Obamacare 2023 Rates for Mecklenburg County

Obamacare > Rates > North Carolina > Mecklenburg 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 Mecklenburg 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, 82 Plans and 2023 Rates for Mecklenburg County, North Carolina

Below, you’ll find a summary of the 82 plans for Mecklenburg 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

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Mecklenburg County Resources

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Blue Cross and Blue Shield of NC

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

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

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

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 		$402.93
$457.33
$514.94
$719.63
$1,093.55 		$711.17
$765.57
$823.18
$1,027.87 		$1,019.41
$1,073.81
$1,131.42
$1,336.11 		$1,327.65
$1,382.05
$1,439.66
$1,644.35 		$308.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$805.86
$914.66
$1,029.88
$1,439.26
$2,187.10 		$1,114.10
$1,222.90
$1,338.12
$1,747.50 		$1,422.34
$1,531.14
$1,646.36
$2,055.74 		$1,730.58
$1,839.38
$1,954.60
$2,363.98 		$308.24
Toc - Plan #2 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Home Gold Standard 2000 | with Novant Health

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 		$401.47
$455.67
$513.08
$717.03
$1,089.59 		$708.59
$762.79
$820.20
$1,024.15 		$1,015.71
$1,069.91
$1,127.32
$1,331.27 		$1,322.83
$1,377.03
$1,434.44
$1,638.39 		$307.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.94
$911.34
$1,026.16
$1,434.06
$2,179.18 		$1,110.06
$1,218.46
$1,333.28
$1,741.18 		$1,417.18
$1,525.58
$1,640.40
$2,048.30 		$1,724.30
$1,832.70
$1,947.52
$2,355.42 		$307.12
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

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

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 		$414.22
$470.14
$529.37
$739.80
$1,124.19 		$731.10
$787.02
$846.25
$1,056.68 		$1,047.98
$1,103.90
$1,163.13
$1,373.56 		$1,364.86
$1,420.78
$1,480.01
$1,690.44 		$316.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.44
$940.28
$1,058.74
$1,479.60
$2,248.38 		$1,145.32
$1,257.16
$1,375.62
$1,796.48 		$1,462.20
$1,574.04
$1,692.50
$2,113.36 		$1,779.08
$1,890.92
$2,009.38
$2,430.24 		$316.88
Toc - Plan #4 Blue Cross and Blue Shield of NC
Silver

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

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 		$423.63
$480.82
$541.40
$756.60
$1,149.73 		$747.71
$804.90
$865.48
$1,080.68 		$1,071.79
$1,128.98
$1,189.56
$1,404.76 		$1,395.87
$1,453.06
$1,513.64
$1,728.84 		$324.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847.26
$961.64
$1,082.80
$1,513.20
$2,299.46 		$1,171.34
$1,285.72
$1,406.88
$1,837.28 		$1,495.42
$1,609.80
$1,730.96
$2,161.36 		$1,819.50
$1,933.88
$2,055.04
$2,485.44 		$324.08
Toc - Plan #5 Blue Cross and Blue Shield of NC
Silver

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

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 		$392.23
$445.18
$501.27
$700.52
$1,064.51 		$692.29
$745.24
$801.33
$1,000.58 		$992.35
$1,045.30
$1,101.39
$1,300.64 		$1,292.41
$1,345.36
$1,401.45
$1,600.70 		$300.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.46
$890.36
$1,002.54
$1,401.04
$2,129.02 		$1,084.52
$1,190.42
$1,302.60
$1,701.10 		$1,384.58
$1,490.48
$1,602.66
$2,001.16 		$1,684.64
$1,790.54
$1,902.72
$2,301.22 		$300.06
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

