Obamacare 2023 Rates for Jackson County

Obamacare > Rates > North Carolina > Jackson County

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Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Jackson County, 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, 149 Plans and 2023 Rates for Jackson County, North Carolina

Below, you’ll find a summary of the 149 plans for Jackson 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 |

Jackson 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
Silver

(PPO) Blue Advantage Silver Simple | $0 Deductible | 3 Free PCP | Nationwide Doctors

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 		$540.34
$613.29
$690.55
$965.05
$1,466.48 		$953.70
$1,026.65
$1,103.91
$1,378.41 		$1,367.06
$1,440.01
$1,517.27
$1,791.77 		$1,780.42
$1,853.37
$1,930.63
$2,205.13 		$413.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,080.68
$1,226.58
$1,381.10
$1,930.10
$2,932.96 		$1,494.04
$1,639.94
$1,794.46
$2,343.46 		$1,907.40
$2,053.30
$2,207.82
$2,756.82 		$2,320.76
$2,466.66
$2,621.18
$3,170.18 		$413.36
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

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 		$500.28
$567.82
$639.36
$893.50
$1,357.76 		$882.99
$950.53
$1,022.07
$1,276.21 		$1,265.70
$1,333.24
$1,404.78
$1,658.92 		$1,648.41
$1,715.95
$1,787.49
$2,041.63 		$382.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,000.56
$1,135.64
$1,278.72
$1,787.00
$2,715.52 		$1,383.27
$1,518.35
$1,661.43
$2,169.71 		$1,765.98
$1,901.06
$2,044.14
$2,552.42 		$2,148.69
$2,283.77
$2,426.85
$2,935.13 		$382.71
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

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 		$520.20
$590.43
$664.82
$929.08
$1,411.82 		$918.15
$988.38
$1,062.77
$1,327.03 		$1,316.10
$1,386.33
$1,460.72
$1,724.98 		$1,714.05
$1,784.28
$1,858.67
$2,122.93 		$397.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,040.40
$1,180.86
$1,329.64
$1,858.16
$2,823.64 		$1,438.35
$1,578.81
$1,727.59
$2,256.11 		$1,836.30
$1,976.76
$2,125.54
$2,654.06 		$2,234.25
$2,374.71
$2,523.49
$3,052.01 		$397.95
Toc - Plan #4 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

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 		$365.18
$414.48
$466.70
$652.21
$991.10 		$644.54
$693.84
$746.06
$931.57 		$923.90
$973.20
$1,025.42
$1,210.93 		$1,203.26
$1,252.56
$1,304.78
$1,490.29 		$279.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.36
$828.96
$933.40
$1,304.42
$1,982.20 		$1,009.72
$1,108.32
$1,212.76
$1,583.78 		$1,289.08
$1,387.68
$1,492.12
$1,863.14 		$1,568.44
$1,667.04
$1,771.48
$2,142.50 		$279.36
Toc - Plan #5 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors

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 		$513.97
$583.36
$656.85
$917.95
$1,394.91 		$907.16
$976.55
$1,050.04
$1,311.14 		$1,300.35
$1,369.74
$1,443.23
$1,704.33 		$1,693.54
$1,762.93
$1,836.42
$2,097.52 		$393.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,027.94
$1,166.72
$1,313.70
$1,835.90
$2,789.82 		$1,421.13
$1,559.91
$1,706.89
$2,229.09 		$1,814.32
$1,953.10
$2,100.08
$2,622.28 		$2,207.51
$2,346.29
$2,493.27
$3,015.47 		$393.19
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

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 		$528.32
$599.64
$675.19
$943.58
$1,433.86 		$932.48
$1,003.80
$1,079.35
$1,347.74 		$1,336.64
$1,407.96
$1,483.51
$1,751.90 		$1,740.80
$1,812.12
$1,887.67
$2,156.06 		$404.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,056.64
$1,199.28
$1,350.38
$1,887.16
$2,867.72 		$1,460.80
$1,603.44
$1,754.54
$2,291.32 		$1,864.96
$2,007.60
$2,158.70
$2,695.48 		$2,269.12
$2,411.76
$2,562.86
$3,099.64 		$404.16
Toc - Plan #7 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide Doctors

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 		$383.21
$434.94
$489.74
$684.41
$1,040.03 		$676.37
$728.10
$782.90
$977.57 		$969.53
$1,021.26
$1,076.06
$1,270.73 		$1,262.69
$1,314.42
$1,369.22
$1,563.89 		$293.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.42
$869.88
$979.48
$1,368.82
$2,080.06 		$1,059.58
$1,163.04
$1,272.64
$1,661.98 		$1,352.74
$1,456.20
$1,565.80
$1,955.14 		$1,645.90
$1,749.36
$1,858.96
$2,248.30 		$293.16
Toc - Plan #8 Blue Cross and Blue Shield of NC
Catastrophic

(PPO) Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide Doctors

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 		$268.34
$304.57
$342.94
$479.26
$728.27 		$473.62
$509.85
$548.22
$684.54 		$678.90
$715.13
$753.50
$889.82 		$884.18
$920.41
$958.78
$1,095.10 		$205.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.68
$609.14
$685.88
$958.52
$1,456.54 		$741.96
$814.42
$891.16
$1,163.80 		$947.24
$1,019.70
$1,096.44
$1,369.08 		$1,152.52
$1,224.98
$1,301.72
$1,574.36 		$205.28
Toc - Plan #9 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

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 		$522.31
$592.82
$667.51
$932.85
$1,417.55 		$921.88
$992.39
$1,067.08
$1,332.42 		$1,321.45
$1,391.96
$1,466.65
$1,731.99 		$1,721.02
$1,791.53
$1,866.22
$2,131.56 		$399.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.62
$1,185.64
$1,335.02
$1,865.70
$2,835.10 		$1,444.19
$1,585.21
$1,734.59
$2,265.27 		$1,843.76
$1,984.78
$2,134.16
$2,664.84 		$2,243.33
$2,384.35
$2,533.73
$3,064.41 		$399.57
Toc - Plan #10 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

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 		$385.91
$438.01
$493.19
$689.24
$1,047.36 		$681.13
$733.23
$788.41
$984.46 		$976.35
$1,028.45
$1,083.63
$1,279.68 		$1,271.57
$1,323.67
$1,378.85
$1,574.90 		$295.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.82
$876.02
$986.38
$1,378.48
$2,094.72 		$1,067.04
$1,171.24
$1,281.60
$1,673.70 		$1,362.26
$1,466.46
$1,576.82
$1,968.92 		$1,657.48
$1,761.68
$1,872.04
$2,264.14 		$295.22
Toc - Plan #11 Blue Cross and Blue Shield of NC
Bronze

(PPO) Blue Advantage Bronze 9100 | Integrated | Nationwide Doctors

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 		$365.88
$415.27
$467.59
$653.46
$993.00 		$645.78
$695.17
$747.49
$933.36 		$925.68
$975.07
$1,027.39
$1,213.26 		$1,205.58
$1,254.97
$1,307.29
$1,493.16 		$279.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.76
$830.54
$935.18
$1,306.92
$1,986.00 		$1,011.66
$1,110.44
$1,215.08
$1,586.82 		$1,291.56
$1,390.34
$1,494.98
$1,866.72 		$1,571.46
$1,670.24
$1,774.88
$2,146.62 		$279.90
Toc - Plan #12 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold Standard 2000 | Nationwide Doctors

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 		$512.08
$581.21
$654.44
$914.57
$1,389.79 		$903.82
$972.95
$1,046.18
$1,306.31 		$1,295.56
$1,364.69
$1,437.92
$1,698.05 		$1,687.30
$1,756.43
$1,829.66
$2,089.79 		$391.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.16
$1,162.42
$1,308.88
$1,829.14
$2,779.58 		$1,415.90
$1,554.16
$1,700.62
$2,220.88 		$1,807.64
$1,945.90
$2,092.36
$2,612.62 		$2,199.38
$2,337.64
$2,484.10
$3,004.36 		$391.74
Toc - Plan #13 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Standard 5800 | Nationwide Doctors

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 		$518.04
$587.98
$662.06
$925.22
$1,405.96 		$914.34
$984.28
$1,058.36
$1,321.52 		$1,310.64
$1,380.58
$1,454.66
$1,717.82 		$1,706.94
$1,776.88
$1,850.96
$2,114.12 		$396.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,036.08
$1,175.96
$1,324.12
$1,850.44
$2,811.92 		$1,432.38
$1,572.26
$1,720.42
$2,246.74 		$1,828.68
$1,968.56
$2,116.72
$2,643.04 		$2,224.98
$2,364.86
$2,513.02
$3,039.34 		$396.30
Toc - Plan #14 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze Standard 7500 | Nationwide Doctors

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 		$365.62
$414.98
$467.26
$653.00
$992.29 		$645.32
$694.68
$746.96
$932.70 		$925.02
$974.38
$1,026.66
$1,212.40 		$1,204.72
$1,254.08
$1,306.36
$1,492.10 		$279.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.24
$829.96
$934.52
$1,306.00
$1,984.58 		$1,010.94
$1,109.66
$1,214.22
$1,585.70 		$1,290.64
$1,389.36
$1,493.92
$1,865.40 		$1,570.34
$1,669.06
$1,773.62
$2,145.10 		$279.70

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-735-2962
Toc - Plan #15 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze HSA Eligible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.43
$448.81
$505.36
$706.24
$1,073.20 		$697.93
$751.31
$807.86
$1,008.74 		$1,000.43
$1,053.81
$1,110.36
$1,311.24 		$1,302.93
$1,356.31
$1,412.86
$1,613.74 		$302.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$790.86
$897.62
$1,010.72
$1,412.48
$2,146.40 		$1,093.36
$1,200.12
$1,313.22
$1,714.98 		$1,395.86
$1,502.62
$1,615.72
$2,017.48 		$1,698.36
$1,805.12
$1,918.22
$2,319.98 		$302.50
Toc - Plan #16 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.77
$402.66
$453.40
$633.62
$962.85 		$626.17
$674.06
$724.80
$905.02 		$897.57
$945.46
$996.20
$1,176.42 		$1,168.97
$1,216.86
$1,267.60
$1,447.82 		$271.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.54
$805.32
$906.80
$1,267.24
$1,925.70 		$980.94
$1,076.72
$1,178.20
$1,538.64 		$1,252.34
$1,348.12
$1,449.60
$1,810.04 		$1,523.74
$1,619.52
$1,721.00
$2,081.44 		$271.40
Toc - Plan #17 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.48
$389.85
$438.97
$613.46
$932.20 		$606.24
$652.61
$701.73
$876.22 		$869.00
$915.37
$964.49
$1,138.98 		$1,131.76
$1,178.13
$1,227.25
$1,401.74 		$262.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.96
$779.70
$877.94
$1,226.92
$1,864.40 		$949.72
$1,042.46
$1,140.70
$1,489.68 		$1,212.48
$1,305.22
$1,403.46
$1,752.44 		$1,475.24
$1,567.98
$1,666.22
$2,015.20 		$262.76
Toc - Plan #18 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$481.19
$546.15
$614.96
$859.41
$1,305.95 		$849.30
$914.26
$983.07
$1,227.52 		$1,217.41
$1,282.37
$1,351.18
$1,595.63 		$1,585.52
$1,650.48
$1,719.29
$1,963.74 		$368.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$962.38
$1,092.30
$1,229.92
$1,718.82
$2,611.90 		$1,330.49
$1,460.41
$1,598.03
$2,086.93 		$1,698.60
$1,828.52
$1,966.14
$2,455.04 		$2,066.71
$2,196.63
$2,334.25
$2,823.15 		$368.11
Toc - Plan #19 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$492.71
$559.23
$629.68
$879.98
$1,337.21 		$869.63
$936.15
$1,006.60
$1,256.90 		$1,246.55
$1,313.07
$1,383.52
$1,633.82 		$1,623.47
$1,689.99
$1,760.44
$2,010.74 		$376.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.42
$1,118.46
$1,259.36
$1,759.96
$2,674.42 		$1,362.34
$1,495.38
$1,636.28
$2,136.88 		$1,739.26
$1,872.30
$2,013.20
$2,513.80 		$2,116.18
$2,249.22
$2,390.12
$2,890.72 		$376.92
Toc - Plan #20 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$520.43
$590.69
$665.11
$929.49
$1,412.45 		$918.56
$988.82
$1,063.24
$1,327.62 		$1,316.69
$1,386.95
$1,461.37
$1,725.75 		$1,714.82
$1,785.08
$1,859.50
$2,123.88 		$398.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,040.86
$1,181.38
$1,330.22
$1,858.98
$2,824.90 		$1,438.99
$1,579.51
$1,728.35
$2,257.11 		$1,837.12
$1,977.64
$2,126.48
$2,655.24 		$2,235.25
$2,375.77
$2,524.61
$3,053.37 		$398.13
Toc - Plan #21 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$544.15
$617.61
$695.42
$971.85
$1,476.82 		$960.42
$1,033.88
$1,111.69
$1,388.12 		$1,376.69
$1,450.15
$1,527.96
$1,804.39 		$1,792.96
$1,866.42
$1,944.23
$2,220.66 		$416.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,088.30
$1,235.22
$1,390.84
$1,943.70
$2,953.64 		$1,504.57
$1,651.49
$1,807.11
$2,359.97 		$1,920.84
$2,067.76
$2,223.38
$2,776.24 		$2,337.11
$2,484.03
$2,639.65
$3,192.51 		$416.27
Toc - Plan #22 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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 		$516.39
$586.10
$659.95
$922.27
$1,401.48 		$911.43
$981.14
$1,054.99
$1,317.31 		$1,306.47
$1,376.18
$1,450.03
$1,712.35 		$1,701.51
$1,771.22
$1,845.07
$2,107.39 		$395.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,032.78
$1,172.20
$1,319.90
$1,844.54
$2,802.96 		$1,427.82
$1,567.24
$1,714.94
$2,239.58 		$1,822.86
$1,962.28
$2,109.98
$2,634.62 		$2,217.90
$2,357.32
$2,505.02
$3,029.66 		$395.04
Toc - Plan #23 CareSource
Expanded Bronze

