Obamacare 2023 Rates for Caswell County

Obamacare > Rates > North Carolina > Caswell County

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Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Caswell County, NC.

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, 75 Plans and 2023 Rates for Caswell County, North Carolina

Below, you’ll find a summary of the 75 plans for Caswell County, North Carolina 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 |

Caswell County Resources

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Blue Cross and Blue Shield of NC

Local: 1-800-324-4973 | Toll Free: 1-800-324-4973

Toc - Plan #1 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Home Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 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 		$394.31
$447.54
$503.93
$704.24
$1,070.16 		$695.96
$749.19
$805.58
$1,005.89 		$997.61
$1,050.84
$1,107.23
$1,307.54 		$1,299.26
$1,352.49
$1,408.88
$1,609.19 		$301.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.62
$895.08
$1,007.86
$1,408.48
$2,140.32 		$1,090.27
$1,196.73
$1,309.51
$1,710.13 		$1,391.92
$1,498.38
$1,611.16
$2,011.78 		$1,693.57
$1,800.03
$1,912.81
$2,313.43 		$301.65
Toc - Plan #2 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Home Gold Standard 2000 | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$392.89
$445.93
$502.11
$701.70
$1,066.30 		$693.45
$746.49
$802.67
$1,002.26 		$994.01
$1,047.05
$1,103.23
$1,302.82 		$1,294.57
$1,347.61
$1,403.79
$1,603.38 		$300.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.78
$891.86
$1,004.22
$1,403.40
$2,132.60 		$1,086.34
$1,192.42
$1,304.78
$1,703.96 		$1,386.90
$1,492.98
$1,605.34
$2,004.52 		$1,687.46
$1,793.54
$1,905.90
$2,305.08 		$300.56
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$405.34
$460.06
$518.02
$723.94
$1,100.09 		$715.43
$770.15
$828.11
$1,034.03 		$1,025.52
$1,080.24
$1,138.20
$1,344.12 		$1,335.61
$1,390.33
$1,448.29
$1,654.21 		$310.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.68
$920.12
$1,036.04
$1,447.88
$2,200.18 		$1,120.77
$1,230.21
$1,346.13
$1,757.97 		$1,430.86
$1,540.30
$1,656.22
$2,068.06 		$1,740.95
$1,850.39
$1,966.31
$2,378.15 		$310.09
Toc - Plan #4 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Simple | $0 Deductible | 3 Free PCP | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$414.58
$470.55
$529.83
$740.44
$1,125.17 		$731.73
$787.70
$846.98
$1,057.59 		$1,048.88
$1,104.85
$1,164.13
$1,374.74 		$1,366.03
$1,422.00
$1,481.28
$1,691.89 		$317.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$829.16
$941.10
$1,059.66
$1,480.88
$2,250.34 		$1,146.31
$1,258.25
$1,376.81
$1,798.03 		$1,463.46
$1,575.40
$1,693.96
$2,115.18 		$1,780.61
$1,892.55
$2,011.11
$2,432.33 		$317.15
Toc - Plan #5 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$383.86
$435.68
$490.57
$685.57
$1,041.80 		$677.51
$729.33
$784.22
$979.22 		$971.16
$1,022.98
$1,077.87
$1,272.87 		$1,264.81
$1,316.63
$1,371.52
$1,566.52 		$293.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.72
$871.36
$981.14
$1,371.14
$2,083.60 		$1,061.37
$1,165.01
$1,274.79
$1,664.79 		$1,355.02
$1,458.66
$1,568.44
$1,958.44 		$1,648.67
$1,752.31
$1,862.09
$2,252.09 		$293.65
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$399.11
$452.99
$510.06
$712.81
$1,083.18 		$704.43
$758.31
$815.38
$1,018.13 		$1,009.75
$1,063.63
$1,120.70
$1,323.45 		$1,315.07
$1,368.95
$1,426.02
$1,628.77 		$305.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.22
$905.98
$1,020.12
$1,425.62
$2,166.36 		$1,103.54
$1,211.30
$1,325.44
$1,730.94 		$1,408.86
$1,516.62
$1,630.76
$2,036.26 		$1,714.18
$1,821.94
$1,936.08
$2,341.58 		$305.32
Toc - Plan #7 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$400.71
$454.81
$512.11
$715.67
$1,087.53 		$707.25
$761.35
$818.65
$1,022.21 		$1,013.79
$1,067.89
$1,125.19
$1,328.75 		$1,320.33
$1,374.43
$1,431.73
$1,635.29 		$306.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.42
$909.62
$1,024.22
$1,431.34
$2,175.06 		$1,107.96
$1,216.16
$1,330.76
$1,737.88 		$1,414.50
$1,522.70
$1,637.30
$2,044.42 		$1,721.04
$1,829.24
$1,943.84
$2,350.96 		$306.54
Toc - Plan #8 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Standard 5800 | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$397.38
$451.03
$507.85
$709.72
$1,078.49 		$701.38
$755.03
$811.85
$1,013.72 		$1,005.38
$1,059.03
$1,115.85
$1,317.72 		$1,309.38
$1,363.03
$1,419.85
$1,621.72 		$304.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.76
$902.06
$1,015.70
$1,419.44
$2,156.98 		$1,098.76
$1,206.06
$1,319.70
$1,723.44 		$1,402.76
$1,510.06
$1,623.70
$2,027.44 		$1,706.76
$1,814.06
$1,927.70
$2,331.44 		$304.00
Toc - Plan #9 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$296.06
$336.03
$378.36
$528.76
$803.51 		$522.55
$562.52
$604.85
$755.25 		$749.04
$789.01
$831.34
$981.74 		$975.53
$1,015.50
$1,057.83
$1,208.23 		$226.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.12
$672.06
$756.72
$1,057.52
$1,607.02 		$818.61
$898.55
$983.21
$1,284.01 		$1,045.10
$1,125.04
$1,209.70
$1,510.50 		$1,271.59
$1,351.53
$1,436.19
$1,736.99 		$226.49
Toc - Plan #10 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$280.11
$317.92
$357.98
$500.28
$760.22 		$494.39
$532.20
$572.26
$714.56 		$708.67
$746.48
$786.54
$928.84 		$922.95
$960.76
$1,000.82
$1,143.12 		$214.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$560.22
$635.84
$715.96
$1,000.56
$1,520.44 		$774.50
$850.12
$930.24
$1,214.84 		$988.78
$1,064.40
$1,144.52
$1,429.12 		$1,203.06
$1,278.68
$1,358.80
$1,643.40 		$214.28
Toc - Plan #11 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze Standard 7500 | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$280.51
$318.38
$358.49
$500.99
$761.30 		$495.10
$532.97
$573.08
$715.58 		$709.69
$747.56
$787.67
$930.17 		$924.28
$962.15
$1,002.26
$1,144.76 		$214.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.02
$636.76
$716.98
$1,001.98
$1,522.60 		$775.61
$851.35
$931.57
$1,216.57 		$990.20
$1,065.94
$1,146.16
$1,431.16 		$1,204.79
$1,280.53
$1,360.75
$1,645.75 		$214.59
Toc - Plan #12 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze 7500 | HSA Eligible | Integrated | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$293.99
$333.68
$375.72
$525.07
$797.89 		$518.89
$558.58
$600.62
$749.97 		$743.79
$783.48
$825.52
$974.87 		$968.69
$1,008.38
$1,050.42
$1,199.77 		$224.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.98
$667.36
$751.44
$1,050.14
$1,595.78 		$812.88
$892.26
$976.34
$1,275.04 		$1,037.78
$1,117.16
$1,201.24
$1,499.94 		$1,262.68
$1,342.06
$1,426.14
$1,724.84 		$224.90
Toc - Plan #13 Blue Cross and Blue Shield of NC
Bronze