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

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 		$407.82
$462.88
$521.19
$728.37
$1,106.82 		$719.80
$774.86
$833.17
$1,040.35 		$1,031.78
$1,086.84
$1,145.15
$1,352.33 		$1,343.76
$1,398.82
$1,457.13
$1,664.31 		$311.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.64
$925.76
$1,042.38
$1,456.74
$2,213.64 		$1,127.62
$1,237.74
$1,354.36
$1,768.72 		$1,439.60
$1,549.72
$1,666.34
$2,080.70 		$1,751.58
$1,861.70
$1,978.32
$2,392.68 		$311.98
Toc - Plan #7 Blue Cross and Blue Shield of NC
Silver

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

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 		$409.46
$464.74
$523.29
$731.30
$1,111.27 		$722.70
$777.98
$836.53
$1,044.54 		$1,035.94
$1,091.22
$1,149.77
$1,357.78 		$1,349.18
$1,404.46
$1,463.01
$1,671.02 		$313.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.92
$929.48
$1,046.58
$1,462.60
$2,222.54 		$1,132.16
$1,242.72
$1,359.82
$1,775.84 		$1,445.40
$1,555.96
$1,673.06
$2,089.08 		$1,758.64
$1,869.20
$1,986.30
$2,402.32 		$313.24
Toc - Plan #8 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Standard 5800 | with Novant Health

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 		$406.10
$460.92
$519.00
$725.29
$1,102.16 		$716.77
$771.59
$829.67
$1,035.96 		$1,027.44
$1,082.26
$1,140.34
$1,346.63 		$1,338.11
$1,392.93
$1,451.01
$1,657.30 		$310.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.20
$921.84
$1,038.00
$1,450.58
$2,204.32 		$1,122.87
$1,232.51
$1,348.67
$1,761.25 		$1,433.54
$1,543.18
$1,659.34
$2,071.92 		$1,744.21
$1,853.85
$1,970.01
$2,382.59 		$310.67
Toc - Plan #9 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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 		$302.53
$343.37
$386.63
$540.32
$821.07 		$533.97
$574.81
$618.07
$771.76 		$765.41
$806.25
$849.51
$1,003.20 		$996.85
$1,037.69
$1,080.95
$1,234.64 		$231.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.06
$686.74
$773.26
$1,080.64
$1,642.14 		$836.50
$918.18
$1,004.70
$1,312.08 		$1,067.94
$1,149.62
$1,236.14
$1,543.52 		$1,299.38
$1,381.06
$1,467.58
$1,774.96 		$231.44
Toc - Plan #10 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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 		$286.24
$324.88
$365.81
$511.22
$776.86 		$505.21
$543.85
$584.78
$730.19 		$724.18
$762.82
$803.75
$949.16 		$943.15
$981.79
$1,022.72
$1,168.13 		$218.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.48
$649.76
$731.62
$1,022.44
$1,553.72 		$791.45
$868.73
$950.59
$1,241.41 		$1,010.42
$1,087.70
$1,169.56
$1,460.38 		$1,229.39
$1,306.67
$1,388.53
$1,679.35 		$218.97
Toc - Plan #11 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze Standard 7500 | with Novant Health

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 		$286.64
$325.34
$366.33
$511.94
$777.94 		$505.92
$544.62
$585.61
$731.22 		$725.20
$763.90
$804.89
$950.50 		$944.48
$983.18
$1,024.17
$1,169.78 		$219.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.28
$650.68
$732.66
$1,023.88
$1,555.88 		$792.56
$869.96
$951.94
$1,243.16 		$1,011.84
$1,089.24
$1,171.22
$1,462.44 		$1,231.12
$1,308.52
$1,390.50
$1,681.72 		$219.28
Toc - Plan #12 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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 		$300.41
$340.97
$383.92
$536.53
$815.31 		$530.22
$570.78
$613.73
$766.34 		$760.03
$800.59
$843.54
$996.15 		$989.84
$1,030.40
$1,073.35
$1,225.96 		$229.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.82
$681.94
$767.84
$1,073.06
$1,630.62 		$830.63
$911.75
$997.65
$1,302.87 		$1,060.44
$1,141.56
$1,227.46
$1,532.68 		$1,290.25
$1,371.37
$1,457.27
$1,762.49 		$229.81
Toc - Plan #13 Blue Cross and Blue Shield of NC
Bronze