(HMO) CareSource Marektplace Bronze First Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.73
$410.56
$462.29
$646.05
$981.74 		$638.45
$687.28
$739.01
$922.77 		$915.17
$964.00
$1,015.73
$1,199.49 		$1,191.89
$1,240.72
$1,292.45
$1,476.21 		$276.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.46
$821.12
$924.58
$1,292.10
$1,963.48 		$1,000.18
$1,097.84
$1,201.30
$1,568.82 		$1,276.90
$1,374.56
$1,478.02
$1,845.54 		$1,553.62
$1,651.28
$1,754.74
$2,122.26 		$276.72
Toc - Plan #24 CareSource
Bronze

(HMO) CareSource Marektplace Bronze Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.06
$397.32
$447.38
$625.21
$950.06 		$617.86
$665.12
$715.18
$893.01 		$885.66
$932.92
$982.98
$1,160.81 		$1,153.46
$1,200.72
$1,250.78
$1,428.61 		$267.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.12
$794.64
$894.76
$1,250.42
$1,900.12 		$967.92
$1,062.44
$1,162.56
$1,518.22 		$1,235.72
$1,330.24
$1,430.36
$1,786.02 		$1,503.52
$1,598.04
$1,698.16
$2,053.82 		$267.80
Toc - Plan #25 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $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 		$488.01
$553.89
$623.68
$871.59
$1,324.46 		$861.34
$927.22
$997.01
$1,244.92 		$1,234.67
$1,300.55
$1,370.34
$1,618.25 		$1,608.00
$1,673.88
$1,743.67
$1,991.58 		$373.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976.02
$1,107.78
$1,247.36
$1,743.18
$2,648.92 		$1,349.35
$1,481.11
$1,620.69
$2,116.51 		$1,722.68
$1,854.44
$1,994.02
$2,489.84 		$2,096.01
$2,227.77
$2,367.35
$2,863.17 		$373.33
Toc - Plan #26 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$499.53
$566.97
$638.40
$892.16
$1,355.72 		$881.67
$949.11
$1,020.54
$1,274.30 		$1,263.81
$1,331.25
$1,402.68
$1,656.44 		$1,645.95
$1,713.39
$1,784.82
$2,038.58 		$382.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$999.06
$1,133.94
$1,276.80
$1,784.32
$2,711.44 		$1,381.20
$1,516.08
$1,658.94
$2,166.46 		$1,763.34
$1,898.22
$2,041.08
$2,548.60 		$2,145.48
$2,280.36
$2,423.22
$2,930.74 		$382.14
Toc - Plan #27 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$527.25
$598.43
$673.83
$941.67
$1,430.96 		$930.60
$1,001.78
$1,077.18
$1,345.02 		$1,333.95
$1,405.13
$1,480.53
$1,748.37 		$1,737.30
$1,808.48
$1,883.88
$2,151.72 		$403.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,054.50
$1,196.86
$1,347.66
$1,883.34
$2,861.92 		$1,457.85
$1,600.21
$1,751.01
$2,286.69 		$1,861.20
$2,003.56
$2,154.36
$2,690.04 		$2,264.55
$2,406.91
$2,557.71
$3,093.39 		$403.35
Toc - Plan #28 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$550.77
$625.12
$703.88
$983.68
$1,494.79 		$972.11
$1,046.46
$1,125.22
$1,405.02 		$1,393.45
$1,467.80
$1,546.56
$1,826.36 		$1,814.79
$1,889.14
$1,967.90
$2,247.70 		$421.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,101.54
$1,250.24
$1,407.76
$1,967.36
$2,989.58 		$1,522.88
$1,671.58
$1,829.10
$2,388.70 		$1,944.22
$2,092.92
$2,250.44
$2,810.04 		$2,365.56
$2,514.26
$2,671.78
$3,231.38 		$421.34
Toc - Plan #29 CareSource
Gold

(HMO) CareSource Marketplace Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$523.68
$594.38
$669.26
$935.29
$1,421.27 		$924.30
$995.00
$1,069.88
$1,335.91 		$1,324.92
$1,395.62
$1,470.50
$1,736.53 		$1,725.54
$1,796.24
$1,871.12
$2,137.15 		$400.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,047.36
$1,188.76
$1,338.52
$1,870.58
$2,842.54 		$1,447.98
$1,589.38
$1,739.14
$2,271.20 		$1,848.60
$1,990.00
$2,139.76
$2,671.82 		$2,249.22
$2,390.62
$2,540.38
$3,072.44 		$400.62

ADVERTISEMENT

AmeriHealth Caritas Next

Local: 1-984-245-3613 | Toll Free: 1-833-613-2262 | TTY: 1-844-214-2471
Toc - Plan #30 AmeriHealth Caritas Next
Bronze

(HMO) AmeriHealth Caritas Next Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.57
$351.36
$395.62
$552.88
$840.15 		$546.39
$588.18
$632.44
$789.70 		$783.21
$825.00
$869.26
$1,026.52 		$1,020.03
$1,061.82
$1,106.08
$1,263.34 		$236.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.14
$702.72
$791.24
$1,105.76
$1,680.30 		$855.96
$939.54
$1,028.06
$1,342.58 		$1,092.78
$1,176.36
$1,264.88
$1,579.40 		$1,329.60
$1,413.18
$1,501.70
$1,816.22 		$236.82
Toc - Plan #31 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$348.56
$395.61
$445.45
$622.52
$945.97 		$615.21
$662.26
$712.10
$889.17 		$881.86
$928.91
$978.75
$1,155.82 		$1,148.51
$1,195.56
$1,245.40
$1,422.47 		$266.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.12
$791.22
$890.90
$1,245.04
$1,891.94 		$963.77
$1,057.87
$1,157.55
$1,511.69 		$1,230.42
$1,324.52
$1,424.20
$1,778.34 		$1,497.07
$1,591.17
$1,690.85
$2,044.99 		$266.65
Toc - Plan #32 AmeriHealth Caritas Next
Silver

(HMO) AmeriHealth Caritas Next Silver + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$474.94
$539.06
$606.98
$848.24
$1,288.99 		$838.27
$902.39
$970.31
$1,211.57 		$1,201.60
$1,265.72
$1,333.64
$1,574.90 		$1,564.93
$1,629.05
$1,696.97
$1,938.23 		$363.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$949.88
$1,078.12
$1,213.96
$1,696.48
$2,577.98 		$1,313.21
$1,441.45
$1,577.29
$2,059.81 		$1,676.54
$1,804.78
$1,940.62
$2,423.14 		$2,039.87
$2,168.11
$2,303.95
$2,786.47 		$363.33
Toc - Plan #33 AmeriHealth Caritas Next
Gold

(HMO) AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$582.99
$661.69
$745.06
$1,041.22
$1,582.23 		$1,028.98
$1,107.68
$1,191.05
$1,487.21 		$1,474.97
$1,553.67
$1,637.04
$1,933.20 		$1,920.96
$1,999.66
$2,083.03
$2,379.19 		$445.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,165.98
$1,323.38
$1,490.12
$2,082.44
$3,164.46 		$1,611.97
$1,769.37
$1,936.11
$2,528.43 		$2,057.96
$2,215.36
$2,382.10
$2,974.42 		$2,503.95
$2,661.35
$2,828.09
$3,420.41 		$445.99

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #34 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 		$564.18
$640.33
$721.01
$1,007.60
$1,531.15 		$995.77
$1,071.92
$1,152.60
$1,439.19 		$1,427.36
$1,503.51
$1,584.19
$1,870.78 		$1,858.95
$1,935.10
$2,015.78
$2,302.37 		$431.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,128.36
$1,280.66
$1,442.02
$2,015.20
$3,062.30 		$1,559.95
$1,712.25
$1,873.61
$2,446.79 		$1,991.54
$2,143.84
$2,305.20
$2,878.38 		$2,423.13
$2,575.43
$2,736.79
$3,309.97 		$431.59
Toc - Plan #35 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 		$723.77
$821.46
$924.96
$1,292.63
$1,964.28 		$1,277.44
$1,375.13
$1,478.63
$1,846.30 		$1,831.11
$1,928.80
$2,032.30
$2,399.97 		$2,384.78
$2,482.47
$2,585.97
$2,953.64 		$553.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,447.54
$1,642.92
$1,849.92
$2,585.26
$3,928.56 		$2,001.21
$2,196.59
$2,403.59
$3,138.93 		$2,554.88
$2,750.26
$2,957.26
$3,692.60 		$3,108.55
$3,303.93
$3,510.93
$4,246.27 		$553.67
Toc - Plan #36 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 		$748.88
$849.97
$957.06
$1,337.48
$2,032.44 		$1,321.77
$1,422.86
$1,529.95
$1,910.37 		$1,894.66
$1,995.75
$2,102.84
$2,483.26 		$2,467.55
$2,568.64
$2,675.73
$3,056.15 		$572.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,497.76
$1,699.94
$1,914.12
$2,674.96
$4,064.88 		$2,070.65
$2,272.83
$2,487.01
$3,247.85 		$2,643.54
$2,845.72
$3,059.90
$3,820.74 		$3,216.43
$3,418.61
$3,632.79
$4,393.63 		$572.89
Toc - Plan #37 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 		$565.12
$641.40
$722.21
$1,009.28
$1,533.71 		$997.43
$1,073.71
$1,154.52
$1,441.59 		$1,429.74
$1,506.02
$1,586.83
$1,873.90 		$1,862.05
$1,938.33
$2,019.14
$2,306.21 		$432.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,130.24
$1,282.80
$1,444.42
$2,018.56
$3,067.42 		$1,562.55
$1,715.11
$1,876.73
$2,450.87 		$1,994.86
$2,147.42
$2,309.04
$2,883.18 		$2,427.17
$2,579.73
$2,741.35
$3,315.49 		$432.31
Toc - Plan #38 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 		$715.01
$811.52
$913.77
$1,276.99
$1,940.51 		$1,261.98
$1,358.49
$1,460.74
$1,823.96 		$1,808.95
$1,905.46
$2,007.71
$2,370.93 		$2,355.92
$2,452.43
$2,554.68
$2,917.90 		$546.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,430.02
$1,623.04
$1,827.54
$2,553.98
$3,881.02 		$1,976.99
$2,170.01
$2,374.51
$3,100.95 		$2,523.96
$2,716.98
$2,921.48
$3,647.92 		$3,070.93
$3,263.95
$3,468.45
$4,194.89 		$546.97
Toc - Plan #39 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 		$728.18
$826.47
$930.60
$1,300.51
$1,976.26 		$1,285.23
$1,383.52
$1,487.65
$1,857.56 		$1,842.28
$1,940.57
$2,044.70
$2,414.61 		$2,399.33
$2,497.62
$2,601.75
$2,971.66 		$557.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,456.36
$1,652.94
$1,861.20
$2,601.02
$3,952.52 		$2,013.41
$2,209.99
$2,418.25
$3,158.07 		$2,570.46
$2,767.04
$2,975.30
$3,715.12 		$3,127.51
$3,324.09
$3,532.35
$4,272.17 		$557.05

