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.54
$882.50
$993.68
$1,388.66
$2,110.20 		$1,074.94
$1,179.90
$1,291.08
$1,686.06 		$1,372.34
$1,477.30
$1,588.48
$1,983.46 		$1,669.74
$1,774.70
$1,885.88
$2,280.86 		$297.40
Toc - Plan #50 Medica
Bronze

(EPO) Balance 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 		$276.83
$314.19
$353.78
$494.41
$751.30 		$488.60
$525.96
$565.55
$706.18 		$700.37
$737.73
$777.32
$917.95 		$912.14
$949.50
$989.09
$1,129.72 		$211.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.66
$628.38
$707.56
$988.82
$1,502.60 		$765.43
$840.15
$919.33
$1,200.59 		$977.20
$1,051.92
$1,131.10
$1,412.36 		$1,188.97
$1,263.69
$1,342.87
$1,624.13 		$211.77

ADVERTISEMENT

Oscar Insurance Company

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

Toc - Plan #51 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 		$300.54
$341.10
$384.07
$536.74
$815.62 		$530.44
$571.00
$613.97
$766.64 		$760.34
$800.90
$843.87
$996.54 		$990.24
$1,030.80
$1,073.77
$1,226.44 		$229.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.08
$682.20
$768.14
$1,073.48
$1,631.24 		$830.98
$912.10
$998.04
$1,303.38 		$1,060.88
$1,142.00
$1,227.94
$1,533.28 		$1,290.78
$1,371.90
$1,457.84
$1,763.18 		$229.90
Toc - Plan #52 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 		$343.34
$389.68
$438.77
$613.19
$931.80 		$605.99
$652.33
$701.42
$875.84 		$868.64
$914.98
$964.07
$1,138.49 		$1,131.29
$1,177.63
$1,226.72
$1,401.14 		$262.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.68
$779.36
$877.54
$1,226.38
$1,863.60 		$949.33
$1,042.01
$1,140.19
$1,489.03 		$1,211.98
$1,304.66
$1,402.84
$1,751.68 		$1,474.63
$1,567.31
$1,665.49
$2,014.33 		$262.65
Toc - Plan #53 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 		$376.63
$427.47
$481.32
$672.65
$1,022.15 		$664.75
$715.59
$769.44
$960.77 		$952.87
$1,003.71
$1,057.56
$1,248.89 		$1,240.99
$1,291.83
$1,345.68
$1,537.01 		$288.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.26
$854.94
$962.64
$1,345.30
$2,044.30 		$1,041.38
$1,143.06
$1,250.76
$1,633.42 		$1,329.50
$1,431.18
$1,538.88
$1,921.54 		$1,617.62
$1,719.30
$1,827.00
$2,209.66 		$288.12
Toc - Plan #54 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 		$371.28
$421.40
$474.49
$663.10
$1,007.64 		$655.30
$705.42
$758.51
$947.12 		$939.32
$989.44
$1,042.53
$1,231.14 		$1,223.34
$1,273.46
$1,326.55
$1,515.16 		$284.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.56
$842.80
$948.98
$1,326.20
$2,015.28 		$1,026.58
$1,126.82
$1,233.00
$1,610.22 		$1,310.60
$1,410.84
$1,517.02
$1,894.24 		$1,594.62
$1,694.86
$1,801.04
$2,178.26 		$284.02
Toc - Plan #55 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 		$249.87
$283.59
$319.32
$446.25
$678.11 		$441.01
$474.73
$510.46
$637.39 		$632.15
$665.87
$701.60
$828.53 		$823.29
$857.01
$892.74
$1,019.67 		$191.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.74
$567.18
$638.64
$892.50
$1,356.22 		$690.88
$758.32
$829.78
$1,083.64 		$882.02
$949.46
$1,020.92
$1,274.78 		$1,073.16
$1,140.60
$1,212.06
$1,465.92 		$191.14
Toc - Plan #56 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 		$320.35
$363.59
$409.40
$572.13
$869.41 		$565.41
$608.65
$654.46
$817.19 		$810.47
$853.71
$899.52
$1,062.25 		$1,055.53
$1,098.77
$1,144.58
$1,307.31 		$245.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.70
$727.18
$818.80
$1,144.26
$1,738.82 		$885.76
$972.24
$1,063.86
$1,389.32 		$1,130.82
$1,217.30
$1,308.92
$1,634.38 		$1,375.88
$1,462.36
$1,553.98
$1,879.44 		$245.06
Toc - Plan #57 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 		$320.39
$363.64
$409.45
$572.21
$869.52 		$565.48
$608.73
$654.54
$817.30 		$810.57
$853.82
$899.63
$1,062.39 		$1,055.66
$1,098.91
$1,144.72
$1,307.48 		$245.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.78
$727.28
$818.90