(EPO) Blue Home Bronze 9100 | Integrated | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$280.68
$318.57
$358.71
$501.29
$761.77 		$495.40
$533.29
$573.43
$716.01 		$710.12
$748.01
$788.15
$930.73 		$924.84
$962.73
$1,002.87
$1,145.45 		$214.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.36
$637.14
$717.42
$1,002.58
$1,523.54 		$776.08
$851.86
$932.14
$1,217.30 		$990.80
$1,066.58
$1,146.86
$1,432.02 		$1,205.52
$1,281.30
$1,361.58
$1,646.74 		$214.72
Toc - Plan #14 Blue Cross and Blue Shield of NC
Catastrophic

(EPO) Blue Home Catastrophic 9100 | 3 PCP $35 | Integrated | with UNC Health Alliance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$205.88
$233.67
$263.11
$367.70
$558.76 		$363.38
$391.17
$420.61
$525.20 		$520.88
$548.67
$578.11
$682.70 		$678.38
$706.17
$735.61
$840.20 		$157.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$411.76
$467.34
$526.22
$735.40
$1,117.52 		$569.26
$624.84
$683.72
$892.90 		$726.76
$782.34
$841.22
$1,050.40 		$884.26
$939.84
$998.72
$1,207.90 		$157.50

ADVERTISEMENT

WellCare of North Carolina

Local: 1-833-705-2175 | Toll Free: 1-833-705-2175

Toc - Plan #15 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 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 		$632.90
$718.33
$808.83
$1,130.34
$1,717.66 		$1,117.06
$1,202.49
$1,292.99
$1,614.50 		$1,601.22
$1,686.65
$1,777.15
$2,098.66 		$2,085.38
$2,170.81
$2,261.31
$2,582.82 		$484.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,265.80
$1,436.66
$1,617.66
$2,260.68
$3,435.32 		$1,749.96
$1,920.82
$2,101.82
$2,744.84 		$2,234.12
$2,404.98
$2,585.98
$3,229.00 		$2,718.28
$2,889.14
$3,070.14
$3,713.16 		$484.16
Toc - Plan #16 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,100 $16,200 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 		$811.93
$921.53
$1,037.63
$1,450.08
$2,203.54 		$1,433.05
$1,542.65
$1,658.75
$2,071.20 		$2,054.17
$2,163.77
$2,279.87
$2,692.32 		$2,675.29
$2,784.89
$2,900.99
$3,313.44 		$621.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,623.86
$1,843.06
$2,075.26
$2,900.16
$4,407.08 		$2,244.98
$2,464.18
$2,696.38
$3,521.28 		$2,866.10
$3,085.30
$3,317.50
$4,142.40 		$3,487.22
$3,706.42
$3,938.62
$4,763.52 		$621.12
Toc - Plan #17 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 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 		$840.10
$953.50
$1,073.64
$1,500.40
$2,280.01 		$1,482.77
$1,596.17
$1,716.31
$2,143.07 		$2,125.44
$2,238.84
$2,358.98
$2,785.74 		$2,768.11
$2,881.51
$3,001.65
$3,428.41 		$642.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,680.20
$1,907.00
$2,147.28
$3,000.80
$4,560.02 		$2,322.87
$2,549.67
$2,789.95
$3,643.47 		$2,965.54
$3,192.34
$3,432.62
$4,286.14 		$3,608.21
$3,835.01
$4,075.29
$4,928.81 		$642.67
Toc - Plan #18 WellCare of North Carolina
Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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 		$633.96
$719.53
$810.18
$1,132.23
$1,720.53 		$1,118.93
$1,204.50
$1,295.15
$1,617.20 		$1,603.90
$1,689.47
$1,780.12
$2,102.17 		$2,088.87
$2,174.44
$2,265.09
$2,587.14 		$484.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,267.92
$1,439.06
$1,620.36
$2,264.46
$3,441.06 		$1,752.89
$1,924.03
$2,105.33
$2,749.43 		$2,237.86
$2,409.00
$2,590.30
$3,234.40 		$2,722.83
$2,893.97
$3,075.27
$3,719.37 		$484.97
Toc - Plan #19 WellCare of North Carolina
Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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 		$802.10
$910.38
$1,025.08
$1,432.54
$2,176.88 		$1,415.70
$1,523.98
$1,638.68
$2,046.14 		$2,029.30
$2,137.58
$2,252.28
$2,659.74 		$2,642.90
$2,751.18
$2,865.88
$3,273.34 		$613.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,604.20
$1,820.76
$2,050.16
$2,865.08
$4,353.76 		$2,217.80
$2,434.36
$2,663.76
$3,478.68 		$2,831.40
$3,047.96
$3,277.36
$4,092.28 		$3,445.00
$3,661.56
$3,890.96
$4,705.88 		$613.60
Toc - Plan #20 WellCare of North Carolina
Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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 		$816.88
$927.15
$1,043.96
$1,458.93
$2,216.99 		$1,441.79
$1,552.06
$1,668.87
$2,083.84 		$2,066.70
$2,176.97
$2,293.78
$2,708.75 		$2,691.61
$2,801.88
$2,918.69
$3,333.66 		$624.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,633.76
$1,854.30
$2,087.92
$2,917.86
$4,433.98 		$2,258.67
$2,479.21
$2,712.83
$3,542.77 		$2,883.58
$3,104.12
$3,337.74
$4,167.68 		$3,508.49
$3,729.03
$3,962.65
$4,792.59 		$624.91