(EPO) Blue Home Bronze 9100 | Integrated | with Novant Health

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 		$286.82
$325.54
$366.56
$512.26
$778.43 		$506.24
$544.96
$585.98
$731.68 		$725.66
$764.38
$805.40
$951.10 		$945.08
$983.80
$1,024.82
$1,170.52 		$219.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.64
$651.08
$733.12
$1,024.52
$1,556.86 		$793.06
$870.50
$952.54
$1,243.94 		$1,012.48
$1,089.92
$1,171.96
$1,463.36 		$1,231.90
$1,309.34
$1,391.38
$1,682.78 		$219.42
Toc - Plan #14 Blue Cross and Blue Shield of NC
Catastrophic

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

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 		$210.37
$238.77
$268.85
$375.72
$570.94 		$371.30
$399.70
$429.78
$536.65 		$532.23
$560.63
$590.71
$697.58 		$693.16
$721.56
$751.64
$858.51 		$160.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$420.74
$477.54
$537.70
$751.44
$1,141.88 		$581.67
$638.47
$698.63
$912.37 		$742.60
$799.40
$859.56
$1,073.30 		$903.53
$960.33
$1,020.49
$1,234.23 		$160.93
Toc - Plan #15 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health

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 		$501.06
$568.70
$640.35
$894.89
$1,359.88 		$884.37
$952.01
$1,023.66
$1,278.20 		$1,267.68
$1,335.32
$1,406.97
$1,661.51 		$1,650.99
$1,718.63
$1,790.28
$2,044.82 		$383.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,002.12
$1,137.40
$1,280.70
$1,789.78
$2,719.76 		$1,385.43
$1,520.71
$1,664.01
$2,173.09 		$1,768.74
$1,904.02
$2,047.32
$2,556.40 		$2,152.05
$2,287.33
$2,430.63
$2,939.71 		$383.31
Toc - Plan #16 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold Standard 2000 | with Atrium Health

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 		$499.25
$566.65
$638.04
$891.66
$1,354.96 		$881.18
$948.58
$1,019.97
$1,273.59 		$1,263.11
$1,330.51
$1,401.90
$1,655.52 		$1,645.04
$1,712.44
$1,783.83
$2,037.45 		$381.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$998.50
$1,133.30
$1,276.08
$1,783.32
$2,709.92 		$1,380.43
$1,515.23
$1,658.01
$2,165.25 		$1,762.36
$1,897.16
$2,039.94
$2,547.18 		$2,144.29
$2,279.09
$2,421.87
$2,929.11 		$381.93
Toc - Plan #17 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health

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 		$515.17
$584.72
$658.39
$920.09
$1,398.17 		$909.28
$978.83
$1,052.50
$1,314.20 		$1,303.39
$1,372.94
$1,446.61
$1,708.31 		$1,697.50
$1,767.05
$1,840.72
$2,102.42 		$394.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,030.34
$1,169.44
$1,316.78
$1,840.18
$2,796.34 		$1,424.45
$1,563.55
$1,710.89
$2,234.29 		$1,818.56
$1,957.66
$2,105.00
$2,628.40 		$2,212.67
$2,351.77
$2,499.11
$3,022.51 		$394.11
Toc - Plan #18 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Simple | $0 Deductible | 3 Free PCP | with Atrium Health