$1,144.42
$1,739.04 		$885.87
$972.37
$1,063.99
$1,389.51 		$1,130.96
$1,217.46
$1,309.08
$1,634.60 		$1,376.05
$1,462.55
$1,554.17
$1,879.69 		$245.09
Toc - Plan #58 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 		$326.28
$370.31
$416.97
$582.71
$885.48 		$575.87
$619.90
$666.56
$832.30 		$825.46
$869.49
$916.15
$1,081.89 		$1,075.05
$1,119.08
$1,165.74
$1,331.48 		$249.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.56
$740.62
$833.94
$1,165.42
$1,770.96 		$902.15
$990.21
$1,083.53
$1,415.01 		$1,151.74
$1,239.80
$1,333.12
$1,664.60 		$1,401.33
$1,489.39
$1,582.71
$1,914.19 		$249.59
Toc - Plan #59 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 		$361.56
$410.36
$462.06
$645.73
$981.25 		$638.15
$686.95
$738.65
$922.32 		$914.74
$963.54
$1,015.24
$1,198.91 		$1,191.33
$1,240.13
$1,291.83
$1,475.50 		$276.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.12
$820.72
$924.12
$1,291.46
$1,962.50 		$999.71
$1,097.31
$1,200.71
$1,568.05 		$1,276.30
$1,373.90
$1,477.30
$1,844.64 		$1,552.89
$1,650.49
$1,753.89
$2,121.23 		$276.59
Toc - Plan #60 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 		$380.67
$432.05
$486.49
$679.87
$1,033.12 		$671.88
$723.26
$777.70
$971.08 		$963.09
$1,014.47
$1,068.91
$1,262.29 		$1,254.30
$1,305.68
$1,360.12
$1,553.50 		$291.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.34
$864.10
$972.98
$1,359.74
$2,066.24 		$1,052.55
$1,155.31
$1,264.19
$1,650.95 		$1,343.76
$1,446.52
$1,555.40
$1,942.16 		$1,634.97
$1,737.73
$1,846.61
$2,233.37 		$291.21
Toc - Plan #61 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 		$372.80
$423.12
$476.43
$665.80
$1,011.75 		$657.98
$708.30
$761.61
$950.98 		$943.16
$993.48
$1,046.79
$1,236.16 		$1,228.34
$1,278.66
$1,331.97
$1,521.34 		$285.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.60
$846.24
$952.86
$1,331.60
$2,023.50 		$1,030.78
$1,131.42
$1,238.04
$1,616.78 		$1,315.96
$1,416.60
$1,523.22
$1,901.96 		$1,601.14
$1,701.78
$1,808.40
$2,187.14 		$285.18
Toc - Plan #62 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 		$318.47
$361.45
$406.99
$568.77
$864.29 		$562.09
$605.07
$650.61
$812.39 		$805.71
$848.69
$894.23
$1,056.01 		$1,049.33
$1,092.31
$1,137.85
$1,299.63 		$243.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.94
$722.90
$813.98
$1,137.54
$1,728.58 		$880.56
$966.52
$1,057.60
$1,381.16 		$1,124.18
$1,210.14
$1,301.22
$1,624.78 		$1,367.80
$1,453.76
$1,544.84
$1,868.40 		$243.62
Toc - Plan #63 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 		$285.84
$324.42
$365.29
$510.49
$775.74 		$504.50
$543.08
$583.95
$729.15 		$723.16
$761.74
$802.61
$947.81 		$941.82
$980.40
$1,021.27
$1,166.47 		$218.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.68
$648.84
$730.58
$1,020.98
$1,551.48 		$790.34
$867.50
$949.24
$1,239.64 		$1,009.00
$1,086.16
$1,167.90
$1,458.30 		$1,227.66
$1,304.82
$1,386.56
$1,676.96 		$218.66
Toc - Plan #64 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 		$365.04
$414.31
$466.51
$651.95
$990.69 		$644.29
$693.56
$745.76
$931.20 		$923.54
$972.81
$1,025.01
$1,210.45 		$1,202.79
$1,252.06
$1,304.26
$1,489.70 		$279.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.08
$828.62
$933.02
$1,303.90
$1,981.38 		$1,009.33
$1,107.87
$1,212.27
$1,583.15 		$1,288.58
$1,387.12
$1,491.52
$1,862.40 		$1,567.83
$1,666.37
$1,770.77
$2,141.65 		$279.25
Toc - Plan #65 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 		$427.29
$484.97
$546.07
$763.13
$1,159.65 		$754.16
$811.84
$872.94
$1,090.00 		$1,081.03
$1,138.71
$1,199.81
$1,416.87 		$1,407.90
$1,465.58
$1,526.68
$1,743.74 		$326.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.58
$969.94
$1,092.14
$1,526.26
$2,319.30 		$1,181.45
$1,296.81
$1,419.01
$1,853.13 		$1,508.32
$1,623.68
$1,745.88
$2,180.00 		$1,835.19
$1,950.55
$2,072.75
$2,506.87 		$326.87