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5357 | Toll Free: 1-800-980-5357 | TTY: 1-800-980-5357
Toc - Plan #40 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$608.41
$690.55
$777.55
$1,086.62
$1,651.23 		$1,073.84
$1,155.98
$1,242.98
$1,552.05 		$1,539.27
$1,621.41
$1,708.41
$2,017.48 		$2,004.70
$2,086.84
$2,173.84
$2,482.91 		$465.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,216.82
$1,381.10
$1,555.10
$2,173.24
$3,302.46 		$1,682.25
$1,846.53
$2,020.53
$2,638.67 		$2,147.68
$2,311.96
$2,485.96
$3,104.10 		$2,613.11
$2,777.39
$2,951.39
$3,569.53 		$465.43
Toc - Plan #41 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$600.65
$681.74
$767.63
$1,072.77
$1,630.17 		$1,060.15
$1,141.24
$1,227.13
$1,532.27 		$1,519.65
$1,600.74
$1,686.63
$1,991.77 		$1,979.15
$2,060.24
$2,146.13
$2,451.27 		$459.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,201.30
$1,363.48
$1,535.26
$2,145.54
$3,260.34 		$1,660.80
$1,822.98
$1,994.76
$2,605.04 		$2,120.30
$2,282.48
$2,454.26
$3,064.54 		$2,579.80
$2,741.98
$2,913.76
$3,524.04 		$459.50
Toc - Plan #42 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 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 		$599.69
$680.65
$766.40
$1,071.04
$1,627.55 		$1,058.45
$1,139.41
$1,225.16
$1,529.80 		$1,517.21
$1,598.17
$1,683.92
$1,988.56 		$1,975.97
$2,056.93
$2,142.68
$2,447.32 		$458.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,199.38
$1,361.30
$1,532.80
$2,142.08
$3,255.10 		$1,658.14
$1,820.06
$1,991.56
$2,600.84 		$2,116.90
$2,278.82
$2,450.32
$3,059.60 		$2,575.66
$2,737.58
$2,909.08
$3,518.36 		$458.76
Toc - Plan #43 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded Saver ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$423.71
$480.91
$541.50
$756.74
$1,149.95 		$747.85
$805.05
$865.64
$1,080.88 		$1,071.99
$1,129.19
$1,189.78
$1,405.02 		$1,396.13
$1,453.33
$1,513.92
$1,729.16 		$324.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847.42
$961.82
$1,083.00
$1,513.48
$2,299.90 		$1,171.56
$1,285.96
$1,407.14
$1,837.62 		$1,495.70
$1,610.10
$1,731.28
$2,161.76 		$1,819.84
$1,934.24
$2,055.42
$2,485.90 		$324.14
Toc - Plan #44 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$631.95
$717.26
$807.63
$1,128.66
$1,715.10 		$1,115.39
$1,200.70
$1,291.07
$1,612.10 		$1,598.83
$1,684.14
$1,774.51
$2,095.54 		$2,082.27
$2,167.58
$2,257.95
$2,578.98 		$483.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,263.90
$1,434.52
$1,615.26
$2,257.32
$3,430.20 		$1,747.34
$1,917.96
$2,098.70
$2,740.76 		$2,230.78
$2,401.40
$2,582.14
$3,224.20 		$2,714.22
$2,884.84
$3,065.58
$3,707.64 		$483.44
Toc - Plan #45 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$655.45
$743.93
$837.66
$1,170.63
$1,778.88 		$1,156.87
$1,245.35
$1,339.08
$1,672.05 		$1,658.29
$1,746.77
$1,840.50
$2,173.47 		$2,159.71
$2,248.19
$2,341.92
$2,674.89 		$501.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,310.90
$1,487.86
$1,675.32
$2,341.26
$3,557.76 		$1,812.32
$1,989.28
$2,176.74
$2,842.68 		$2,313.74
$2,490.70
$2,678.16
$3,344.10 		$2,815.16
$2,992.12
$3,179.58
$3,845.52 		$501.42
Toc - Plan #46 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$450.63
$511.46
$575.90
$804.82
$1,223.01 		$795.36
$856.19
$920.63
$1,149.55 		$1,140.09
$1,200.92
$1,265.36
$1,494.28 		$1,484.82
$1,545.65
$1,610.09
$1,839.01 		$344.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.26
$1,022.92
$1,151.80
$1,609.64
$2,446.02 		$1,245.99
$1,367.65
$1,496.53
$1,954.37 		$1,590.72
$1,712.38
$1,841.26
$2,299.10 		$1,935.45
$2,057.11
$2,185.99
$2,643.83 		$344.73
Toc - Plan #47 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$600.07
$681.08
$766.89
$1,071.72
$1,628.59 		$1,059.12
$1,140.13
$1,225.94
$1,530.77 		$1,518.17
$1,599.18
$1,684.99
$1,989.82 		$1,977.22
$2,058.23
$2,144.04
$2,448.87 		$459.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,200.14
$1,362.16
$1,533.78
$2,143.44
$3,257.18 		$1,659.19
$1,821.21
$1,992.83
$2,602.49 		$2,118.24
$2,280.26
$2,451.88
$3,061.54 		$2,577.29
$2,739.31
$2,910.93
$3,520.59 		$459.05
Toc - Plan #48 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$428.90
$486.81
$548.14
$766.02
$1,164.05 		$757.01
$814.92
$876.25
$1,094.13 		$1,085.12
$1,143.03
$1,204.36
$1,422.24 		$1,413.23
$1,471.14
$1,532.47
$1,750.35 		$328.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.80
$973.62
$1,096.28
$1,532.04
$2,328.10 		$1,185.91
$1,301.73
$1,424.39
$1,860.15 		$1,514.02
$1,629.84
$1,752.50
$2,188.26 		$1,842.13
$1,957.95
$2,080.61
$2,516.37 		$328.11
Toc - Plan #49 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$619.28
$702.88
$791.44
$1,106.03
$1,680.72 		$1,093.03
$1,176.63
$1,265.19
$1,579.78 		$1,566.78
$1,650.38
$1,738.94
$2,053.53 		$2,040.53
$2,124.13
$2,212.69
$2,527.28 		$473.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,238.56
$1,405.76
$1,582.88
$2,212.06
$3,361.44 		$1,712.31
$1,879.51
$2,056.63
$2,685.81 		$2,186.06
$2,353.26
$2,530.38
$3,159.56 		$2,659.81
$2,827.01
$3,004.13
$3,633.31 		$473.75
Toc - Plan #50 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$609.05
$691.28
$778.37
$1,087.77
$1,652.97 		$1,074.98
$1,157.21
$1,244.30
$1,553.70 		$1,540.91
$1,623.14
$1,710.23
$2,019.63 		$2,006.84
$2,089.07
$2,176.16
$2,485.56 		$465.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,218.10
$1,382.56
$1,556.74
$2,175.54
$3,305.94 		$1,684.03
$1,848.49
$2,022.67
$2,641.47 		$2,149.96
$2,314.42
$2,488.60
$3,107.40 		$2,615.89
$2,780.35
$2,954.53
$3,573.33 		$465.93
Toc - Plan #51 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $2,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$594.68
$674.96
$760.00
$1,062.10
$1,613.97 		$1,049.61
$1,129.89
$1,214.93
$1,517.03 		$1,504.54
$1,584.82
$1,669.86
$1,971.96 		$1,959.47
$2,039.75
$2,124.79
$2,426.89 		$454.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,189.36
$1,349.92
$1,520.00
$2,124.20
$3,227.94 		$1,644.29
$1,804.85
$1,974.93
$2,579.13 		$2,099.22
$2,259.78
$2,429.86
$3,034.06 		$2,554.15
$2,714.71
$2,884.79
$3,488.99 		$454.93
Toc - Plan #52 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$627.00
$711.65
$801.31
$1,119.82
$1,701.68 		$1,106.66
$1,191.31
$1,280.97
$1,599.48 		$1,586.32
$1,670.97
$1,760.63
$2,079.14 		$2,065.98
$2,150.63
$2,240.29
$2,558.80 		$479.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,254.00
$1,423.30
$1,602.62
$2,239.64
$3,403.36 		$1,733.66
$1,902.96
$2,082.28
$2,719.30 		$2,213.32
$2,382.62
$2,561.94
$3,198.96 		$2,692.98
$2,862.28
$3,041.60
$3,678.62 		$479.66
Toc - Plan #53 UnitedHealthcare
Silver

(HMO) UHC Silver Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$598.02
$678.75
$764.27
$1,068.06
$1,623.02 		$1,055.50
$1,136.23
$1,221.75
$1,525.54 		$1,512.98
$1,593.71
$1,679.23
$1,983.02 		$1,970.46
$2,051.19
$2,136.71
$2,440.50 		$457.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,196.04
$1,357.50
$1,528.54
$2,136.12
$3,246.04 		$1,653.52
$1,814.98
$1,986.02
$2,593.60 		$2,111.00
$2,272.46
$2,443.50
$3,051.08 		$2,568.48
$2,729.94
$2,900.98
$3,508.56 		$457.48
Toc - Plan #54 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$409.84
$465.17
$523.77
$731.97
$1,112.30 		$723.37
$778.70
$837.30
$1,045.50 		$1,036.90
$1,092.23
$1,150.83
$1,359.03 		$1,350.43
$1,405.76
$1,464.36
$1,672.56 		$313.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.68
$930.34
$1,047.54
$1,463.94
$2,224.60 		$1,133.21
$1,243.87
$1,361.07
$1,777.47 		$1,446.74
$1,557.40
$1,674.60
$2,091.00 		$1,760.27
$1,870.93
$1,988.13
$2,404.53 		$313.53
Toc - Plan #55 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$408.42
$463.56
$521.96
$729.44
$1,108.45 		$720.86
$776.00
$834.40
$1,041.88 		$1,033.30
$1,088.44
$1,146.84
$1,354.32 		$1,345.74
$1,400.88
$1,459.28
$1,666.76 		$312.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.84
$927.12
$1,043.92
$1,458.88
$2,216.90 		$1,129.28
$1,239.56
$1,356.36
$1,771.32 		$1,441.72
$1,552.00
$1,668.80
$2,083.76 		$1,754.16
$1,864.44
$1,981.24
$2,396.20 		$312.44
Toc - Plan #56 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$429.61
$487.60
$549.04
$767.28
$1,165.96 		$758.26
$816.25
$877.69
$1,095.93 		$1,086.91
$1,144.90
$1,206.34
$1,424.58 		$1,415.56
$1,473.55
$1,534.99
$1,753.23 		$328.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$859.22
$975.20
$1,098.08
$1,534.56
$2,331.92 		$1,187.87
$1,303.85
$1,426.73
$1,863.21 		$1,516.52
$1,632.50
$1,755.38
$2,191.86 		$1,845.17
$1,961.15
$2,084.03
$2,520.51 		$328.65
Toc - Plan #57 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $6,350 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.33
$474.81
$534.63
$747.15
$1,135.36 		$738.36
$794.84
$854.66
$1,067.18 		$1,058.39
$1,114.87
$1,174.69
$1,387.21 		$1,378.42
$1,434.90
$1,494.72
$1,707.24 		$320.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$836.66
$949.62
$1,069.26
$1,494.30
$2,270.72 		$1,156.69
$1,269.65
$1,389.29
$1,814.33 		$1,476.72
$1,589.68
$1,709.32
$2,134.36 		$1,796.75
$1,909.71
$2,029.35
$2,454.39 		$320.03