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 		$526.88
$598.01
$673.35
$941.01
$1,429.95 		$929.94
$1,001.07
$1,076.41
$1,344.07 		$1,333.00
$1,404.13
$1,479.47
$1,747.13 		$1,736.06
$1,807.19
$1,882.53
$2,150.19 		$403.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,053.76
$1,196.02
$1,346.70
$1,882.02
$2,859.90 		$1,456.82
$1,599.08
$1,749.76
$2,285.08 		$1,859.88
$2,002.14
$2,152.82
$2,688.14 		$2,262.94
$2,405.20
$2,555.88
$3,091.20 		$403.06
Toc - Plan #19 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Atrium Health

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 		$487.80
$553.65
$623.41
$871.21
$1,323.89 		$860.97
$926.82
$996.58
$1,244.38 		$1,234.14
$1,299.99
$1,369.75
$1,617.55 		$1,607.31
$1,673.16
$1,742.92
$1,990.72 		$373.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$975.60
$1,107.30
$1,246.82
$1,742.42
$2,647.78 		$1,348.77
$1,480.47
$1,619.99
$2,115.59 		$1,721.94
$1,853.64
$1,993.16
$2,488.76 		$2,095.11
$2,226.81
$2,366.33
$2,861.93 		$373.17
Toc - Plan #20 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with Atrium Health

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 		$507.21
$575.68
$648.21
$905.88
$1,376.57 		$895.23
$963.70
$1,036.23
$1,293.90 		$1,283.25
$1,351.72
$1,424.25
$1,681.92 		$1,671.27
$1,739.74
$1,812.27
$2,069.94 		$388.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,014.42
$1,151.36
$1,296.42
$1,811.76
$2,753.14 		$1,402.44
$1,539.38
$1,684.44
$2,199.78 		$1,790.46
$1,927.40
$2,072.46
$2,587.80 		$2,178.48
$2,315.42
$2,460.48
$2,975.82 		$388.02
Toc - Plan #21 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health

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 		$509.17
$577.91
$650.72
$909.38
$1,381.89 		$898.69
$967.43
$1,040.24
$1,298.90 		$1,288.21
$1,356.95
$1,429.76
$1,688.42 		$1,677.73
$1,746.47
$1,819.28
$2,077.94 		$389.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,018.34
$1,155.82
$1,301.44
$1,818.76
$2,763.78 		$1,407.86
$1,545.34
$1,690.96
$2,208.28 		$1,797.38
$1,934.86
$2,080.48
$2,597.80 		$2,186.90
$2,324.38
$2,470.00
$2,987.32 		$389.52
Toc - Plan #22 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with Atrium Health

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 		$376.25
$427.04
$480.85
$671.98
$1,021.14 		$664.08
$714.87
$768.68
$959.81 		$951.91
$1,002.70
$1,056.51
$1,247.64 		$1,239.74
$1,290.53
$1,344.34
$1,535.47 		$287.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.50
$854.08
$961.70
$1,343.96
$2,042.28 		$1,040.33
$1,141.91
$1,249.53
$1,631.79 		$1,328.16
$1,429.74
$1,537.36
$1,919.62 		$1,615.99
$1,717.57
$1,825.19
$2,207.45 		$287.83
Toc - Plan #23 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Standard 5800 | with Atrium Health

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 		$505.03
$573.21
$645.43
$901.98
$1,370.65 		$891.38
$959.56
$1,031.78
$1,288.33 		$1,277.73
$1,345.91
$1,418.13
$1,674.68 		$1,664.08
$1,732.26
$1,804.48
$2,061.03 		$386.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,010.06
$1,146.42
$1,290.86
$1,803.96
$2,741.30 		$1,396.41
$1,532.77
$1,677.21
$2,190.31 		$1,782.76
$1,919.12
$2,063.56
$2,576.66 		$2,169.11
$2,305.47
$2,449.91
$2,963.01 		$386.35
Toc - Plan #24 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Atrium Health