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #66 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 		$367.89
$417.56
$470.17
$657.05
$998.46 		$649.33
$699.00
$751.61
$938.49 		$930.77
$980.44
$1,033.05
$1,219.93 		$1,212.21
$1,261.88
$1,314.49
$1,501.37 		$281.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.78
$835.12
$940.34
$1,314.10
$1,996.92 		$1,017.22
$1,116.56
$1,221.78
$1,595.54 		$1,298.66
$1,398.00
$1,503.22
$1,876.98 		$1,580.10
$1,679.44
$1,784.66
$2,158.42 		$281.44
Toc - Plan #67 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 		$408.20
$463.30
$521.68
$729.04
$1,107.85 		$720.47
$775.57
$833.95
$1,041.31 		$1,032.74
$1,087.84
$1,146.22
$1,353.58 		$1,345.01
$1,400.11
$1,458.49
$1,665.85 		$312.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.40
$926.60
$1,043.36
$1,458.08
$2,215.70 		$1,128.67
$1,238.87
$1,355.63
$1,770.35 		$1,440.94
$1,551.14
$1,667.90
$2,082.62 		$1,753.21
$1,863.41
$1,980.17
$2,394.89 		$312.27
Toc - Plan #68 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 		$577.16
$655.07
$737.61
$1,030.80
$1,566.40 		$1,018.68
$1,096.59
$1,179.13
$1,472.32 		$1,460.20
$1,538.11
$1,620.65
$1,913.84 		$1,901.72
$1,979.63
$2,062.17
$2,355.36 		$441.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,154.32
$1,310.14
$1,475.22
$2,061.60
$3,132.80 		$1,595.84
$1,751.66
$1,916.74
$2,503.12 		$2,037.36
$2,193.18
$2,358.26
$2,944.64 		$2,478.88
$2,634.70
$2,799.78
$3,386.16 		$441.52
Toc - Plan #69 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 		$352.81
$400.44
$450.89
$630.11
$957.52 		$622.71
$670.34
$720.79
$900.01 		$892.61
$940.24
$990.69
$1,169.91 		$1,162.51
$1,210.14
$1,260.59
$1,439.81 		$269.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.62
$800.88
$901.78
$1,260.22
$1,915.04 		$975.52
$1,070.78
$1,171.68
$1,530.12 		$1,245.42
$1,340.68
$1,441.58
$1,800.02 		$1,515.32
$1,610.58
$1,711.48
$2,069.92 		$269.90
Toc - Plan #70 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 		$405.75
$460.52
$518.55
$724.67
$1,101.20 		$716.15
$770.92
$828.95
$1,035.07 		$1,026.55
$1,081.32
$1,139.35
$1,345.47 		$1,336.95
$1,391.72
$1,449.75
$1,655.87 		$310.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.50
$921.04
$1,037.10
$1,449.34
$2,202.40 		$1,121.90
$1,231.44
$1,347.50
$1,759.74 		$1,432.30
$1,541.84
$1,657.90
$2,070.14 		$1,742.70
$1,852.24
$1,968.30
$2,380.54 		$310.40
Toc - Plan #71 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 		$575.05
$652.68
$734.91
$1,027.04
$1,560.69 		$1,014.96
$1,092.59
$1,174.82
$1,466.95 		$1,454.87
$1,532.50
$1,614.73
$1,906.86 		$1,894.78
$1,972.41
$2,054.64
$2,346.77 		$439.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,150.10
$1,305.36
$1,469.82
$2,054.08
$3,121.38 		$1,590.01
$1,745.27
$1,909.73
$2,493.99 		$2,029.92
$2,185.18
$2,349.64
$2,933.90 		$2,469.83
$2,625.09
$2,789.55
$3,373.81 		$439.91