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #21 Aetna CVS Health
Expanded Bronze

(HMO) 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 		$307.35
$348.84
$392.79
$548.92
$834.13 		$542.47
$583.96
$627.91
$784.04 		$777.59
$819.08
$863.03
$1,019.16 		$1,012.71
$1,054.20
$1,098.15
$1,254.28 		$235.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.70
$697.68
$785.58
$1,097.84
$1,668.26 		$849.82
$932.80
$1,020.70
$1,332.96 		$1,084.94
$1,167.92
$1,255.82
$1,568.08 		$1,320.06
$1,403.04
$1,490.94
$1,803.20 		$235.12
Toc - Plan #22 Aetna CVS Health
Expanded Bronze

(HMO) 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
$8,800 $17,600 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 		$276.57
$313.90
$353.45
$493.95
$750.60 		$488.14
$525.47
$565.02
$705.52 		$699.71
$737.04
$776.59
$917.09 		$911.28
$948.61
$988.16
$1,128.66 		$211.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.14
$627.80
$706.90
$987.90
$1,501.20 		$764.71
$839.37
$918.47
$1,199.47 		$976.28
$1,050.94
$1,130.04
$1,411.04 		$1,187.85
$1,262.51
$1,341.61
$1,622.61 		$211.57
Toc - Plan #23 Aetna CVS Health
Gold

(HMO) 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 		$453.57
$514.80
$579.66
$810.07
$1,230.99 		$800.55
$861.78
$926.64
$1,157.05 		$1,147.53
$1,208.76
$1,273.62
$1,504.03 		$1,494.51
$1,555.74
$1,620.60
$1,851.01 		$346.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$907.14
$1,029.60
$1,159.32
$1,620.14
$2,461.98 		$1,254.12
$1,376.58
$1,506.30
$1,967.12 		$1,601.10
$1,723.56
$1,853.28
$2,314.10 		$1,948.08
$2,070.54
$2,200.26
$2,661.08 		$346.98
Toc - Plan #24 Aetna CVS Health
Silver

(HMO) 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
$4,300 $8,600 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 		$425.64
$483.11
$543.97
$760.20
$1,155.20 		$751.26
$808.73
$869.59
$1,085.82 		$1,076.88
$1,134.35
$1,195.21
$1,411.44 		$1,402.50
$1,459.97
$1,520.83
$1,737.06 		$325.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.28
$966.22
$1,087.94
$1,520.40
$2,310.40 		$1,176.90
$1,291.84
$1,413.56
$1,846.02 		$1,502.52
$1,617.46
$1,739.18
$2,171.64 		$1,828.14
$1,943.08
$2,064.80
$2,497.26 		$325.62
Toc - Plan #25 Aetna CVS Health
Silver

(HMO) 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
$8,000 $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 		$404.01
$458.55
$516.32
$721.55
$1,096.47 		$713.07
$767.61
$825.38
$1,030.61 		$1,022.13
$1,076.67
$1,134.44
$1,339.67 		$1,331.19
$1,385.73
$1,443.50
$1,648.73 		$309.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.02
$917.10
$1,032.64
$1,443.10
$2,192.94 		$1,117.08
$1,226.16
$1,341.70
$1,752.16 		$1,426.14
$1,535.22
$1,650.76
$2,061.22 		$1,735.20
$1,844.28
$1,959.82
$2,370.28 		$309.06
Toc - Plan #26 Aetna CVS Health
Expanded Bronze

(HMO) 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 		$286.64
$325.34
$366.33
$511.94
$777.94 		$505.92
$544.62
$585.61
$731.22 		$725.20
$763.90
$804.89
$950.50 		$944.48
$983.18
$1,024.17
$1,169.78 		$219.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.28
$650.68
$732.66
$1,023.88
$1,555.88 		$792.56
$869.96
$951.94
$1,243.16 		$1,011.84
$1,089.24
$1,171.22
$1,462.44 		$1,231.12
$1,308.52
$1,390.50
$1,681.72 		$219.28
Toc - Plan #27 Aetna CVS Health
Gold

(HMO) 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 		$445.22
$505.32
$568.99
$795.16
$1,208.32 		$785.81
$845.91
$909.58
$1,135.75 		$1,126.40
$1,186.50
$1,250.17
$1,476.34 		$1,466.99
$1,527.09
$1,590.76
$1,816.93 		$340.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.44
$1,010.64
$1,137.98
$1,590.32
$2,416.64 		$1,231.03
$1,351.23
$1,478.57
$1,930.91 		$1,571.62
$1,691.82
$1,819.16
$2,271.50 		$1,912.21
$2,032.41
$2,159.75
$2,612.09 		$340.59
Toc - Plan #28 Aetna CVS Health
Silver