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #58 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 		$339.14
$384.92
$433.42
$605.70
$920.42 		$598.58
$644.36
$692.86
$865.14 		$858.02
$903.80
$952.30
$1,124.58 		$1,117.46
$1,163.24
$1,211.74
$1,384.02 		$259.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.28
$769.84
$866.84
$1,211.40
$1,840.84 		$937.72
$1,029.28
$1,126.28
$1,470.84 		$1,197.16
$1,288.72
$1,385.72
$1,730.28 		$1,456.60
$1,548.16
$1,645.16
$1,989.72 		$259.44
Toc - Plan #59 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 		$305.17
$346.37
$390.01
$545.04
$828.24 		$538.63
$579.83
$623.47
$778.50 		$772.09
$813.29
$856.93
$1,011.96 		$1,005.55
$1,046.75
$1,090.39
$1,245.42 		$233.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.34
$692.74
$780.02
$1,090.08
$1,656.48 		$843.80
$926.20
$1,013.48
$1,323.54 		$1,077.26
$1,159.66
$1,246.94
$1,557.00 		$1,310.72
$1,393.12
$1,480.40
$1,790.46 		$233.46
Toc - Plan #60 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 		$500.49
$568.05
$639.62
$893.87
$1,358.32 		$883.36
$950.92
$1,022.49
$1,276.74 		$1,266.23
$1,333.79
$1,405.36
$1,659.61 		$1,649.10
$1,716.66
$1,788.23
$2,042.48 		$382.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,000.98
$1,136.10
$1,279.24
$1,787.74
$2,716.64 		$1,383.85
$1,518.97
$1,662.11
$2,170.61 		$1,766.72
$1,901.84
$2,044.98
$2,553.48 		$2,149.59
$2,284.71
$2,427.85
$2,936.35 		$382.87
Toc - Plan #61 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 		$469.67
$533.08
$600.24
$838.83
$1,274.69 		$828.97
$892.38
$959.54
$1,198.13 		$1,188.27
$1,251.68
$1,318.84
$1,557.43 		$1,547.57
$1,610.98
$1,678.14
$1,916.73 		$359.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.34
$1,066.16
$1,200.48
$1,677.66
$2,549.38 		$1,298.64
$1,425.46
$1,559.78
$2,036.96 		$1,657.94
$1,784.76
$1,919.08
$2,396.26 		$2,017.24
$2,144.06
$2,278.38
$2,755.56 		$359.30
Toc - Plan #62 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 		$445.80
$505.98
$569.73
$796.19
$1,209.89 		$786.83
$847.01
$910.76
$1,137.22 		$1,127.86
$1,188.04
$1,251.79
$1,478.25 		$1,468.89
$1,529.07
$1,592.82
$1,819.28 		$341.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891.60
$1,011.96
$1,139.46
$1,592.38
$2,419.78 		$1,232.63
$1,352.99
$1,480.49
$1,933.41 		$1,573.66
$1,694.02
$1,821.52
$2,274.44 		$1,914.69
$2,035.05
$2,162.55
$2,615.47 		$341.03
Toc - Plan #63 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 		$316.29
$358.99
$404.22
$564.90
$858.42 		$558.25
$600.95
$646.18
$806.86 		$800.21
$842.91
$888.14
$1,048.82 		$1,042.17
$1,084.87
$1,130.10
$1,290.78 		$241.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.58
$717.98
$808.44
$1,129.80
$1,716.84 		$874.54
$959.94
$1,050.40
$1,371.76 		$1,116.50
$1,201.90
$1,292.36
$1,613.72 		$1,358.46
$1,443.86
$1,534.32
$1,855.68 		$241.96
Toc - Plan #64 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 		$491.27
$557.59
$627.84
$877.41
$1,333.31 		$867.09
$933.41
$1,003.66
$1,253.23 		$1,242.91
$1,309.23
$1,379.48
$1,629.05 		$1,618.73
$1,685.05
$1,755.30
$2,004.87 		$375.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$982.54
$1,115.18
$1,255.68
$1,754.82
$2,666.62 		$1,358.36
$1,491.00
$1,631.50
$2,130.64 		$1,734.18
$1,866.82
$2,007.32
$2,506.46 		$2,110.00
$2,242.64
$2,383.14
$2,882.28 		$375.82
Toc - Plan #65 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 		$461.12
$523.37
$589.31
$823.56
$1,251.48 		$813.88
$876.13
$942.07
$1,176.32 		$1,166.64
$1,228.89
$1,294.83
$1,529.08 		$1,519.40
$1,581.65
$1,647.59
$1,881.84 		$352.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.24
$1,046.74
$1,178.62
$1,647.12
$2,502.96 		$1,275.00
$1,399.50
$1,531.38
$1,999.88 		$1,627.76
$1,752.26
$1,884.14
$2,352.64 		$1,980.52
$2,105.02
$2,236.90
$2,705.40 		$352.76
Toc - Plan #66 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 		$435.37
$494.15
$556.41
$777.58
$1,181.60 		$768.43
$827.21
$889.47
$1,110.64 		$1,101.49
$1,160.27
$1,222.53
$1,443.70 		$1,434.55
$1,493.33
$1,555.59
$1,776.76 		$333.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.74
$988.30
$1,112.82
$1,555.16
$2,363.20 		$1,203.80
$1,321.36
$1,445.88
$1,888.22 		$1,536.86
$1,654.42
$1,778.94
$2,221.28 		$1,869.92
$1,987.48
$2,112.00
$2,554.34 		$333.06

ADVERTISEMENT

Oscar Health Plan of North Carolina, Inc

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755 | TTY: 1-855-672-2755
Toc - Plan #67 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Classic- PCP Saver

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 		$383.63
$435.41
$490.26
$685.14
$1,041.14 		$677.10
$728.88
$783.73
$978.61 		$970.57
$1,022.35
$1,077.20
$1,272.08 		$1,264.04
$1,315.82
$1,370.67
$1,565.55 		$293.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.26
$870.82
$980.52
$1,370.28
$2,082.28 		$1,060.73
$1,164.29
$1,273.99
$1,663.75 		$1,354.20
$1,457.76
$1,567.46
$1,957.22 		$1,647.67
$1,751.23
$1,860.93
$2,250.69 		$293.47
Toc - Plan #68 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$373.79
$424.24
$477.69
$667.57
$1,014.44 		$659.73
$710.18
$763.63
$953.51 		$945.67
$996.12
$1,049.57
$1,239.45 		$1,231.61
$1,282.06
$1,335.51
$1,525.39 		$285.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.58
$848.48
$955.38
$1,335.14
$2,028.88 		$1,033.52
$1,134.42
$1,241.32
$1,621.08 		$1,319.46
$1,420.36
$1,527.26
$1,907.02 		$1,605.40
$1,706.30
$1,813.20
$2,192.96 		$285.94
Toc - Plan #69 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Elite- Deductible + PCP Saver Plus

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 		$454.28
$515.60
$580.56
$811.33
$1,232.90 		$801.80
$863.12
$928.08
$1,158.85 		$1,149.32
$1,210.64
$1,275.60
$1,506.37 		$1,496.84
$1,558.16
$1,623.12
$1,853.89 		$347.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.56
$1,031.20
$1,161.12
$1,622.66
$2,465.80 		$1,256.08
$1,378.72
$1,508.64
$1,970.18 		$1,603.60
$1,726.24
$1,856.16
$2,317.70 		$1,951.12
$2,073.76
$2,203.68
$2,665.22 		$347.52
Toc - Plan #70 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$521.48
$591.87
$666.44
$931.35
$1,415.27 		$920.41
$990.80
$1,065.37
$1,330.28 		$1,319.34
$1,389.73
$1,464.30
$1,729.21 		$1,718.27
$1,788.66
$1,863.23
$2,128.14 		$398.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.96
$1,183.74
$1,332.88
$1,862.70
$2,830.54 		$1,441.89
$1,582.67
$1,731.81
$2,261.63 		$1,840.82
$1,981.60
$2,130.74
$2,660.56 		$2,239.75
$2,380.53
$2,529.67
$3,059.49 		$398.93
Toc - Plan #71 Oscar Health Plan of North Carolina, Inc
Catastrophic

(HMO) 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 		$321.36
$364.74
$410.69
$573.94
$872.15 		$567.20
$610.58
$656.53
$819.78 		$813.04
$856.42
$902.37
$1,065.62 		$1,058.88
$1,102.26
$1,148.21
$1,311.46 		$245.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.72
$729.48
$821.38
$1,147.88
$1,744.30 		$888.56
$975.32
$1,067.22
$1,393.72 		$1,134.40
$1,221.16
$1,313.06
$1,639.56 		$1,380.24
$1,467.00
$1,558.90
$1,885.40 		$245.84
Toc - Plan #72 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Elite- Deductible + Specialist Saver Plus

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 		$452.16
$513.19
$577.84
$807.53
$1,227.13 		$798.05
$859.08
$923.73
$1,153.42 		$1,143.94
$1,204.97
$1,269.62
$1,499.31 		$1,489.83
$1,550.86
$1,615.51
$1,845.20 		$345.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.32
$1,026.38
$1,155.68
$1,615.06
$2,454.26 		$1,250.21
$1,372.27
$1,501.57
$1,960.95 		$1,596.10
$1,718.16
$1,847.46
$2,306.84 		$1,941.99
$2,064.05
$2,193.35
$2,652.73 		$345.89
Toc - Plan #73 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$543.29
$616.62
$694.31
$970.29
$1,474.45 		$958.90
$1,032.23
$1,109.92
$1,385.90 		$1,374.51
$1,447.84
$1,525.53
$1,801.51 		$1,790.12
$1,863.45
$1,941.14
$2,217.12 		$415.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,086.58
$1,233.24
$1,388.62
$1,940.58
$2,948.90 		$1,502.19
$1,648.85
$1,804.23
$2,356.19 		$1,917.80
$2,064.46
$2,219.84
$2,771.80 		$2,333.41
$2,480.07
$2,635.45
$3,187.41 		$415.61
Toc - Plan #74 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$403.99
$458.52
$516.28
$721.51
$1,096.40 		$713.03
$767.56
$825.32
$1,030.55 		$1,022.07
$1,076.60
$1,134.36
$1,339.59 		$1,331.11
$1,385.64
$1,443.40
$1,648.63 		$309.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.98
$917.04
$1,032.56
$1,443.02
$2,192.80 		$1,117.02
$1,226.08
$1,341.60
$1,752.06 		$1,426.06
$1,535.12
$1,650.64
$2,061.10 		$1,735.10
$1,844.16
$1,959.68
$2,370.14 		$309.04
Toc - Plan #75 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$514.96
$584.47
$658.10
$919.70
$1,397.57 		$908.89
$978.40
$1,052.03
$1,313.63 		$1,302.82
$1,372.33
$1,445.96
$1,707.56 		$1,696.75
$1,766.26
$1,839.89
$2,101.49 		$393.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,029.92
$1,168.94
$1,316.20
$1,839.40
$2,795.14 		$1,423.85
$1,562.87
$1,710.13
$2,233.33 		$1,817.78
$1,956.80
$2,104.06
$2,627.26 		$2,211.71
$2,350.73
$2,497.99
$3,021.19 		$393.93
Toc - Plan #76 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Classic- Deductible 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
$9,000 $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 		$548.75
$622.82
$701.29
$980.04
$1,489.27 		$968.53
$1,042.60
$1,121.07
$1,399.82 		$1,388.31
$1,462.38
$1,540.85
$1,819.60 		$1,808.09
$1,882.16
$1,960.63
$2,239.38 		$419.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,097.50
$1,245.64
$1,402.58
$1,960.08
$2,978.54 		$1,517.28
$1,665.42
$1,822.36
$2,379.86 		$1,937.06
$2,085.20
$2,242.14
$2,799.64 		$2,356.84
$2,504.98
$2,661.92
$3,219.42 		$419.78
Toc - Plan #77 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Classic- Deductible Saver