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-632-4195 | Toll Free: 1-877-632-4195 | TTY: 1-877-940-4172
Toc - Plan #72 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 		$375.67
$426.39
$480.11
$670.95
$1,019.57 		$663.06
$713.78
$767.50
$958.34 		$950.45
$1,001.17
$1,054.89
$1,245.73 		$1,237.84
$1,288.56
$1,342.28
$1,533.12 		$287.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.34
$852.78
$960.22
$1,341.90
$2,039.14 		$1,038.73
$1,140.17
$1,247.61
$1,629.29 		$1,326.12
$1,427.56
$1,535.00
$1,916.68 		$1,613.51
$1,714.95
$1,822.39
$2,204.07 		$287.39
Toc - Plan #73 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 		$395.45
$448.84
$505.39
$706.27
$1,073.25 		$697.97
$751.36
$807.91
$1,008.79 		$1,000.49
$1,053.88
$1,110.43
$1,311.31 		$1,303.01
$1,356.40
$1,412.95
$1,613.83 		$302.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.90
$897.68
$1,010.78
$1,412.54
$2,146.50 		$1,093.42
$1,200.20
$1,313.30
$1,715.06 		$1,395.94
$1,502.72
$1,615.82
$2,017.58 		$1,698.46
$1,805.24
$1,918.34
$2,320.10 		$302.52
Toc - Plan #74 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 		$348.85
$395.94
$445.83
$623.04
$946.77 		$615.72
$662.81
$712.70
$889.91 		$882.59
$929.68
$979.57
$1,156.78 		$1,149.46
$1,196.55
$1,246.44
$1,423.65 		$266.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.70
$791.88
$891.66
$1,246.08
$1,893.54 		$964.57
$1,058.75
$1,158.53
$1,512.95 		$1,231.44
$1,325.62
$1,425.40
$1,779.82 		$1,498.31
$1,592.49
$1,692.27
$2,046.69 		$266.87
Toc - Plan #75 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 		$344.95
$391.52
$440.85
$616.08
$936.20 		$608.84
$655.41
$704.74
$879.97 		$872.73
$919.30
$968.63
$1,143.86 		$1,136.62
$1,183.19
$1,232.52
$1,407.75 		$263.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.90
$783.04
$881.70
$1,232.16
$1,872.40 		$953.79
$1,046.93
$1,145.59
$1,496.05 		$1,217.68
$1,310.82
$1,409.48
$1,759.94 		$1,481.57
$1,574.71
$1,673.37
$2,023.83 		$263.89
Toc - Plan #76 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 		$359.57
$408.12
$459.54
$642.20
$975.88 		$634.64
$683.19
$734.61
$917.27 		$909.71
$958.26
$1,009.68
$1,192.34 		$1,184.78
$1,233.33
$1,284.75
$1,467.41 		$275.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.14
$816.24
$919.08
$1,284.40
$1,951.76 		$994.21
$1,091.31
$1,194.15
$1,559.47 		$1,269.28
$1,366.38
$1,469.22
$1,834.54 		$1,544.35
$1,641.45
$1,744.29
$2,109.61 		$275.07
Toc - Plan #77 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 		$353.61
$401.34
$451.91
$631.54
$959.68 		$624.12
$671.85
$722.42
$902.05 		$894.63
$942.36
$992.93
$1,172.56 		$1,165.14
$1,212.87
$1,263.44
$1,443.07 		$270.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.22
$802.68
$903.82
$1,263.08
$1,919.36 		$977.73
$1,073.19
$1,174.33
$1,533.59 		$1,248.24
$1,343.70
$1,444.84
$1,804.10 		$1,518.75
$1,614.21
$1,715.35
$2,074.61 		$270.51
Toc - Plan #78 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 		$351.60
$399.07
$449.35
$627.96
$954.24 		$620.57
$668.04
$718.32
$896.93 		$889.54
$937.01
$987.29
$1,165.90 		$1,158.51
$1,205.98
$1,256.26
$1,434.87 		$268.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.20
$798.14
$898.70
$1,255.92
$1,908.48 		$972.17
$1,067.11
$1,167.67
$1,524.89 		$1,241.14