(HMO) 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
$6,500 $13,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.89
$474.31
$534.07
$746.36
$1,134.16 		$737.58
$794.00
$853.76
$1,066.05 		$1,057.27
$1,113.69
$1,173.45
$1,385.74 		$1,376.96
$1,433.38
$1,493.14
$1,705.43 		$319.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.78
$948.62
$1,068.14
$1,492.72
$2,268.32 		$1,155.47
$1,268.31
$1,387.83
$1,812.41 		$1,475.16
$1,588.00
$1,707.52
$2,132.10 		$1,794.85
$1,907.69
$2,027.21
$2,451.79 		$319.69
Toc - Plan #29 Aetna CVS Health
Silver

(HMO) 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 		$394.56
$447.83
$504.25
$704.68
$1,070.83 		$696.40
$749.67
$806.09
$1,006.52 		$998.24
$1,051.51
$1,107.93
$1,308.36 		$1,300.08
$1,353.35
$1,409.77
$1,610.20 		$301.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.12
$895.66
$1,008.50
$1,409.36
$2,141.66 		$1,090.96
$1,197.50
$1,310.34
$1,711.20 		$1,392.80
$1,499.34
$1,612.18
$2,013.04 		$1,694.64
$1,801.18
$1,914.02
$2,314.88 		$301.84