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 		$356.03
$404.09
$455.01
$635.87
$966.27 		$628.39
$676.45
$727.37
$908.23 		$900.75
$948.81
$999.73
$1,180.59 		$1,173.11
$1,221.17
$1,272.09
$1,452.95 		$272.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.06
$808.18
$910.02
$1,271.74
$1,932.54 		$984.42
$1,080.54
$1,182.38
$1,544.10 		$1,256.78
$1,352.90
$1,454.74
$1,816.46 		$1,529.14
$1,625.26
$1,727.10
$2,088.82 		$272.36
Toc - Plan #25 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze Standard 7500 | with Atrium Health

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 		$356.46
$404.58
$455.56
$636.64
$967.43 		$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
$1,934.86 		$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 #26 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 7500 | HSA Eligible | Integrated | with Atrium Health

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 		$373.58
$424.01
$477.44
$667.21
$1,013.90 		$659.37
$709.80
$763.23
$953.00 		$945.16
$995.59
$1,049.02
$1,238.79 		$1,230.95
$1,281.38
$1,334.81
$1,524.58 		$285.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.16
$848.02
$954.88
$1,334.42
$2,027.80 		$1,032.95
$1,133.81
$1,240.67
$1,620.21 		$1,318.74
$1,419.60
$1,526.46
$1,906.00 		$1,604.53
$1,705.39
$1,812.25
$2,191.79 		$285.79
Toc - Plan #27 Blue Cross and Blue Shield of NC
Bronze

(EPO) Blue Local Bronze 9100 | Integrated | with Atrium Health

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 		$356.75
$404.91
$455.93
$637.16
$968.22 		$629.66
$677.82
$728.84
$910.07 		$902.57
$950.73
$1,001.75
$1,182.98 		$1,175.48
$1,223.64
$1,274.66
$1,455.89 		$272.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.50
$809.82
$911.86
$1,274.32
$1,936.44 		$986.41
$1,082.73
$1,184.77
$1,547.23 		$1,259.32
$1,355.64
$1,457.68
$1,820.14 		$1,532.23
$1,628.55
$1,730.59
$2,093.05 		$272.91
Toc - Plan #28 Blue Cross and Blue Shield of NC
Catastrophic

(EPO) Blue Local Catastrophic 9100 | 3 PCP $35 | Integrated | with Atrium Health

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 		$261.61
$296.93
$334.34
$467.24
$710.01 		$461.74
$497.06
$534.47
$667.37 		$661.87
$697.19
$734.60
$867.50 		$862.00
$897.32
$934.73
$1,067.63 		$200.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$523.22
$593.86
$668.68
$934.48
$1,420.02 		$723.35
$793.99
$868.81
$1,134.61 		$923.48
$994.12
$1,068.94
$1,334.74 		$1,123.61
$1,194.25
$1,269.07
$1,534.87 		$200.13