$1,336.08
$1,436.64
$1,793.86 		$1,510.11
$1,605.05
$1,705.61
$2,062.83 		$268.97
Toc - Plan #79 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 		$350.64
$397.98
$448.12
$626.25
$951.65 		$618.88
$666.22
$716.36
$894.49 		$887.12
$934.46
$984.60
$1,162.73 		$1,155.36
$1,202.70
$1,252.84
$1,430.97 		$268.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.28
$795.96
$896.24
$1,252.50
$1,903.30 		$969.52
$1,064.20
$1,164.48
$1,520.74 		$1,237.76
$1,332.44
$1,432.72
$1,788.98 		$1,506.00
$1,600.68
$1,700.96
$2,057.22 		$268.24
Toc - Plan #80 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 		$384.77
$436.71
$491.73
$687.19
$1,044.26 		$679.12
$731.06
$786.08
$981.54 		$973.47
$1,025.41
$1,080.43
$1,275.89 		$1,267.82
$1,319.76
$1,374.78
$1,570.24 		$294.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.54
$873.42
$983.46
$1,374.38
$2,088.52 		$1,063.89
$1,167.77
$1,277.81
$1,668.73 		$1,358.24
$1,462.12
$1,572.16
$1,963.08 		$1,652.59
$1,756.47
$1,866.51
$2,257.43 		$294.35
Toc - Plan #81 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 		$288.69
$327.67
$368.95
$515.61
$783.51 		$509.54
$548.52
$589.80
$736.46 		$730.39
$769.37
$810.65
$957.31 		$951.24
$990.22
$1,031.50
$1,178.16 		$220.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.38
$655.34
$737.90
$1,031.22
$1,567.02 		$798.23
$876.19
$958.75
$1,252.07 		$1,019.08
$1,097.04
$1,179.60
$1,472.92 		$1,239.93
$1,317.89
$1,400.45
$1,693.77 		$220.85
Toc - Plan #82 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 		$300.63
$341.22
$384.21
$536.93
$815.92 		$530.62
$571.21
$614.20
$766.92 		$760.61
$801.20
$844.19
$996.91 		$990.60
$1,031.19
$1,074.18
$1,226.90 		$229.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.26
$682.44
$768.42
$1,073.86
$1,631.84 		$831.25
$912.43
$998.41
$1,303.85 		$1,061.24
$1,142.42
$1,228.40
$1,533.84 		$1,291.23
$1,372.41
$1,458.39
$1,763.83 		$229.99
Toc - Plan #83 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 		$299.26
$339.66
$382.45
$534.47
$812.18 		$528.19
$568.59
$611.38
$763.40 		$757.12
$797.52
$840.31
$992.33 		$986.05
$1,026.45
$1,069.24
$1,221.26 		$228.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.52
$679.32
$764.90
$1,068.94
$1,624.36 		$827.45
$908.25
$993.83
$1,297.87 		$1,056.38
$1,137.18
$1,222.76
$1,526.80 		$1,285.31
$1,366.11
$1,451.69
$1,755.73 		$228.93
Toc - Plan #84 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 		$302.63
$343.48
$386.75
$540.49
$821.32 		$534.14
$574.99
$618.26
$772.00 		$765.65
$806.50
$849.77
$1,003.51 		$997.16
$1,038.01
$1,081.28
$1,235.02 		$231.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.26
$686.96
$773.50
$1,080.98
$1,642.64 		$836.77
$918.47
$1,005.01
$1,312.49 		$1,068.28
$1,149.98
$1,236.52
$1,544.00 		$1,299.79
$1,381.49
$1,468.03
$1,775.51 		$231.51
Toc - Plan #85 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 		$281.07
$319.01
$359.20
$501.98
$762.81 		$496.09
$534.03
$574.22
$717.00 		$711.11
$749.05
$789.24
$932.02 		$926.13
$964.07
$1,004.26
$1,147.04 		$215.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.14
$638.02
$718.40
$1,003.96
$1,525.62 		$777.16
$853.04
$933.42
$1,218.98 		$992.18
$1,068.06
$1,148.44
$1,434.00 		$1,207.20
$1,283.08
$1,363.46
$1,649.02 		$215.02