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310 | TTY: 1-833-863-1310
Toc - Plan #30 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$355.18
$403.12
$453.91
$634.34
$963.94 		$626.89
$674.83
$725.62
$906.05 		$898.60
$946.54
$997.33
$1,177.76 		$1,170.31
$1,218.25
$1,269.04
$1,449.47 		$271.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.36
$806.24
$907.82
$1,268.68
$1,927.88 		$982.07
$1,077.95
$1,179.53
$1,540.39 		$1,253.78
$1,349.66
$1,451.24
$1,812.10 		$1,525.49
$1,621.37
$1,722.95
$2,083.81 		$271.71
Toc - Plan #31 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$390.59
$443.30
$499.16
$697.57
$1,060.02 		$689.38
$742.09
$797.95
$996.36 		$988.17
$1,040.88
$1,096.74
$1,295.15 		$1,286.96
$1,339.67
$1,395.53
$1,593.94 		$298.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.18
$886.60
$998.32
$1,395.14
$2,120.04 		$1,079.97
$1,185.39
$1,297.11
$1,693.93 		$1,378.76
$1,484.18
$1,595.90
$1,992.72 		$1,677.55
$1,782.97
$1,894.69
$2,291.51 		$298.79
Toc - Plan #32 Ambetter of North Carolina
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$481.67
$546.68
$615.56
$860.24
$1,307.22 		$850.14
$915.15
$984.03
$1,228.71 		$1,218.61
$1,283.62
$1,352.50
$1,597.18 		$1,587.08
$1,652.09
$1,720.97
$1,965.65 		$368.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$963.34
$1,093.36
$1,231.12
$1,720.48
$2,614.44 		$1,331.81
$1,461.83
$1,599.59
$2,088.95 		$1,700.28
$1,830.30
$1,968.06
$2,457.42 		$2,068.75
$2,198.77
$2,336.53
$2,825.89 		$368.47
Toc - Plan #33 Ambetter of North Carolina
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$502.47
$570.30
$642.15
$897.40
$1,363.69 		$886.86
$954.69
$1,026.54
$1,281.79 		$1,271.25
$1,339.08
$1,410.93
$1,666.18 		$1,655.64
$1,723.47
$1,795.32
$2,050.57 		$384.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,004.94
$1,140.60
$1,284.30
$1,794.80
$2,727.38 		$1,389.33
$1,524.99
$1,668.69
$2,179.19 		$1,773.72
$1,909.38
$2,053.08
$2,563.58 		$2,158.11
$2,293.77
$2,437.47
$2,947.97 		$384.39
Toc - Plan #34 Ambetter of North Carolina
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477.19
$541.60
$609.83
$852.24
$1,295.06 		$842.23
$906.64
$974.87
$1,217.28 		$1,207.27
$1,271.68
$1,339.91
$1,582.32 		$1,572.31
$1,636.72
$1,704.95
$1,947.36 		$365.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.38
$1,083.20
$1,219.66
$1,704.48
$2,590.12 		$1,319.42
$1,448.24
$1,584.70
$2,069.52 		$1,684.46
$1,813.28
$1,949.74
$2,434.56 		$2,049.50
$2,178.32
$2,314.78
$2,799.60 		$365.04
Toc - Plan #35 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.98
$430.13
$484.32
$676.84
$1,028.52 		$668.89
$720.04
$774.23
$966.75 		$958.80
$1,009.95
$1,064.14
$1,256.66 		$1,248.71
$1,299.86
$1,354.05
$1,546.57 		$289.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.96
$860.26
$968.64
$1,353.68
$2,057.04 		$1,047.87
$1,150.17
$1,258.55
$1,643.59 		$1,337.78
$1,440.08
$1,548.46
$1,933.50 		$1,627.69
$1,729.99
$1,838.37
$2,223.41 		$289.91
Toc - Plan #36 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$426.47
$484.03
$545.01
$761.66
$1,157.41 		$752.71
$810.27
$871.25
$1,087.90 		$1,078.95
$1,136.51
$1,197.49
$1,414.14 		$1,405.19
$1,462.75
$1,523.73
$1,740.38 		$326.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.94
$968.06
$1,090.02
$1,523.32
$2,314.82 		$1,179.18
$1,294.30
$1,416.26
$1,849.56 		$1,505.42
$1,620.54
$1,742.50
$2,175.80 		$1,831.66
$1,946.78
$2,068.74
$2,502.04 		$326.24
Toc - Plan #37 Ambetter of North Carolina
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$475.94
$540.18
$608.23
$850.00
$1,291.66 		$840.02
$904.26
$972.31
$1,214.08 		$1,204.10
$1,268.34
$1,336.39
$1,578.16 		$1,568.18
$1,632.42
$1,700.47
$1,942.24 		$364.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$951.88
$1,080.36
$1,216.46
$1,700.00
$2,583.32 		$1,315.96
$1,444.44
$1,580.54
$2,064.08 		$1,680.04
$1,808.52
$1,944.62
$2,428.16 		$2,044.12
$2,172.60
$2,308.70
$2,792.24 		$364.08
Toc - Plan #38 Ambetter of North Carolina
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$476.13
$540.39
$608.48
$850.35
$1,292.18 		$840.36
$904.62
$972.71
$1,214.58 		$1,204.59
$1,268.85
$1,336.94
$1,578.81 		$1,568.82
$1,633.08
$1,701.17
$1,943.04 		$364.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.26
$1,080.78
$1,216.96
$1,700.70
$2,584.36 		$1,316.49
$1,445.01
$1,581.19
$2,064.93 		$1,680.72
$1,809.24
$1,945.42
$2,429.16 		$2,044.95
$2,173.47
$2,309.65
$2,793.39 		$364.23
Toc - Plan #39 Ambetter of North Carolina
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$371.61
$421.76
$474.90
$663.67
$1,008.52 		$655.88
$706.03
$759.17
$947.94 		$940.15
$990.30
$1,043.44
$1,232.21 		$1,224.42
$1,274.57
$1,327.71
$1,516.48 		$284.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.22
$843.52
$949.80
$1,327.34
$2,017.04 		$1,027.49
$1,127.79
$1,234.07
$1,611.61 		$1,311.76
$1,412.06
$1,518.34
$1,895.88 		$1,596.03
$1,696.33
$1,802.61
$2,180.15 		$284.27
Toc - Plan #40 Ambetter of North Carolina
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$471.26
$534.87
$602.26
$841.66
$1,278.98 		$831.77
$895.38
$962.77
$1,202.17 		$1,192.28
$1,255.89
$1,323.28
$1,562.68 		$1,552.79
$1,616.40
$1,683.79
$1,923.19 		$360.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$942.52
$1,069.74
$1,204.52
$1,683.32
$2,557.96 		$1,303.03
$1,430.25
$1,565.03
$2,043.83 		$1,663.54
$1,790.76
$1,925.54
$2,404.34 		$2,024.05
$2,151.27
$2,286.05
$2,764.85 		$360.51
Toc - Plan #41 Ambetter of North Carolina
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$476.90
$541.27
$609.46
$851.72
$1,294.28 		$841.72
$906.09
$974.28
$1,216.54 		$1,206.54
$1,270.91
$1,339.10
$1,581.36 		$1,571.36
$1,635.73
$1,703.92
$1,946.18 		$364.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.80
$1,082.54
$1,218.92
$1,703.44
$2,588.56 		$1,318.62
$1,447.36
$1,583.74
$2,068.26 		$1,683.44
$1,812.18
$1,948.56
$2,433.08 		$2,048.26
$2,177.00
$2,313.38
$2,797.90 		$364.82
Toc - Plan #42 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$370.14
$420.10
$473.03
$661.06
$1,004.54 		$653.29
$703.25
$756.18
$944.21 		$936.44
$986.40
$1,039.33
$1,227.36 		$1,219.59
$1,269.55
$1,322.48
$1,510.51 		$283.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.28
$840.20
$946.06
$1,322.12
$2,009.08 		$1,023.43
$1,123.35
$1,229.21
$1,605.27 		$1,306.58
$1,406.50
$1,512.36
$1,888.42 		$1,589.73
$1,689.65
$1,795.51
$2,171.57 		$283.15
Toc - Plan #43 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$407.04
$461.98
$520.18
$726.95
$1,104.67 		$718.42
$773.36
$831.56
$1,038.33 		$1,029.80
$1,084.74
$1,142.94
$1,349.71 		$1,341.18
$1,396.12
$1,454.32
$1,661.09 		$311.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.08
$923.96
$1,040.36
$1,453.90
$2,209.34 		$1,125.46
$1,235.34
$1,351.74
$1,765.28 		$1,436.84
$1,546.72
$1,663.12
$2,076.66 		$1,748.22
$1,858.10
$1,974.50
$2,388.04 		$311.38
Toc - Plan #44 Ambetter of North Carolina
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$501.95
$569.71
$641.48
$896.47
$1,362.28 		$885.94
$953.70
$1,025.47
$1,280.46 		$1,269.93
$1,337.69
$1,409.46
$1,664.45 		$1,653.92
$1,721.68
$1,793.45
$2,048.44 		$383.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.90
$1,139.42
$1,282.96
$1,792.94
$2,724.56 		$1,387.89
$1,523.41
$1,666.95
$2,176.93 		$1,771.88
$1,907.40
$2,050.94
$2,560.92 		$2,155.87
$2,291.39
$2,434.93
$2,944.91 		$383.99
Toc - Plan #45 Ambetter of North Carolina
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$523.64
$594.32
$669.20
$935.20
$1,421.13 		$924.22
$994.90
$1,069.78
$1,335.78 		$1,324.80
$1,395.48
$1,470.36
$1,736.36 		$1,725.38
$1,796.06
$1,870.94
$2,136.94 		$400.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.28
$1,188.64
$1,338.40
$1,870.40
$2,842.26 		$1,447.86
$1,589.22
$1,738.98
$2,270.98 		$1,848.44
$1,989.80
$2,139.56
$2,671.56 		$2,249.02
$2,390.38
$2,540.14
$3,072.14 		$400.58
Toc - Plan #46 Ambetter of North Carolina
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$497.29
$564.41
$635.52
$888.14
$1,349.61 		$877.71
$944.83
$1,015.94
$1,268.56 		$1,258.13
$1,325.25
$1,396.36
$1,648.98 		$1,638.55
$1,705.67
$1,776.78
$2,029.40 		$380.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$994.58
$1,128.82
$1,271.04
$1,776.28
$2,699.22 		$1,375.00
$1,509.24
$1,651.46
$2,156.70 		$1,755.42
$1,889.66
$2,031.88
$2,537.12 		$2,135.84
$2,270.08
$2,412.30
$2,917.54 		$380.42
Toc - Plan #47 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$394.94
$448.25
$504.72
$705.34
$1,071.84 		$697.06
$750.37
$806.84
$1,007.46 		$999.18
$1,052.49
$1,108.96
$1,309.58 		$1,301.30
$1,354.61
$1,411.08
$1,611.70 		$302.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.88
$896.50
$1,009.44
$1,410.68
$2,143.68 		$1,092.00
$1,198.62
$1,311.56
$1,712.80 		$1,394.12
$1,500.74
$1,613.68
$2,014.92 		$1,696.24
$1,802.86
$1,915.80
$2,317.04 		$302.12
Toc - Plan #48 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$444.43
$504.42
$567.97
$793.74
$1,206.16 		$784.41
$844.40
$907.95
$1,133.72 		$1,124.39
$1,184.38
$1,247.93
$1,473.70 		$1,464.37
$1,524.36
$1,587.91
$1,813.68 		$339.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.86
$1,008.84
$1,135.94
$1,587.48
$2,412.32 		$1,228.84
$1,348.82
$1,475.92
$1,927.46 		$1,568.82
$1,688.80
$1,815.90
$2,267.44 		$1,908.80
$2,028.78
$2,155.88
$2,607.42 		$339.98
Toc - Plan #49 Ambetter of North Carolina
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$496.18
$563.15
$634.11
$886.16
$1,346.61 		$875.75
$942.72
$1,013.68
$1,265.73 		$1,255.32
$1,322.29
$1,393.25
$1,645.30 		$1,634.89
$1,701.86
$1,772.82
$2,024.87 		$379.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$992.36
$1,126.30
$1,268.22
$1,772.32
$2,693.22 		$1,371.93
$1,505.87
$1,647.79
$2,151.89 		$1,751.50
$1,885.44
$2,027.36
$2,531.46 		$2,131.07
$2,265.01
$2,406.93
$2,911.03 		$379.57
Toc - Plan #50 Ambetter of North Carolina
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$495.98
$562.93
$633.85
$885.80
$1,346.07 		$875.40
$942.35
$1,013.27
$1,265.22 		$1,254.82
$1,321.77
$1,392.69
$1,644.64 		$1,634.24
$1,701.19
$1,772.11
$2,024.06 		$379.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.96
$1,125.86
$1,267.70
$1,771.60
$2,692.14 		$1,371.38
$1,505.28
$1,647.12
$2,151.02 		$1,750.80
$1,884.70
$2,026.54
$2,530.44 		$2,130.22
$2,264.12
$2,405.96
$2,909.86 		$379.42
Toc - Plan #51 Ambetter of North Carolina
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$370.07
$420.01
$472.93
$660.92
$1,004.33 		$653.16
$703.10
$756.02
$944.01 		$936.25
$986.19
$1,039.11
$1,227.10 		$1,219.34
$1,269.28
$1,322.20
$1,510.19 		$283.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.14
$840.02
$945.86
$1,321.84
$2,008.66 		$1,023.23
$1,123.11
$1,228.95
$1,604.93 		$1,306.32
$1,406.20
$1,512.04
$1,888.02 		$1,589.41
$1,689.29
$1,795.13
$2,171.11 		$283.09
Toc - Plan #52 Ambetter of North Carolina
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$465.72
$528.59
$595.18
$831.77
$1,263.95 		$821.99
$884.86
$951.45
$1,188.04 		$1,178.26
$1,241.13
$1,307.72
$1,544.31 		$1,534.53
$1,597.40
$1,663.99
$1,900.58 		$356.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$931.44
$1,057.18
$1,190.36
$1,663.54
$2,527.90 		$1,287.71
$1,413.45
$1,546.63
$2,019.81 		$1,643.98
$1,769.72
$1,902.90
$2,376.08 		$2,000.25
$2,125.99
$2,259.17
$2,732.35 		$356.27
Toc - Plan #53 Ambetter of North Carolina
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$488.22
$554.12
$623.93
$871.94
$1,324.99 		$861.70
$927.60
$997.41
$1,245.42 		$1,235.18
$1,301.08
$1,370.89
$1,618.90 		$1,608.66
$1,674.56
$1,744.37
$1,992.38 		$373.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976.44
$1,108.24
$1,247.86
$1,743.88
$2,649.98 		$1,349.92
$1,481.72
$1,621.34
$2,117.36 		$1,723.40
$1,855.20
$1,994.82
$2,490.84 		$2,096.88
$2,228.68
$2,368.30
$2,864.32 		$373.48