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 		$404.04
$458.58
$516.36
$721.61
$1,096.55 		$713.13
$767.67
$825.45
$1,030.70 		$1,022.22
$1,076.76
$1,134.54
$1,339.79 		$1,331.31
$1,385.85
$1,443.63
$1,648.88 		$309.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.08
$917.16
$1,032.72
$1,443.22
$2,193.10 		$1,117.17
$1,226.25
$1,341.81
$1,752.31 		$1,426.26
$1,535.34
$1,650.90
$2,061.40 		$1,735.35
$1,844.43
$1,959.99
$2,370.49 		$309.09
Toc - Plan #78 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$501.96
$569.72
$641.49
$896.49
$1,362.30 		$885.95
$953.71
$1,025.48
$1,280.48 		$1,269.94
$1,337.70
$1,409.47
$1,664.47 		$1,653.93
$1,721.69
$1,793.46
$2,048.46 		$383.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.92
$1,139.44
$1,282.98
$1,792.98
$2,724.60 		$1,387.91
$1,523.43
$1,666.97
$2,176.97 		$1,771.90
$1,907.42
$2,050.96
$2,560.96 		$2,155.89
$2,291.41
$2,434.95
$2,944.95 		$383.99
Toc - Plan #79 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Elite- Deductible Saver Plus

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 		$529.20
$600.63
$676.31
$945.13
$1,436.22 		$934.03
$1,005.46
$1,081.14
$1,349.96 		$1,338.86
$1,410.29
$1,485.97
$1,754.79 		$1,743.69
$1,815.12
$1,890.80
$2,159.62 		$404.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,058.40
$1,201.26
$1,352.62
$1,890.26
$2,872.44 		$1,463.23
$1,606.09
$1,757.45
$2,295.09 		$1,868.06
$2,010.92
$2,162.28
$2,699.92 		$2,272.89
$2,415.75
$2,567.11
$3,104.75 		$404.83
Toc - Plan #80 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) Gold Elite- Deductible Saver Plus

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

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 		$610.28
$692.66
$779.93
$1,089.95
$1,656.28 		$1,077.14
$1,159.52
$1,246.79
$1,556.81 		$1,544.00
$1,626.38
$1,713.65
$2,023.67 		$2,010.86
$2,093.24
$2,180.51
$2,490.53 		$466.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,220.56
$1,385.32
$1,559.86
$2,179.90
$3,312.56 		$1,687.42
$1,852.18
$2,026.72
$2,646.76 		$2,154.28
$2,319.04
$2,493.58
$3,113.62 		$2,621.14
$2,785.90
$2,960.44
$3,580.48 		$466.86
Toc - Plan #81 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) Gold Elite

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,500 $11,000 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 		$568.51
$645.25
$726.55
$1,015.35
$1,542.92 		$1,003.42
$1,080.16
$1,161.46
$1,450.26 		$1,438.33
$1,515.07
$1,596.37
$1,885.17 		$1,873.24
$1,949.98
$2,031.28
$2,320.08 		$434.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,137.02
$1,290.50
$1,453.10
$2,030.70
$3,085.84 		$1,571.93
$1,725.41
$1,888.01
$2,465.61 		$2,006.84
$2,160.32
$2,322.92
$2,900.52 		$2,441.75
$2,595.23
$2,757.83
$3,335.43 		$434.91
Toc - Plan #82 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Elite- Deductible Saver Plus

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 		$449.33
$509.98
$574.23
$802.49
$1,219.45 		$793.06
$853.71
$917.96
$1,146.22 		$1,136.79
$1,197.44
$1,261.69
$1,489.95 		$1,480.52
$1,541.17
$1,605.42
$1,833.68 		$343.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$898.66
$1,019.96
$1,148.46
$1,604.98
$2,438.90 		$1,242.39
$1,363.69
$1,492.19
$1,948.71 		$1,586.12
$1,707.42
$1,835.92
$2,292.44 		$1,929.85
$2,051.15
$2,179.65
$2,636.17 		$343.73
Toc - Plan #83 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$517.70
$587.58
$661.61
$924.59
$1,405.01 		$913.73
$983.61
$1,057.64
$1,320.62 		$1,309.76
$1,379.64
$1,453.67
$1,716.65 		$1,705.79
$1,775.67
$1,849.70
$2,112.68 		$396.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,035.40
$1,175.16
$1,323.22
$1,849.18
$2,810.02 		$1,431.43
$1,571.19
$1,719.25
$2,245.21 		$1,827.46
$1,967.22
$2,115.28
$2,641.24 		$2,223.49
$2,363.25
$2,511.31
$3,037.27 		$396.03
Toc - Plan #84 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) 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 		$395.71
$449.12
$505.71
$706.73
$1,073.94 		$698.42
$751.83
$808.42
$1,009.44 		$1,001.13
$1,054.54
$1,111.13
$1,312.15 		$1,303.84
$1,357.25
$1,413.84
$1,614.86 		$302.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.42
$898.24
$1,011.42
$1,413.46
$2,147.88 		$1,094.13
$1,200.95
$1,314.13
$1,716.17 		$1,396.84
$1,503.66
$1,616.84
$2,018.88 		$1,699.55
$1,806.37
$1,919.55
$2,321.59 		$302.71
Toc - Plan #85 Oscar Health Plan of North Carolina, Inc
Bronze

(HMO) 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 		$353.87
$401.63
$452.23
$631.99
$960.38 		$624.57
$672.33
$722.93
$902.69 		$895.27
$943.03
$993.63
$1,173.39 		$1,165.97
$1,213.73
$1,264.33
$1,444.09 		$270.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$707.74
$803.26
$904.46
$1,263.98
$1,920.76 		$978.44
$1,073.96
$1,175.16
$1,534.68 		$1,249.14
$1,344.66
$1,445.86
$1,805.38 		$1,519.84
$1,615.36
$1,716.56
$2,076.08 		$270.70
Toc - Plan #86 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) 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 		$506.77
$575.17
$647.64
$905.07
$1,375.35 		$894.44
$962.84
$1,035.31
$1,292.74 		$1,282.11
$1,350.51
$1,422.98
$1,680.41 		$1,669.78
$1,738.18
$1,810.65
$2,068.08 		$387.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,013.54
$1,150.34
$1,295.28
$1,810.14
$2,750.70 		$1,401.21
$1,538.01
$1,682.95
$2,197.81 		$1,788.88
$1,925.68
$2,070.62
$2,585.48 		$2,176.55
$2,313.35
$2,458.29
$2,973.15 		$387.67
Toc - Plan #87 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) 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 		$514.83
$584.32
$657.94
$919.47
$1,397.22 		$908.67
$978.16
$1,051.78
$1,313.31 		$1,302.51
$1,372.00
$1,445.62
$1,707.15 		$1,696.35
$1,765.84
$1,839.46
$2,100.99 		$393.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,029.66
$1,168.64
$1,315.88
$1,838.94
$2,794.44 		$1,423.50
$1,562.48
$1,709.72
$2,232.78 		$1,817.34
$1,956.32
$2,103.56
$2,626.62 		$2,211.18
$2,350.16
$2,497.40
$3,020.46 		$393.84

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #88 Cigna Healthcare
Gold

(HMO) Cigna Connect 2100

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

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$758.75
$861.18
$969.68
$1,355.13
$2,059.25 		$1,339.19
$1,441.62
$1,550.12
$1,935.57 		$1,919.63
$2,022.06
$2,130.56
$2,516.01 		$2,500.07
$2,602.50
$2,711.00
$3,096.45 		$580.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,517.50
$1,722.36
$1,939.36
$2,710.26
$4,118.50 		$2,097.94
$2,302.80
$2,519.80
$3,290.70 		$2,678.38
$2,883.24
$3,100.24
$3,871.14 		$3,258.82
$3,463.68
$3,680.68
$4,451.58 		$580.44
Toc - Plan #89 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.40
$506.66
$570.50
$797.27
$1,211.52 		$787.89
$848.15
$911.99
$1,138.76 		$1,129.38
$1,189.64
$1,253.48
$1,480.25 		$1,470.87
$1,531.13
$1,594.97
$1,821.74 		$341.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.80
$1,013.32
$1,141.00
$1,594.54
$2,423.04 		$1,234.29
$1,354.81
$1,482.49
$1,936.03 		$1,575.78
$1,696.30
$1,823.98
$2,277.52 		$1,917.27
$2,037.79
$2,165.47
$2,619.01 		$341.49
Toc - Plan #90 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7800

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

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$469.91
$533.35
$600.54
$839.26
$1,275.33 		$829.39
$892.83
$960.02
$1,198.74 		$1,188.87
$1,252.31
$1,319.50
$1,558.22 		$1,548.35
$1,611.79
$1,678.98
$1,917.70 		$359.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.82
$1,066.70
$1,201.08
$1,678.52
$2,550.66 		$1,299.30
$1,426.18
$1,560.56
$2,038.00 		$1,658.78
$1,785.66
$1,920.04
$2,397.48 		$2,018.26
$2,145.14
$2,279.52
$2,756.96 		$359.48
Toc - Plan #91 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5900

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$463.83
$526.44
$592.77
$828.40
$1,258.83 		$818.66
$881.27
$947.60
$1,183.23 		$1,173.49
$1,236.10
$1,302.43
$1,538.06 		$1,528.32
$1,590.93
$1,657.26
$1,892.89 		$354.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$927.66
$1,052.88
$1,185.54
$1,656.80
$2,517.66 		$1,282.49
$1,407.71
$1,540.37
$2,011.63 		$1,637.32
$1,762.54
$1,895.20
$2,366.46 		$1,992.15
$2,117.37
$2,250.03
$2,721.29 		$354.83
Toc - Plan #92 Cigna Healthcare
Silver

(HMO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $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 		$547.59
$621.51
$699.82
$977.99
$1,486.16 		$966.50
$1,040.42
$1,118.73
$1,396.90 		$1,385.41
$1,459.33
$1,537.64
$1,815.81 		$1,804.32
$1,878.24
$1,956.55
$2,234.72 		$418.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,095.18
$1,243.02
$1,399.64
$1,955.98
$2,972.32 		$1,514.09
$1,661.93
$1,818.55
$2,374.89 		$1,933.00
$2,080.84
$2,237.46
$2,793.80 		$2,351.91
$2,499.75
$2,656.37
$3,212.71 		$418.91
Toc - Plan #93 Cigna Healthcare
Silver