ADVERTISEMENT

Ambetter from Home State Health

Local: 1-855-650-3789 | Toll Free: 1-855-650-3789 | TTY: 1-855-650-3789
Toc - Plan #86 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 		$307.19
$348.65
$392.58
$548.63
$833.70 		$542.19
$583.65
$627.58
$783.63 		$777.19
$818.65
$862.58
$1,018.63 		$1,012.19
$1,053.65
$1,097.58
$1,253.63 		$235.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.38
$697.30
$785.16
$1,097.26
$1,667.40 		$849.38
$932.30
$1,020.16
$1,332.26 		$1,084.38
$1,167.30
$1,255.16
$1,567.26 		$1,319.38
$1,402.30
$1,490.16
$1,802.26 		$235.00
Toc - Plan #87 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 		$355.80
$403.82
$454.69
$635.43
$965.60 		$627.98
$676.00
$726.87
$907.61 		$900.16
$948.18
$999.05
$1,179.79 		$1,172.34
$1,220.36
$1,271.23
$1,451.97 		$272.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.60
$807.64
$909.38
$1,270.86
$1,931.20 		$983.78
$1,079.82
$1,181.56
$1,543.04 		$1,255.96
$1,352.00
$1,453.74
$1,815.22 		$1,528.14
$1,624.18
$1,725.92
$2,087.40 		$272.18
Toc - Plan #88 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 		$354.48
$402.32
$453.01
$633.08
$962.03 		$625.65
$673.49
$724.18
$904.25 		$896.82
$944.66
$995.35
$1,175.42 		$1,167.99
$1,215.83
$1,266.52
$1,446.59 		$271.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.96
$804.64
$906.02
$1,266.16
$1,924.06 		$980.13
$1,075.81
$1,177.19
$1,537.33 		$1,251.30
$1,346.98
$1,448.36
$1,808.50 		$1,522.47
$1,618.15
$1,719.53
$2,079.67 		$271.17
Toc - Plan #89 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 		$440.76
$500.25
$563.27
$787.17
$1,196.19 		$777.93
$837.42
$900.44
$1,124.34 		$1,115.10
$1,174.59
$1,237.61
$1,461.51 		$1,452.27
$1,511.76
$1,574.78
$1,798.68 		$337.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.52
$1,000.50
$1,126.54
$1,574.34
$2,392.38 		$1,218.69
$1,337.67
$1,463.71
$1,911.51 		$1,555.86
$1,674.84
$1,800.88
$2,248.68 		$1,893.03
$2,012.01
$2,138.05
$2,585.85 		$337.17
Toc - Plan #90 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 		$332.63
$377.53
$425.09
$594.07
$902.74 		$587.09
$631.99
$679.55
$848.53 		$841.55
$886.45
$934.01
$1,102.99 		$1,096.01
$1,140.91
$1,188.47
$1,357.45 		$254.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.26
$755.06
$850.18
$1,188.14
$1,805.48 		$919.72
$1,009.52
$1,104.64
$1,442.60 		$1,174.18
$1,263.98
$1,359.10
$1,697.06 		$1,428.64
$1,518.44
$1,613.56
$1,951.52 		$254.46
Toc - Plan #91 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 		$337.65
$383.22
$431.50
$603.03
$916.36 		$595.94
$641.51
$689.79
$861.32 		$854.23
$899.80
$948.08
$1,119.61 		$1,112.52
$1,158.09
$1,206.37
$1,377.90 		$258.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.30
$766.44
$863.00
$1,206.06
$1,832.72 		$933.59
$1,024.73
$1,121.29
$1,464.35 		$1,191.88
$1,283.02
$1,379.58
$1,722.64 		$1,450.17
$1,541.31
$1,637.87
$1,980.93 		$258.29
Toc - Plan #92 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 		$372.55
$422.84
$476.11
$665.36
$1,011.08 		$657.55
$707.84
$761.11
$950.36 		$942.55
$992.84
$1,046.11
$1,235.36 		$1,227.55
$1,277.84
$1,331.11
$1,520.36 		$285.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.10
$845.68
$952.22
$1,330.72
$2,022.16 		$1,030.10
$1,130.68
$1,237.22
$1,615.72 		$1,315.10
$1,415.68
$1,522.22
$1,900.72 		$1,600.10
$1,700.68
$1,807.22
$2,185.72 		$285.00
Toc - Plan #93 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 		$343.02
$389.32
$438.37
$612.62
$930.94 		$605.42
$651.72
$700.77
$875.02 		$867.82
$914.12
$963.17
$1,137.42 		$1,130.22
$1,176.52
$1,225.57
$1,399.82 		$262.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.04
$778.64
$876.74
$1,225.24
$1,861.88 		$948.44
$1,041.04
$1,139.14
$1,487.64 		$1,210.84
$1,303.44
$1,401.54
$1,750.04 		$1,473.24
$1,565.84
$1,663.94
$2,012.44 		$262.40
Toc - Plan #94 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 		$349.46
$396.63
$446.60
$624.12
$948.41 		$616.79
$663.96
$713.93
$891.45 		$884.12
$931.29
$981.26
$1,158.78 		$1,151.45
$1,198.62
$1,248.59
$1,426.11 		$267.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$698.92
$793.26
$893.20
$1,248.24
$1,896.82 		$966.25
$1,060.59
$1,160.53
$1,515.57 		$1,233.58
$1,327.92
$1,427.86
$1,782.90 		$1,500.91
$1,595.25
$1,695.19
$2,050.23 		$267.33
Toc - Plan #95 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 		$422.15
$479.13
$539.49
$753.94
$1,145.69 		$745.09
$802.07
$862.43
$1,076.88 		$1,068.03
$1,125.01
$1,185.37
$1,399.82 		$1,390.97
$1,447.95
$1,508.31