ADVERTISEMENT

Friday Health Plans

Local: 1-844-465-5500 | Toll Free: 1-844-465-5500 | TTY: 1-800-659-2656
Toc - Plan #54 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$203.99
$231.53
$260.70
$364.33
$553.64 		$360.05
$387.59
$416.76
$520.39 		$516.11
$543.65
$572.82
$676.45 		$672.17
$699.71
$728.88
$832.51 		$156.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$407.98
$463.06
$521.40
$728.66
$1,107.28 		$564.04
$619.12
$677.46
$884.72 		$720.10
$775.18
$833.52
$1,040.78 		$876.16
$931.24
$989.58
$1,196.84 		$156.06
Toc - Plan #55 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$267.42
$303.53
$341.77
$477.62
$725.79 		$472.00
$508.11
$546.35
$682.20 		$676.58
$712.69
$750.93
$886.78 		$881.16
$917.27
$955.51
$1,091.36 		$204.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.84
$607.06
$683.54
$955.24
$1,451.58 		$739.42
$811.64
$888.12
$1,159.82 		$944.00
$1,016.22
$1,092.70
$1,364.40 		$1,148.58
$1,220.80
$1,297.28
$1,568.98 		$204.58
Toc - Plan #56 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$270.11
$306.58
$345.20
$482.42
$733.08 		$476.75
$513.22
$551.84
$689.06 		$683.39
$719.86
$758.48
$895.70 		$890.03
$926.50
$965.12
$1,102.34 		$206.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.22
$613.16
$690.40
$964.84
$1,466.16 		$746.86
$819.80
$897.04
$1,171.48 		$953.50
$1,026.44
$1,103.68
$1,378.12 		$1,160.14
$1,233.08
$1,310.32
$1,584.76 		$206.64
Toc - Plan #57 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$285.55
$324.10
$364.93
$509.99
$774.98 		$504.00
$542.55
$583.38
$728.44 		$722.45
$761.00
$801.83
$946.89 		$940.90
$979.45
$1,020.28
$1,165.34 		$218.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$571.10
$648.20
$729.86
$1,019.98
$1,549.96 		$789.55
$866.65
$948.31
$1,238.43 		$1,008.00
$1,085.10
$1,166.76
$1,456.88 		$1,226.45
$1,303.55
$1,385.21
$1,675.33 		$218.45
Toc - Plan #58 Friday Health Plans
Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$372.56
$422.85
$476.13
$665.39
$1,011.12 		$657.57
$707.86
$761.14
$950.40 		$942.58
$992.87
$1,046.15
$1,235.41 		$1,227.59
$1,277.88
$1,331.16
$1,520.42 		$285.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.12
$845.70
$952.26
$1,330.78
$2,022.24 		$1,030.13
$1,130.71
$1,237.27
$1,615.79 		$1,315.14
$1,415.72
$1,522.28
$1,900.80 		$1,600.15
$1,700.73
$1,807.29
$2,185.81 		$285.01
Toc - Plan #59 Friday Health Plans
Gold