(HMO) Cigna Connect 4500

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

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 		$546.84
$620.66
$698.86
$976.65
$1,484.12 		$965.17
$1,038.99
$1,117.19
$1,394.98 		$1,383.50
$1,457.32
$1,535.52
$1,813.31 		$1,801.83
$1,875.65
$1,953.85
$2,231.64 		$418.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,093.68
$1,241.32
$1,397.72
$1,953.30
$2,968.24 		$1,512.01
$1,659.65
$1,816.05
$2,371.63 		$1,930.34
$2,077.98
$2,234.38
$2,789.96 		$2,348.67
$2,496.31
$2,652.71
$3,208.29 		$418.33
Toc - Plan #94 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500

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

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 		$549.16
$623.29
$701.82
$980.79
$1,490.41 		$969.26
$1,043.39
$1,121.92
$1,400.89 		$1,389.36
$1,463.49
$1,542.02
$1,820.99 		$1,809.46
$1,883.59
$1,962.12
$2,241.09 		$420.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,098.32
$1,246.58
$1,403.64
$1,961.58
$2,980.82 		$1,518.42
$1,666.68
$1,823.74
$2,381.68 		$1,938.52
$2,086.78
$2,243.84
$2,801.78 		$2,358.62
$2,506.88
$2,663.94
$3,221.88 		$420.10
Toc - Plan #95 Cigna Healthcare
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$551.98
$626.50
$705.43
$985.83
$1,498.07 		$974.24
$1,048.76
$1,127.69
$1,408.09 		$1,396.50
$1,471.02
$1,549.95
$1,830.35 		$1,818.76
$1,893.28
$1,972.21
$2,252.61 		$422.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,103.96
$1,253.00
$1,410.86
$1,971.66
$2,996.14 		$1,526.22
$1,675.26
$1,833.12
$2,393.92 		$1,948.48
$2,097.52
$2,255.38
$2,816.18 		$2,370.74
$2,519.78
$2,677.64
$3,238.44 		$422.26
Toc - Plan #96 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7050

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

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$466.02
$528.93
$595.58
$832.31
$1,264.78 		$822.53
$885.44
$952.09
$1,188.82 		$1,179.04
$1,241.95
$1,308.60
$1,545.33 		$1,535.55
$1,598.46
$1,665.11
$1,901.84 		$356.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$932.04
$1,057.86
$1,191.16
$1,664.62
$2,529.56 		$1,288.55
$1,414.37
$1,547.67
$2,021.13 		$1,645.06
$1,770.88
$1,904.18
$2,377.64 		$2,001.57
$2,127.39
$2,260.69
$2,734.15 		$356.51
Toc - Plan #97 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$550.35
$624.65
$703.34
$982.92
$1,493.64 		$971.37
$1,045.67
$1,124.36
$1,403.94 		$1,392.39
$1,466.69
$1,545.38
$1,824.96 		$1,813.41
$1,887.71
$1,966.40
$2,245.98 		$421.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,100.70
$1,249.30
$1,406.68
$1,965.84
$2,987.28 		$1,521.72
$1,670.32
$1,827.70
$2,386.86 		$1,942.74
$2,091.34
$2,248.72
$2,807.88 		$2,363.76
$2,512.36
$2,669.74
$3,228.90 		$421.02
Toc - Plan #98 Cigna Healthcare
Bronze

(HMO) 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 		$442.01
$501.68
$564.89
$789.43
$1,199.61 		$780.15
$839.82
$903.03
$1,127.57 		$1,118.29
$1,177.96
$1,241.17
$1,465.71 		$1,456.43
$1,516.10
$1,579.31
$1,803.85 		$338.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.02
$1,003.36
$1,129.78
$1,578.86
$2,399.22 		$1,222.16
$1,341.50
$1,467.92
$1,917.00 		$1,560.30
$1,679.64
$1,806.06
$2,255.14 		$1,898.44
$2,017.78
$2,144.20
$2,593.28 		$338.14
Toc - Plan #99 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Simple Choice 7500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.76
$522.96
$588.84
$822.91
$1,250.49 		$813.24
$875.44
$941.32
$1,175.39 		$1,165.72
$1,227.92
$1,293.80
$1,527.87 		$1,518.20
$1,580.40
$1,646.28
$1,880.35 		$352.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$921.52
$1,045.92
$1,177.68
$1,645.82
$2,500.98 		$1,274.00
$1,398.40
$1,530.16
$1,998.30 		$1,626.48
$1,750.88
$1,882.64
$2,350.78 		$1,978.96
$2,103.36
$2,235.12
$2,703.26 		$352.48
Toc - Plan #100 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 0A

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$492.54
$559.04
$629.47
$879.68
$1,336.76 		$869.33
$935.83
$1,006.26
$1,256.47 		$1,246.12
$1,312.62
$1,383.05
$1,633.26 		$1,622.91
$1,689.41
$1,759.84
$2,010.05 		$376.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.08
$1,118.08
$1,258.94
$1,759.36
$2,673.52 		$1,361.87
$1,494.87
$1,635.73
$2,136.15 		$1,738.66
$1,871.66
$2,012.52
$2,512.94 		$2,115.45
$2,248.45
$2,389.31
$2,889.73 		$376.79
Toc - Plan #101 Cigna Healthcare
Silver

(HMO) 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 		$547.09
$620.94
$699.18
$977.10
$1,484.80 		$965.61
$1,039.46
$1,117.70
$1,395.62 		$1,384.13
$1,457.98
$1,536.22
$1,814.14 		$1,802.65
$1,876.50
$1,954.74
$2,232.66 		$418.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,094.18
$1,241.88
$1,398.36
$1,954.20
$2,969.60 		$1,512.70
$1,660.40
$1,816.88
$2,372.72 		$1,931.22
$2,078.92
$2,235.40
$2,791.24 		$2,349.74
$2,497.44
$2,653.92
$3,209.76 		$418.52
Toc - Plan #102 Cigna Healthcare
Gold

(HMO) 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 		$762.70
$865.66
$974.73
$1,362.18
$2,069.97 		$1,346.17
$1,449.13
$1,558.20
$1,945.65 		$1,929.64
$2,032.60
$2,141.67
$2,529.12 		$2,513.11
$2,616.07
$2,725.14
$3,112.59 		$583.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,525.40
$1,731.32
$1,949.46
$2,724.36
$4,139.94 		$2,108.87
$2,314.79
$2,532.93
$3,307.83 		$2,692.34
$2,898.26
$3,116.40
$3,891.30 		$3,275.81
$3,481.73
$3,699.87
$4,474.77 		$583.47
Toc - Plan #103 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$464.20
$526.87
$593.25
$829.07
$1,259.85 		$819.32
$881.99
$948.37
$1,184.19 		$1,174.44
$1,237.11
$1,303.49
$1,539.31 		$1,529.56
$1,592.23
$1,658.61
$1,894.43 		$355.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$928.40
$1,053.74
$1,186.50
$1,658.14
$2,519.70 		$1,283.52
$1,408.86
$1,541.62
$2,013.26 		$1,638.64
$1,763.98
$1,896.74
$2,368.38 		$1,993.76
$2,119.10
$2,251.86
$2,723.50 		$355.12