$1,722.76 		$322.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.30
$958.26
$1,078.98
$1,507.88
$2,291.38 		$1,167.24
$1,281.20
$1,401.92
$1,830.82 		$1,490.18
$1,604.14
$1,724.86
$2,153.76 		$1,813.12
$1,927.08
$2,047.80
$2,476.70 		$322.94
Toc - Plan #96 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 		$415.89
$472.02
$531.49
$742.76
$1,128.69 		$734.04
$790.17
$849.64
$1,060.91 		$1,052.19
$1,108.32
$1,167.79
$1,379.06 		$1,370.34
$1,426.47
$1,485.94
$1,697.21 		$318.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.78
$944.04
$1,062.98
$1,485.52
$2,257.38 		$1,149.93
$1,262.19
$1,381.13
$1,803.67 		$1,468.08
$1,580.34
$1,699.28
$2,121.82 		$1,786.23
$1,898.49
$2,017.43
$2,439.97 		$318.15
Toc - Plan #97 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 		$482.42
$547.53
$616.52
$861.58
$1,309.26 		$851.46
$916.57
$985.56
$1,230.62 		$1,220.50
$1,285.61
$1,354.60
$1,599.66 		$1,589.54
$1,654.65
$1,723.64
$1,968.70 		$369.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.84
$1,095.06
$1,233.04
$1,723.16
$2,618.52 		$1,333.88
$1,464.10
$1,602.08
$2,092.20 		$1,702.92
$1,833.14
$1,971.12
$2,461.24 		$2,071.96
$2,202.18
$2,340.16
$2,830.28 		$369.04
Toc - Plan #98 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 		$292.86
$332.38
$374.26
$523.02
$794.79 		$516.89
$556.41
$598.29
$747.05 		$740.92
$780.44
$822.32
$971.08 		$964.95
$1,004.47
$1,046.35
$1,195.11 		$224.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.72
$664.76
$748.52
$1,046.04
$1,589.58 		$809.75
$888.79
$972.55
$1,270.07 		$1,033.78
$1,112.82
$1,196.58
$1,494.10 		$1,257.81
$1,336.85
$1,420.61
$1,718.13 		$224.03
Toc - Plan #99 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 		$322.17
$365.66
$411.72
$575.38
$874.35 		$568.63
$612.12
$658.18
$821.84 		$815.09
$858.58
$904.64
$1,068.30 		$1,061.55
$1,105.04
$1,151.10
$1,314.76 		$246.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.34
$731.32
$823.44
$1,150.76
$1,748.70 		$890.80
$977.78
$1,069.90
$1,397.22 		$1,137.26
$1,224.24
$1,316.36
$1,643.68 		$1,383.72
$1,470.70
$1,562.82
$1,890.14 		$246.46
Toc - Plan #100 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 		$342.38
$388.59
$437.55
$611.48
$929.20 		$604.29
$650.50
$699.46
$873.39 		$866.20
$912.41
$961.37
$1,135.30 		$1,128.11
$1,174.32
$1,223.28
$1,397.21 		$261.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.76
$777.18
$875.10
$1,222.96
$1,858.40 		$946.67
$1,039.09
$1,137.01
$1,484.87 		$1,208.58
$1,301.00
$1,398.92
$1,746.78 		$1,470.49
$1,562.91
$1,660.83
$2,008.69 		$261.91
Toc - Plan #101 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 		$416.17
$472.34
$531.85
$743.27
$1,129.46 		$734.53
$790.70
$850.21
$1,061.63 		$1,052.89
$1,109.06
$1,168.57
$1,379.99 		$1,371.25
$1,427.42
$1,486.93
$1,698.35 		$318.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$832.34
$944.68
$1,063.70
$1,486.54
$2,258.92 		$1,150.70
$1,263.04
$1,382.06
$1,804.90 		$1,469.06
$1,581.40
$1,700.42
$2,123.26 		$1,787.42
$1,899.76
$2,018.78
$2,441.62 		$318.36
Toc - Plan #102 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 		$317.20
$360.01
$405.36
$566.49
$860.84 		$559.85
$602.66
$648.01
$809.14 		$802.50
$845.31
$890.66
$1,051.79 		$1,045.15
$1,087.96
$1,133.31
$1,294.44 		$242.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.40
$720.02
$810.72
$1,132.98
$1,721.68 		$877.05
$962.67
$1,053.37
$1,375.63 		$1,119.70
$1,205.32
$1,296.02
$1,618.28 		$1,362.35
$1,447.97
$1,538.67
$1,860.93 		$242.65
Toc - Plan #103 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 		$343.46
$389.82
$438.93
$613.41
$932.13 		$606.20
$652.56
$701.67
$876.15 		$868.94
$915.30
$964.41
$1,138.89 		$1,131.68
$1,178.04
$1,227.15
$1,401.63 		$262.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.92
$779.64
$877.86
$1,226.82
$1,864.26 		$949.66
$1,042.38
$1,140.60
$1,489.56 		$1,212.40
$1,305.12
$1,403.34
$1,752.30 		$1,475.14
$1,567.86
$1,666.08
$2,015.04 		$262.74
Toc - Plan #104 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 		$455.11
$516.53
$581.61
$812.80
$1,235.13 		$803.26
$864.68
$929.76
$1,160.95 		$1,151.41
$1,212.83
$1,277.91
$1,509.10 		$1,499.56
$1,560.98
$1,626.06
$1,857.25 		$348.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.22
$1,033.06
$1,163.22
$1,625.60
$2,470.26 		$1,258.37
$1,381.21
$1,511.37
$1,973.75 		$1,606.52
$1,729.36
$1,859.52
$2,321.90 		$1,954.67
$2,077.51
$2,207.67
$2,670.05 		$348.15
Toc - Plan #105 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 		$366.02