(HMO) Friday Gold + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 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 		$391.68
$444.55
$500.56
$699.54
$1,063.01 		$691.31
$744.18
$800.19
$999.17 		$990.94
$1,043.81
$1,099.82
$1,298.80 		$1,290.57
$1,343.44
$1,399.45
$1,598.43 		$299.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.36
$889.10
$1,001.12
$1,399.08
$2,126.02 		$1,082.99
$1,188.73
$1,300.75
$1,698.71 		$1,382.62
$1,488.36
$1,600.38
$1,998.34 		$1,682.25
$1,787.99
$1,900.01
$2,297.97 		$299.63
Toc - Plan #60 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$267.23
$303.31
$341.52
$477.27
$725.26 		$471.66
$507.74
$545.95
$681.70 		$676.09
$712.17
$750.38
$886.13 		$880.52
$916.60
$954.81
$1,090.56 		$204.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.46
$606.62
$683.04
$954.54
$1,450.52 		$738.89
$811.05
$887.47
$1,158.97 		$943.32
$1,015.48
$1,091.90
$1,363.40 		$1,147.75
$1,219.91
$1,296.33
$1,567.83 		$204.43
Toc - Plan #61 Friday Health Plans
Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$382.42
$434.05
$488.73
$683.00
$1,037.88 		$674.97
$726.60
$781.28
$975.55 		$967.52
$1,019.15
$1,073.83
$1,268.10 		$1,260.07
$1,311.70
$1,366.38
$1,560.65 		$292.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.84
$868.10
$977.46
$1,366.00
$2,075.76 		$1,057.39
$1,160.65
$1,270.01
$1,658.55 		$1,349.94
$1,453.20
$1,562.56
$1,951.10 		$1,642.49
$1,745.75
$1,855.11
$2,243.65 		$292.55
Toc - Plan #62 Friday Health Plans
Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 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 		$406.91
$461.84
$520.03
$726.74
$1,104.35 		$718.20
$773.13
$831.32
$1,038.03 		$1,029.49
$1,084.42
$1,142.61
$1,349.32 		$1,340.78
$1,395.71
$1,453.90
$1,660.61 		$311.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.82
$923.68
$1,040.06
$1,453.48
$2,208.70 		$1,125.11
$1,234.97
$1,351.35
$1,764.77 		$1,436.40
$1,546.26
$1,662.64
$2,076.06 		$1,747.69
$1,857.55
$1,973.93
$2,387.35 		$311.29
Toc - Plan #63 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$267.08
$303.14
$341.33
$477.01
$724.87 		$471.40
$507.46
$545.65
$681.33 		$675.72
$711.78
$749.97
$885.65 		$880.04
$916.10
$954.29
$1,089.97 		$204.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.16
$606.28
$682.66
$954.02
$1,449.74 		$738.48
$810.60
$886.98
$1,158.34 		$942.80
$1,014.92
$1,091.30
$1,362.66 		$1,147.12
$1,219.24
$1,295.62
$1,566.98 		$204.32
Toc - Plan #64 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$269.77
$306.19
$344.77
$481.81
$732.16 		$476.15
$512.57
$551.15
$688.19 		$682.53
$718.95
$757.53
$894.57 		$888.91
$925.33
$963.91
$1,100.95 		$206.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.54
$612.38
$689.54
$963.62
$1,464.32 		$745.92
$818.76
$895.92
$1,170.00 		$952.30
$1,025.14
$1,102.30
$1,376.38 		$1,158.68
$1,231.52
$1,308.68
$1,582.76 		$206.38
Toc - Plan #65 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$266.89
$302.92
$341.09
$476.67
$724.35 		$471.06
$507.09
$545.26
$680.84 		$675.23
$711.26
$749.43
$885.01 		$879.40
$915.43
$953.60
$1,089.18 		$204.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$533.78
$605.84
$682.18
$953.34
$1,448.70 		$737.95
$810.01
$886.35
$1,157.51 		$942.12
$1,014.18
$1,090.52
$1,361.68 		$1,146.29
$1,218.35
$1,294.69
$1,565.85 		$204.17
Toc - Plan #66 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$372.22
$422.47
$475.69
$664.78
$1,010.20 		$656.97
$707.22
$760.44
$949.53 		$941.72
$991.97
$1,045.19
$1,234.28 		$1,226.47
$1,276.72
$1,329.94
$1,519.03 		$284.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.44
$844.94
$951.38
$1,329.56
$2,020.40 		$1,029.19
$1,129.69
$1,236.13
$1,614.31 		$1,313.94
$1,414.44
$1,520.88
$1,899.06 		$1,598.69
$1,699.19
$1,805.63
$2,183.81 		$284.75
Toc - Plan #67 Friday Health Plans
Silver