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310 | TTY: 1-833-863-1310
Toc - Plan #104 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 		$397.43
$451.07
$507.90
$709.79
$1,078.59 		$701.46
$755.10
$811.93
$1,013.82 		$1,005.49
$1,059.13
$1,115.96
$1,317.85 		$1,309.52
$1,363.16
$1,419.99
$1,621.88 		$304.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.86
$902.14
$1,015.80
$1,419.58
$2,157.18 		$1,098.89
$1,206.17
$1,319.83
$1,723.61 		$1,402.92
$1,510.20
$1,623.86
$2,027.64 		$1,706.95
$1,814.23
$1,927.89
$2,331.67 		$304.03
Toc - Plan #105 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 		$437.04
$496.03
$558.53
$780.54
$1,186.10 		$771.37
$830.36
$892.86
$1,114.87 		$1,105.70
$1,164.69
$1,227.19
$1,449.20 		$1,440.03
$1,499.02
$1,561.52
$1,783.53 		$334.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.08
$992.06
$1,117.06
$1,561.08
$2,372.20 		$1,208.41
$1,326.39
$1,451.39
$1,895.41 		$1,542.74
$1,660.72
$1,785.72
$2,229.74 		$1,877.07
$1,995.05
$2,120.05
$2,564.07 		$334.33
Toc - Plan #106 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 		$538.96
$611.70
$688.77
$962.56
$1,462.70 		$951.25
$1,023.99
$1,101.06
$1,374.85 		$1,363.54
$1,436.28
$1,513.35
$1,787.14 		$1,775.83
$1,848.57
$1,925.64
$2,199.43 		$412.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,077.92
$1,223.40
$1,377.54
$1,925.12
$2,925.40 		$1,490.21
$1,635.69
$1,789.83
$2,337.41 		$1,902.50
$2,047.98
$2,202.12
$2,749.70 		$2,314.79
$2,460.27
$2,614.41
$3,161.99 		$412.29
Toc - Plan #107 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 		$562.24
$638.13
$718.53
$1,004.14
$1,525.89 		$992.34
$1,068.23
$1,148.63
$1,434.24 		$1,422.44
$1,498.33
$1,578.73
$1,864.34 		$1,852.54
$1,928.43
$2,008.83
$2,294.44 		$430.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,124.48
$1,276.26
$1,437.06
$2,008.28
$3,051.78 		$1,554.58
$1,706.36
$1,867.16
$2,438.38 		$1,984.68
$2,136.46
$2,297.26
$2,868.48 		$2,414.78
$2,566.56
$2,727.36
$3,298.58 		$430.10
Toc - Plan #108 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 		$533.94
$606.01
$682.37
$953.61
$1,449.10 		$942.40
$1,014.47
$1,090.83
$1,362.07 		$1,350.86
$1,422.93
$1,499.29
$1,770.53 		$1,759.32
$1,831.39
$1,907.75
$2,178.99 		$408.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,067.88
$1,212.02
$1,364.74
$1,907.22
$2,898.20 		$1,476.34
$1,620.48
$1,773.20
$2,315.68 		$1,884.80
$2,028.94
$2,181.66
$2,724.14 		$2,293.26
$2,437.40
$2,590.12
$3,132.60 		$408.46
Toc - Plan #109 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 		$424.05
$481.29
$541.93
$757.34
$1,150.85 		$748.44
$805.68
$866.32
$1,081.73 		$1,072.83
$1,130.07
$1,190.71
$1,406.12 		$1,397.22
$1,454.46
$1,515.10
$1,730.51 		$324.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.10
$962.58
$1,083.86
$1,514.68
$2,301.70 		$1,172.49
$1,286.97
$1,408.25
$1,839.07 		$1,496.88
$1,611.36
$1,732.64
$2,163.46 		$1,821.27
$1,935.75
$2,057.03
$2,487.85 		$324.39
Toc - Plan #110 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 		$477.19
$541.60
$609.84
$852.25
$1,295.07 		$842.23
$906.64
$974.88
$1,217.29 		$1,207.27
$1,271.68
$1,339.92
$1,582.33 		$1,572.31
$1,636.72
$1,704.96
$1,947.37 		$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
$1,219.68
$1,704.50
$2,590.14 		$1,319.42
$1,448.24
$1,584.72
$2,069.54 		$1,684.46
$1,813.28
$1,949.76
$2,434.58 		$2,049.50
$2,178.32
$2,314.80
$2,799.62 		$365.04
Toc - Plan #111 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 		$532.54
$604.42
$680.58
$951.10
$1,445.29 		$939.93
$1,011.81
$1,087.97
$1,358.49 		$1,347.32
$1,419.20
$1,495.36
$1,765.88 		$1,754.71
$1,826.59
$1,902.75
$2,173.27 		$407.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,065.08
$1,208.84
$1,361.16
$1,902.20
$2,890.58 		$1,472.47
$1,616.23
$1,768.55
$2,309.59 		$1,879.86
$2,023.62
$2,175.94
$2,716.98 		$2,287.25
$2,431.01
$2,583.33
$3,124.37 		$407.39
Toc - Plan #112 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 		$532.76
$604.67
$680.85
$951.49
$1,445.88 		$940.31
$1,012.22
$1,088.40
$1,359.04 		$1,347.86
$1,419.77
$1,495.95
$1,766.59 		$1,755.41
$1,827.32
$1,903.50
$2,174.14 		$407.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,065.52
$1,209.34
$1,361.70
$1,902.98
$2,891.76 		$1,473.07
$1,616.89
$1,769.25
$2,310.53 		$1,880.62
$2,024.44
$2,176.80
$2,718.08 		$2,288.17
$2,431.99
$2,584.35
$3,125.63 		$407.55
Toc - Plan #113 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 		$415.81
$471.93
$531.39
$742.61
$1,128.47 		$733.89
$790.01
$849.47
$1,060.69 		$1,051.97
$1,108.09
$1,167.55
$1,378.77 		$1,370.05
$1,426.17
$1,485.63
$1,696.85 		$318.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.62
$943.86
$1,062.78
$1,485.22
$2,256.94 		$1,149.70
$1,261.94
$1,380.86
$1,803.30 		$1,467.78
$1,580.02
$1,698.94
$2,121.38 		$1,785.86
$1,898.10
$2,017.02
$2,439.46 		$318.08
Toc - Plan #114 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 		$527.31
$598.49
$673.90
$941.77
$1,431.11 		$930.70
$1,001.88
$1,077.29
$1,345.16 		$1,334.09
$1,405.27
$1,480.68
$1,748.55 		$1,737.48
$1,808.66
$1,884.07
$2,151.94 		$403.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,054.62
$1,196.98
$1,347.80
$1,883.54
$2,862.22 		$1,458.01
$1,600.37
$1,751.19
$2,286.93 		$1,861.40
$2,003.76
$2,154.58
$2,690.32 		$2,264.79
$2,407.15
$2,557.97
$3,093.71 		$403.39
Toc - Plan #115 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 		$533.62
$605.65
$681.95
$953.03
$1,448.22 		$941.83
$1,013.86
$1,090.16
$1,361.24 		$1,350.04
$1,422.07
$1,498.37
$1,769.45 		$1,758.25
$1,830.28
$1,906.58
$2,177.66 		$408.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,067.24
$1,211.30
$1,363.90
$1,906.06
$2,896.44 		$1,475.45
$1,619.51
$1,772.11
$2,314.27 		$1,883.66
$2,027.72
$2,180.32
$2,722.48 		$2,291.87
$2,435.93
$2,588.53
$3,130.69 		$408.21
Toc - Plan #116 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 		$414.17
$470.07
$529.29
$739.69
$1,124.02 		$731.00
$786.90
$846.12
$1,056.52 		$1,047.83
$1,103.73
$1,162.95
$1,373.35 		$1,364.66
$1,420.56
$1,479.78
$1,690.18 		$316.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.34
$940.14
$1,058.58
$1,479.38
$2,248.04 		$1,145.17
$1,256.97
$1,375.41
$1,796.21 		$1,462.00
$1,573.80
$1,692.24
$2,113.04 		$1,778.83
$1,890.63
$2,009.07
$2,429.87 		$316.83
Toc - Plan #117 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 		$455.45
$516.92
$582.05
$813.41
$1,236.06 		$803.86
$865.33
$930.46
$1,161.82 		$1,152.27
$1,213.74
$1,278.87
$1,510.23 		$1,500.68
$1,562.15
$1,627.28
$1,858.64 		$348.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.90
$1,033.84
$1,164.10
$1,626.82
$2,472.12 		$1,259.31
$1,382.25
$1,512.51
$1,975.23 		$1,607.72
$1,730.66
$1,860.92
$2,323.64 		$1,956.13
$2,079.07
$2,209.33
$2,672.05 		$348.41
Toc - Plan #118 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 		$561.66
$637.47
$717.78
$1,003.10
$1,524.31 		$991.32
$1,067.13
$1,147.44
$1,432.76 		$1,420.98
$1,496.79
$1,577.10
$1,862.42 		$1,850.64
$1,926.45
$2,006.76
$2,292.08 		$429.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,123.32
$1,274.94
$1,435.56
$2,006.20
$3,048.62 		$1,552.98
$1,704.60
$1,865.22
$2,435.86 		$1,982.64
$2,134.26
$2,294.88
$2,865.52 		$2,412.30
$2,563.92
$2,724.54
$3,295.18 		$429.66
Toc - Plan #119 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 		$585.92
$665.01
$748.79
$1,046.43
$1,590.16 		$1,034.14
$1,113.23
$1,197.01
$1,494.65 		$1,482.36
$1,561.45
$1,645.23
$1,942.87 		$1,930.58
$2,009.67
$2,093.45
$2,391.09 		$448.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,171.84
$1,330.02
$1,497.58
$2,092.86
$3,180.32 		$1,620.06
$1,778.24
$1,945.80
$2,541.08 		$2,068.28
$2,226.46
$2,394.02
$2,989.30 		$2,516.50
$2,674.68
$2,842.24
$3,437.52 		$448.22
Toc - Plan #120 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 		$556.43
$631.54
$711.11
$993.77
$1,510.13 		$982.09
$1,057.20
$1,136.77
$1,419.43 		$1,407.75
$1,482.86
$1,562.43
$1,845.09 		$1,833.41
$1,908.52
$1,988.09
$2,270.75 		$425.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,112.86
$1,263.08
$1,422.22
$1,987.54
$3,020.26 		$1,538.52
$1,688.74
$1,847.88
$2,413.20 		$1,964.18
$2,114.40
$2,273.54
$2,838.86 		$2,389.84
$2,540.06
$2,699.20
$3,264.52 		$425.66
Toc - Plan #121 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 		$441.91
$501.56
$564.75
$789.24
$1,199.33 		$779.97
$839.62
$902.81
$1,127.30 		$1,118.03
$1,177.68
$1,240.87
$1,465.36 		$1,456.09
$1,515.74
$1,578.93
$1,803.42 		$338.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.82
$1,003.12
$1,129.50
$1,578.48
$2,398.66 		$1,221.88
$1,341.18
$1,467.56
$1,916.54 		$1,559.94
$1,679.24
$1,805.62
$2,254.60 		$1,898.00
$2,017.30
$2,143.68
$2,592.66 		$338.06
Toc - Plan #122 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 		$497.29
$564.41
$635.53
$888.15
$1,349.62 		$877.71
$944.83
$1,015.95
$1,268.57 		$1,258.13
$1,325.25
$1,396.37
$1,648.99 		$1,638.55
$1,705.67
$1,776.79
$2,029.41 		$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
$1,271.06
$1,776.30
$2,699.24 		$1,375.00
$1,509.24
$1,651.48
$2,156.72 		$1,755.42
$1,889.66
$2,031.90
$2,537.14 		$2,135.84
$2,270.08
$2,412.32
$2,917.56 		$380.42
Toc - Plan #123 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 		$555.20
$630.14
$709.53
$991.56
$1,506.78 		$979.92
$1,054.86
$1,134.25
$1,416.28 		$1,404.64
$1,479.58
$1,558.97
$1,841.00 		$1,829.36
$1,904.30
$1,983.69
$2,265.72 		$424.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,110.40
$1,260.28
$1,419.06
$1,983.12
$3,013.56 		$1,535.12
$1,685.00
$1,843.78
$2,407.84 		$1,959.84
$2,109.72
$2,268.50
$2,832.56 		$2,384.56
$2,534.44
$2,693.22
$3,257.28 		$424.72
Toc - Plan #124 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 		$554.97
$629.88
$709.24
$991.16
$1,506.17 		$979.52
$1,054.43
$1,133.79
$1,415.71 		$1,404.07
$1,478.98
$1,558.34
$1,840.26 		$1,828.62
$1,903.53
$1,982.89
$2,264.81 		$424.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,109.94
$1,259.76
$1,418.48
$1,982.32
$3,012.34 		$1,534.49
$1,684.31
$1,843.03
$2,406.87 		$1,959.04
$2,108.86
$2,267.58
$2,831.42 		$2,383.59
$2,533.41
$2,692.13
$3,255.97 		$424.55
Toc - Plan #125 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 		$414.08
$469.97
$529.18
$739.53
$1,123.79 		$730.85
$786.74
$845.95
$1,056.30 		$1,047.62
$1,103.51
$1,162.72
$1,373.07 		$1,364.39
$1,420.28
$1,479.49
$1,689.84 		$316.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.16
$939.94
$1,058.36
$1,479.06
$2,247.58 		$1,144.93
$1,256.71
$1,375.13
$1,795.83 		$1,461.70
$1,573.48
$1,691.90
$2,112.60 		$1,778.47
$1,890.25
$2,008.67
$2,429.37 		$316.77
Toc - Plan #126 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 		$521.12
$591.46
$665.97
$930.70
$1,414.28 		$919.77
$990.11
$1,064.62
$1,329.35 		$1,318.42
$1,388.76
$1,463.27
$1,728.00 		$1,717.07
$1,787.41
$1,861.92
$2,126.65 		$398.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,042.24
$1,182.92
$1,331.94
$1,861.40
$2,828.56 		$1,440.89
$1,581.57
$1,730.59
$2,260.05 		$1,839.54
$1,980.22
$2,129.24
$2,658.70 		$2,238.19
$2,378.87
$2,527.89
$3,057.35 		$398.65
Toc - Plan #127 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 		$546.29
$620.02
$698.14
$975.65
$1,482.59 		$964.19
$1,037.92
$1,116.04
$1,393.55 		$1,382.09
$1,455.82
$1,533.94
$1,811.45 		$1,799.99
$1,873.72
$1,951.84
$2,229.35 		$417.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,092.58
$1,240.04
$1,396.28
$1,951.30
$2,965.18 		$1,510.48
$1,657.94
$1,814.18
$2,369.20 		$1,928.38
$2,075.84
$2,232.08
$2,787.10 		$2,346.28
$2,493.74
$2,649.98
$3,205.00 		$417.90