$415.42
$467.76
$653.69
$993.35 		$646.02
$695.42
$747.76
$933.69 		$926.02
$975.42
$1,027.76
$1,213.69 		$1,206.02
$1,255.42
$1,307.76
$1,493.69 		$280.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.04
$830.84
$935.52
$1,307.38
$1,986.70 		$1,012.04
$1,110.84
$1,215.52
$1,587.38 		$1,292.04
$1,390.84
$1,495.52
$1,867.38 		$1,572.04
$1,670.84
$1,775.52
$2,147.38 		$280.00
Toc - Plan #106 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 		$367.38
$416.96
$469.50
$656.12
$997.04 		$648.42
$698.00
$750.54
$937.16 		$929.46
$979.04
$1,031.58
$1,218.20 		$1,210.50
$1,260.08
$1,312.62
$1,499.24 		$281.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.76
$833.92
$939.00
$1,312.24
$1,994.08 		$1,015.80
$1,114.96
$1,220.04
$1,593.28 		$1,296.84
$1,396.00
$1,501.08
$1,874.32 		$1,577.88
$1,677.04
$1,782.12
$2,155.36 		$281.04
Toc - Plan #107 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 		$348.64
$395.70
$445.55
$622.66
$946.19 		$615.34
$662.40
$712.25
$889.36 		$882.04
$929.10
$978.95
$1,156.06 		$1,148.74
$1,195.80
$1,245.65
$1,422.76 		$266.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.28
$791.40
$891.10
$1,245.32
$1,892.38 		$963.98
$1,058.10
$1,157.80
$1,512.02 		$1,230.68
$1,324.80
$1,424.50
$1,778.72 		$1,497.38
$1,591.50
$1,691.20
$2,045.42 		$266.70
Toc - Plan #108 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 		$384.68
$436.60
$491.61
$687.02
$1,044.00 		$678.95
$730.87
$785.88
$981.29 		$973.22
$1,025.14
$1,080.15
$1,275.56 		$1,267.49
$1,319.41
$1,374.42
$1,569.83 		$294.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.36
$873.20
$983.22
$1,374.04
$2,088.00 		$1,063.63
$1,167.47
$1,277.49
$1,668.31 		$1,357.90
$1,461.74
$1,571.76
$1,962.58 		$1,652.17
$1,756.01
$1,866.03
$2,256.85 		$294.27
Toc - Plan #109 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 		$360.84
$409.54
$461.14
$644.44
$979.29 		$636.87
$685.57
$737.17
$920.47 		$912.90
$961.60
$1,013.20
$1,196.50 		$1,188.93
$1,237.63
$1,289.23
$1,472.53 		$276.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.68
$819.08
$922.28
$1,288.88
$1,958.58 		$997.71
$1,095.11
$1,198.31
$1,564.91 		$1,273.74
$1,371.14
$1,474.34
$1,840.94 		$1,549.77
$1,647.17
$1,750.37
$2,116.97 		$276.03
Toc - Plan #110 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 		$435.89
$494.73
$557.06
$778.49
$1,182.98 		$769.34
$828.18
$890.51
$1,111.94 		$1,102.79
$1,161.63
$1,223.96
$1,445.39 		$1,436.24
$1,495.08
$1,557.41
$1,778.84 		$333.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.78
$989.46
$1,114.12
$1,556.98
$2,365.96 		$1,205.23
$1,322.91
$1,447.57
$1,890.43 		$1,538.68
$1,656.36
$1,781.02
$2,223.88 		$1,872.13
$1,989.81
$2,114.47
$2,557.33 		$333.45
Toc - Plan #111 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 		$354.19
$401.99
$452.64
$632.56
$961.24 		$625.14
$672.94
$723.59
$903.51 		$896.09
$943.89
$994.54
$1,174.46 		$1,167.04
$1,214.84
$1,265.49
$1,445.41 		$270.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.38
$803.98
$905.28
$1,265.12
$1,922.48 		$979.33
$1,074.93
$1,176.23
$1,536.07 		$1,250.28
$1,345.88
$1,447.18
$1,807.02 		$1,521.23
$1,616.83
$1,718.13
$2,077.97 		$270.95
Toc - Plan #112 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 		$429.43
$487.39
$548.79
$766.94
$1,165.44 		$757.93
$815.89
$877.29
$1,095.44 		$1,086.43
$1,144.39
$1,205.79
$1,423.94 		$1,414.93
$1,472.89
$1,534.29
$1,752.44 		$328.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.86
$974.78
$1,097.58
$1,533.88
$2,330.88 		$1,187.36
$1,303.28
$1,426.08
$1,862.38 		$1,515.86
$1,631.78
$1,754.58
$2,190.88 		$1,844.36
$1,960.28
$2,083.08
$2,519.38 		$328.50
Toc - Plan #113 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 		$498.12
$565.36
$636.59
$889.63
$1,351.88 		$879.18
$946.42
$1,017.65
$1,270.69 		$1,260.24
$1,327.48
$1,398.71
$1,651.75 		$1,641.30
$1,708.54
$1,779.77
$2,032.81 		$381.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$996.24
$1,130.72
$1,273.18
$1,779.26
$2,703.76 		$1,377.30
$1,511.78
$1,654.24
$2,160.32 		$1,758.36
$1,892.84
$2,035.30
$2,541.38 		$2,139.42
$2,273.90
$2,416.36
$2,922.44 		$381.06

‡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 Saint Louis County here.

Saint Louis County is in “Rating Area 6” of Missouri.

Currently, there are 113 plans offered in Rating Area 6.

Top

2023 Obamacare Plans for Saint Louis County, MO

Plan Browser: 113 Plans
scroll down for more
Speak with a Health Insurance Expert 800-943-6832Ads by +HealthNetwork