(HMO) Friday Silver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$376.75
$427.61
$481.48
$672.87
$1,022.49 		$664.96
$715.82
$769.69
$961.08 		$953.17
$1,004.03
$1,057.90
$1,249.29 		$1,241.38
$1,292.24
$1,346.11
$1,537.50 		$288.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.50
$855.22
$962.96
$1,345.74
$2,044.98 		$1,041.71
$1,143.43
$1,251.17
$1,633.95 		$1,329.92
$1,431.64
$1,539.38
$1,922.16 		$1,618.13
$1,719.85
$1,827.59
$2,210.37 		$288.21
Toc - Plan #68 Friday Health Plans
Silver

(HMO) Friday Silver Zero Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$384.52
$436.43
$491.41
$686.75
$1,043.58 		$678.68
$730.59
$785.57
$980.91 		$972.84
$1,024.75
$1,079.73
$1,275.07 		$1,267.00
$1,318.91
$1,373.89
$1,569.23 		$294.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.04
$872.86
$982.82
$1,373.50
$2,087.16 		$1,063.20
$1,167.02
$1,276.98
$1,667.66 		$1,357.36
$1,461.18
$1,571.14
$1,961.82 		$1,651.52
$1,755.34
$1,865.30
$2,255.98 		$294.16
Toc - Plan #69 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$382.08
$433.66
$488.30
$682.39
$1,036.97 		$674.37
$725.95
$780.59
$974.68 		$966.66
$1,018.24
$1,072.88
$1,266.97 		$1,258.95
$1,310.53
$1,365.17
$1,559.26 		$292.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.16
$867.32
$976.60
$1,364.78
$2,073.94 		$1,056.45
$1,159.61
$1,268.89
$1,657.07 		$1,348.74
$1,451.90
$1,561.18
$1,949.36 		$1,641.03
$1,744.19
$1,853.47
$2,241.65 		$292.29
Toc - Plan #70 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 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 		$391.34
$444.17
$500.13
$698.93
$1,062.09 		$690.71
$743.54
$799.50
$998.30 		$990.08
$1,042.91
$1,098.87
$1,297.67 		$1,289.45
$1,342.28
$1,398.24
$1,597.04 		$299.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.68
$888.34
$1,000.26
$1,397.86
$2,124.18 		$1,082.05
$1,187.71
$1,299.63
$1,697.23 		$1,381.42
$1,487.08
$1,599.00
$1,996.60 		$1,680.79
$1,786.45
$1,898.37
$2,295.97 		$299.37
Toc - Plan #71 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 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 		$406.57
$461.46
$519.60
$726.14
$1,103.43 		$717.60
$772.49
$830.63
$1,037.17 		$1,028.63
$1,083.52
$1,141.66
$1,348.20 		$1,339.66
$1,394.55
$1,452.69
$1,659.23 		$311.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.14
$922.92
$1,039.20
$1,452.28
$2,206.86 		$1,124.17
$1,233.95
$1,350.23
$1,763.31 		$1,435.20
$1,544.98
$1,661.26
$2,074.34 		$1,746.23
$1,856.01
$1,972.29
$2,385.37 		$311.03
Toc - Plan #72 Friday Health Plans
Bronze

(HMO) Friday Standard Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$267.08
$303.14
$341.33
$477.01
$724.87 		$471.40
$507.46
$545.65
$681.33 		$675.72
$711.78
$749.97
$885.65 		$880.04
$916.10
$954.29
$1,089.97 		$204.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.16
$606.28
$682.66
$954.02
$1,449.74 		$738.48
$810.60
$886.98
$1,158.34 		$942.80
$1,014.92
$1,091.30
$1,362.66 		$1,147.12
$1,219.24
$1,295.62
$1,566.98 		$204.32
Toc - Plan #73 Friday Health Plans
Expanded Bronze

(HMO) Friday Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$265.63
$301.49
$339.47
$474.41
$720.91 		$468.83
$504.69
$542.67
$677.61 		$672.03
$707.89
$745.87
$880.81 		$875.23
$911.09
$949.07
$1,084.01 		$203.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$531.26
$602.98
$678.94
$948.82
$1,441.82 		$734.46
$806.18
$882.14
$1,152.02 		$937.66
$1,009.38
$1,085.34
$1,355.22 		$1,140.86
$1,212.58
$1,288.54
$1,558.42 		$203.20
Toc - Plan #74 Friday Health Plans
Silver

(HMO) Friday Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$369.27
$419.12
$471.93
$659.52
$1,002.21 		$651.76
$701.61
$754.42
$942.01 		$934.25
$984.10
$1,036.91
$1,224.50 		$1,216.74
$1,266.59
$1,319.40
$1,506.99 		$282.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.54
$838.24
$943.86
$1,319.04
$2,004.42 		$1,021.03
$1,120.73
$1,226.35
$1,601.53 		$1,303.52
$1,403.22
$1,508.84
$1,884.02 		$1,586.01
$1,685.71
$1,791.33
$2,166.51 		$282.49
Toc - Plan #75 Friday Health Plans
Gold

(HMO) Friday Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$404.87
$459.52
$517.42
$723.09
$1,098.81 		$714.59
$769.24
$827.14
$1,032.81 		$1,024.31
$1,078.96
$1,136.86
$1,342.53 		$1,334.03
$1,388.68
$1,446.58
$1,652.25 		$309.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.74
$919.04
$1,034.84
$1,446.18
$2,197.62 		$1,119.46
$1,228.76
$1,344.56
$1,755.90 		$1,429.18
$1,538.48
$1,654.28
$2,065.62 		$1,738.90
$1,848.20
$1,964.00
$2,375.34 		$309.72

‡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 Caswell County here.

Caswell County is in “Rating Area 11” of North Carolina.

Currently, there are 75 plans offered in Rating Area 11.

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2023 Obamacare Plans for Caswell County, NC

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