ADVERTISEMENT

Friday Health Plans

Local: 1-844-465-5500 | Toll Free: 1-844-465-5500 | TTY: 1-800-659-2656
Toc - Plan #128 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 		$272.11
$308.84
$347.76
$485.99
$738.51 		$480.27
$517.00
$555.92
$694.15 		$688.43
$725.16
$764.08
$902.31 		$896.59
$933.32
$972.24
$1,110.47 		$208.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$544.22
$617.68
$695.52
$971.98
$1,477.02 		$752.38
$825.84
$903.68
$1,180.14 		$960.54
$1,034.00
$1,111.84
$1,388.30 		$1,168.70
$1,242.16
$1,320.00
$1,596.46 		$208.16
Toc - Plan #129 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 		$356.72
$404.88
$455.89
$637.10
$968.13 		$629.61
$677.77
$728.78
$909.99 		$902.50
$950.66
$1,001.67
$1,182.88 		$1,175.39
$1,223.55
$1,274.56
$1,455.77 		$272.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.44
$809.76
$911.78
$1,274.20
$1,936.26 		$986.33
$1,082.65
$1,184.67
$1,547.09 		$1,259.22
$1,355.54
$1,457.56
$1,819.98 		$1,532.11
$1,628.43
$1,730.45
$2,092.87 		$272.89
Toc - Plan #130 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 		$360.31
$408.95
$460.47
$643.50
$977.87 		$635.94
$684.58
$736.10
$919.13 		$911.57
$960.21
$1,011.73
$1,194.76 		$1,187.20
$1,235.84
$1,287.36
$1,470.39 		$275.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.62
$817.90
$920.94
$1,287.00
$1,955.74 		$996.25
$1,093.53
$1,196.57
$1,562.63 		$1,271.88
$1,369.16
$1,472.20
$1,838.26 		$1,547.51
$1,644.79
$1,747.83
$2,113.89 		$275.63
Toc - Plan #131 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 		$380.90
$432.32
$486.79
$680.28
$1,033.75 		$672.29
$723.71
$778.18
$971.67 		$963.68
$1,015.10
$1,069.57
$1,263.06 		$1,255.07
$1,306.49
$1,360.96
$1,554.45 		$291.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.80
$864.64
$973.58
$1,360.56
$2,067.50 		$1,053.19
$1,156.03
$1,264.97
$1,651.95 		$1,344.58
$1,447.42
$1,556.36
$1,943.34 		$1,635.97
$1,738.81
$1,847.75
$2,234.73 		$291.39
Toc - Plan #132 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 		$496.96
$564.05
$635.11
$887.57
$1,348.74 		$877.13
$944.22
$1,015.28
$1,267.74 		$1,257.30
$1,324.39
$1,395.45
$1,647.91 		$1,637.47
$1,704.56
$1,775.62
$2,028.08 		$380.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$993.92
$1,128.10
$1,270.22
$1,775.14
$2,697.48 		$1,374.09
$1,508.27
$1,650.39
$2,155.31 		$1,754.26
$1,888.44
$2,030.56
$2,535.48 		$2,134.43
$2,268.61
$2,410.73
$2,915.65 		$380.17
Toc - Plan #133 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 		$522.46
$593.00
$667.71
$933.12
$1,417.96 		$922.14
$992.68
$1,067.39
$1,332.80 		$1,321.82
$1,392.36
$1,467.07
$1,732.48 		$1,721.50
$1,792.04
$1,866.75
$2,132.16 		$399.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.92
$1,186.00
$1,335.42
$1,866.24
$2,835.92 		$1,444.60
$1,585.68
$1,735.10
$2,265.92 		$1,844.28
$1,985.36
$2,134.78
$2,665.60 		$2,243.96
$2,385.04
$2,534.46
$3,065.28 		$399.68
Toc - Plan #134 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 		$356.46
$404.58
$455.56
$636.64
$967.44 		$629.15
$677.27
$728.25
$909.33 		$901.84
$949.96
$1,000.94
$1,182.02 		$1,174.53
$1,222.65
$1,273.63
$1,454.71 		$272.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.92
$809.16
$911.12
$1,273.28
$1,934.88 		$985.61
$1,081.85
$1,183.81
$1,545.97 		$1,258.30
$1,354.54
$1,456.50
$1,818.66 		$1,530.99
$1,627.23
$1,729.19
$2,091.35 		$272.69
Toc - Plan #135 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 		$510.11
$578.98
$651.92
$911.06
$1,384.45 		$900.35
$969.22
$1,042.16
$1,301.30 		$1,290.59
$1,359.46
$1,432.40
$1,691.54 		$1,680.83
$1,749.70
$1,822.64
$2,081.78 		$390.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,020.22
$1,157.96
$1,303.84
$1,822.12
$2,768.90 		$1,410.46
$1,548.20
$1,694.08
$2,212.36 		$1,800.70
$1,938.44
$2,084.32
$2,602.60 		$2,190.94
$2,328.68
$2,474.56
$2,992.84 		$390.24
Toc - Plan #136 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 		$542.78
$616.06
$693.67
$969.41
$1,473.11 		$958.01
$1,031.29
$1,108.90
$1,384.64 		$1,373.24
$1,446.52
$1,524.13
$1,799.87 		$1,788.47
$1,861.75
$1,939.36
$2,215.10 		$415.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,085.56
$1,232.12
$1,387.34
$1,938.82
$2,946.22 		$1,500.79
$1,647.35
$1,802.57
$2,354.05 		$1,916.02
$2,062.58
$2,217.80
$2,769.28 		$2,331.25
$2,477.81
$2,633.03
$3,184.51 		$415.23
Toc - Plan #137 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 		$356.27
$404.36
$455.31
$636.29
$966.91 		$628.81
$676.90
$727.85
$908.83 		$901.35
$949.44
$1,000.39
$1,181.37 		$1,173.89
$1,221.98
$1,272.93
$1,453.91 		$272.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.54
$808.72
$910.62
$1,272.58
$1,933.82 		$985.08
$1,081.26
$1,183.16
$1,545.12 		$1,257.62
$1,353.80
$1,455.70
$1,817.66 		$1,530.16
$1,626.34
$1,728.24
$2,090.20 		$272.54
Toc - Plan #138 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 		$359.85
$408.43
$459.89
$642.70
$976.64 		$635.14
$683.72
$735.18
$917.99 		$910.43
$959.01
$1,010.47
$1,193.28 		$1,185.72
$1,234.30
$1,285.76
$1,468.57 		$275.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.70
$816.86
$919.78
$1,285.40
$1,953.28 		$994.99
$1,092.15
$1,195.07
$1,560.69 		$1,270.28
$1,367.44
$1,470.36
$1,835.98 		$1,545.57
$1,642.73
$1,745.65
$2,111.27 		$275.29
Toc - Plan #139 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 		$356.01
$404.07
$454.98
$635.83
$966.21 		$628.36
$676.42
$727.33
$908.18 		$900.71
$948.77
$999.68
$1,180.53 		$1,173.06
$1,221.12
$1,272.03
$1,452.88 		$272.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.02
$808.14
$909.96
$1,271.66
$1,932.42 		$984.37
$1,080.49
$1,182.31
$1,544.01 		$1,256.72
$1,352.84
$1,454.66
$1,816.36 		$1,529.07
$1,625.19
$1,727.01
$2,088.71 		$272.35
Toc - Plan #140 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 		$496.51
$563.53
$634.53
$886.76
$1,347.52 		$876.34
$943.36
$1,014.36
$1,266.59 		$1,256.17
$1,323.19
$1,394.19
$1,646.42 		$1,636.00
$1,703.02
$1,774.02
$2,026.25 		$379.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$993.02
$1,127.06
$1,269.06
$1,773.52
$2,695.04 		$1,372.85
$1,506.89
$1,648.89
$2,153.35 		$1,752.68
$1,886.72
$2,028.72
$2,533.18 		$2,132.51
$2,266.55
$2,408.55
$2,913.01 		$379.83
Toc - Plan #141 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 		$502.55
$570.39
$642.25
$897.55
$1,363.91 		$887.00
$954.84
$1,026.70
$1,282.00 		$1,271.45
$1,339.29
$1,411.15
$1,666.45 		$1,655.90
$1,723.74
$1,795.60
$2,050.90 		$384.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,005.10
$1,140.78
$1,284.50
$1,795.10
$2,727.82 		$1,389.55
$1,525.23
$1,668.95
$2,179.55 		$1,774.00
$1,909.68
$2,053.40
$2,564.00 		$2,158.45
$2,294.13
$2,437.85
$2,948.45 		$384.45
Toc - Plan #142 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 		$512.91
$582.15
$655.50
$916.06
$1,392.04 		$905.29
$974.53
$1,047.88
$1,308.44 		$1,297.67
$1,366.91
$1,440.26
$1,700.82 		$1,690.05
$1,759.29
$1,832.64
$2,093.20 		$392.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,025.82
$1,164.30
$1,311.00
$1,832.12
$2,784.08 		$1,418.20
$1,556.68
$1,703.38
$2,224.50 		$1,810.58
$1,949.06
$2,095.76
$2,616.88 		$2,202.96
$2,341.44
$2,488.14
$3,009.26 		$392.38
Toc - Plan #143 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 		$509.66
$578.47
$651.35
$910.25
$1,383.22 		$899.55
$968.36
$1,041.24
$1,300.14 		$1,289.44
$1,358.25
$1,431.13
$1,690.03 		$1,679.33
$1,748.14
$1,821.02
$2,079.92 		$389.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,019.32
$1,156.94
$1,302.70
$1,820.50
$2,766.44 		$1,409.21
$1,546.83
$1,692.59
$2,210.39 		$1,799.10
$1,936.72
$2,082.48
$2,600.28 		$2,188.99
$2,326.61
$2,472.37
$2,990.17 		$389.89
Toc - Plan #144 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 		$522.01
$592.48
$667.13
$932.31
$1,416.74 		$921.35
$991.82
$1,066.47
$1,331.65 		$1,320.69
$1,391.16
$1,465.81
$1,730.99 		$1,720.03
$1,790.50
$1,865.15
$2,130.33 		$399.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.02
$1,184.96
$1,334.26
$1,864.62
$2,833.48 		$1,443.36
$1,584.30
$1,733.60
$2,263.96 		$1,842.70
$1,983.64
$2,132.94
$2,663.30 		$2,242.04
$2,382.98
$2,532.28
$3,062.64 		$399.34
Toc - Plan #145 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 		$542.33
$615.54
$693.10
$968.60
$1,471.88 		$957.21
$1,030.42
$1,107.98
$1,383.48 		$1,372.09
$1,445.30
$1,522.86
$1,798.36 		$1,786.97
$1,860.18
$1,937.74
$2,213.24 		$414.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,084.66
$1,231.08
$1,386.20
$1,937.20
$2,943.76 		$1,499.54
$1,645.96
$1,801.08
$2,352.08 		$1,914.42
$2,060.84
$2,215.96
$2,766.96 		$2,329.30
$2,475.72
$2,630.84
$3,181.84 		$414.88
Toc - Plan #146 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 		$356.27
$404.36
$455.31
$636.29
$966.91 		$628.81
$676.90
$727.85
$908.83 		$901.35
$949.44
$1,000.39
$1,181.37 		$1,173.89
$1,221.98
$1,272.93
$1,453.91 		$272.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.54
$808.72
$910.62
$1,272.58
$1,933.82 		$985.08
$1,081.26
$1,183.16
$1,545.12 		$1,257.62
$1,353.80
$1,455.70
$1,817.66 		$1,530.16
$1,626.34
$1,728.24
$2,090.20 		$272.54
Toc - Plan #147 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 		$354.32
$402.16
$452.82
$632.82
$961.63 		$625.38
$673.22
$723.88
$903.88 		$896.44
$944.28
$994.94
$1,174.94 		$1,167.50
$1,215.34
$1,266.00
$1,446.00 		$271.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.64
$804.32
$905.64
$1,265.64
$1,923.26 		$979.70
$1,075.38
$1,176.70
$1,536.70 		$1,250.76
$1,346.44
$1,447.76
$1,807.76 		$1,521.82
$1,617.50
$1,718.82
$2,078.82 		$271.06
Toc - Plan #148 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 		$492.58
$559.07
$629.51
$879.74
$1,336.85 		$869.40
$935.89
$1,006.33
$1,256.56 		$1,246.22
$1,312.71
$1,383.15
$1,633.38 		$1,623.04
$1,689.53
$1,759.97
$2,010.20 		$376.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.16
$1,118.14
$1,259.02
$1,759.48
$2,673.70 		$1,361.98
$1,494.96
$1,635.84
$2,136.30 		$1,738.80
$1,871.78
$2,012.66
$2,513.12 		$2,115.62
$2,248.60
$2,389.48
$2,889.94 		$376.82
Toc - Plan #149 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 		$540.06
$612.97
$690.19
$964.54
$1,465.72 		$953.20
$1,026.11
$1,103.33
$1,377.68 		$1,366.34
$1,439.25
$1,516.47
$1,790.82 		$1,779.48
$1,852.39
$1,929.61
$2,203.96 		$413.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,080.12
$1,225.94
$1,380.38
$1,929.08
$2,931.44 		$1,493.26
$1,639.08
$1,793.52
$2,342.22 		$1,906.40
$2,052.22
$2,206.66
$2,755.36 		$2,319.54
$2,465.36
$2,619.80
$3,168.50 		$413.14

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Jackson County here.

Jackson County is in “Rating Area 1” of North Carolina.

Currently, there are 149 plans offered in Rating Area 1.

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2023 Obamacare Plans for Jackson County, NC

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