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #29 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 		$732.63
$831.52
$936.29
$1,308.45
$1,988.32 		$1,293.08
$1,391.97
$1,496.74
$1,868.90 		$1,853.53
$1,952.42
$2,057.19
$2,429.35 		$2,413.98
$2,512.87
$2,617.64
$2,989.80 		$560.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,465.26
$1,663.04
$1,872.58
$2,616.90
$3,976.64 		$2,025.71
$2,223.49
$2,433.03
$3,177.35 		$2,586.16
$2,783.94
$2,993.48
$3,737.80 		$3,146.61
$3,344.39
$3,553.93
$4,298.25 		$560.45
Toc - Plan #30 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 		$939.87
$1,066.74
$1,201.14
$1,678.58
$2,550.77 		$1,658.86
$1,785.73
$1,920.13
$2,397.57 		$2,377.85
$2,504.72
$2,639.12
$3,116.56 		$3,096.84
$3,223.71
$3,358.11
$3,835.55 		$718.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,879.74
$2,133.48
$2,402.28
$3,357.16
$5,101.54 		$2,598.73
$2,852.47
$3,121.27
$4,076.15 		$3,317.72
$3,571.46
$3,840.26
$4,795.14 		$4,036.71
$4,290.45
$4,559.25
$5,514.13 		$718.99
Toc - Plan #31 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 		$972.48
$1,103.75
$1,242.81
$1,736.83
$2,639.28 		$1,716.42
$1,847.69
$1,986.75
$2,480.77 		$2,460.36
$2,591.63
$2,730.69
$3,224.71 		$3,204.30
$3,335.57
$3,474.63
$3,968.65 		$743.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,944.96
$2,207.50
$2,485.62
$3,473.66
$5,278.56 		$2,688.90
$2,951.44
$3,229.56
$4,217.60 		$3,432.84
$3,695.38
$3,973.50
$4,961.54 		$4,176.78
$4,439.32
$4,717.44
$5,705.48 		$743.94
Toc - Plan #32 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 		$733.85
$832.91
$937.85
$1,310.64
$1,991.64 		$1,295.24
$1,394.30
$1,499.24
$1,872.03 		$1,856.63
$1,955.69
$2,060.63
$2,433.42 		$2,418.02
$2,517.08
$2,622.02
$2,994.81 		$561.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,467.70
$1,665.82
$1,875.70
$2,621.28
$3,983.28 		$2,029.09
$2,227.21
$2,437.09
$3,182.67 		$2,590.48
$2,788.60
$2,998.48
$3,744.06 		$3,151.87
$3,349.99
$3,559.87
$4,305.45 		$561.39
Toc - Plan #33 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 		$928.49
$1,053.83
$1,186.60
$1,658.27
$2,519.90 		$1,638.78
$1,764.12
$1,896.89
$2,368.56 		$2,349.07
$2,474.41
$2,607.18
$3,078.85 		$3,059.36
$3,184.70
$3,317.47
$3,789.14 		$710.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,856.98
$2,107.66
$2,373.20
$3,316.54
$5,039.80 		$2,567.27
$2,817.95
$3,083.49
$4,026.83 		$3,277.56
$3,528.24
$3,793.78
$4,737.12 		$3,987.85
$4,238.53
$4,504.07
$5,447.41 		$710.29
Toc - Plan #34 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 		$945.60
$1,073.24
$1,208.46
$1,688.82
$2,566.33 		$1,668.98
$1,796.62
$1,931.84
$2,412.20 		$2,392.36
$2,520.00
$2,655.22
$3,135.58 		$3,115.74
$3,243.38
$3,378.60
$3,858.96 		$723.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,891.20
$2,146.48
$2,416.92
$3,377.64
$5,132.66 		$2,614.58
$2,869.86
$3,140.30
$4,101.02 		$3,337.96
$3,593.24
$3,863.68
$4,824.40 		$4,061.34
$4,316.62
$4,587.06
$5,547.78 		$723.38

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5357 | Toll Free: 1-800-980-5357 | TTY: 1-800-980-5357
Toc - Plan #35 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 		$578.90
$657.05
$739.84
$1,033.92
$1,571.14 		$1,021.76
$1,099.91
$1,182.70
$1,476.78 		$1,464.62
$1,542.77
$1,625.56
$1,919.64 		$1,907.48
$1,985.63
$2,068.42
$2,362.50 		$442.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,157.80
$1,314.10
$1,479.68
$2,067.84
$3,142.28 		$1,600.66
$1,756.96
$1,922.54
$2,510.70 		$2,043.52
$2,199.82
$2,365.40
$2,953.56 		$2,486.38
$2,642.68
$2,808.26
$3,396.42 		$442.86
Toc - Plan #36 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 		$571.52
$648.67
$730.40
$1,020.73
$1,551.10 		$1,008.73
$1,085.88
$1,167.61
$1,457.94 		$1,445.94
$1,523.09
$1,604.82
$1,895.15 		$1,883.15
$1,960.30
$2,042.03
$2,332.36 		$437.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,143.04
$1,297.34
$1,460.80
$2,041.46
$3,102.20 		$1,580.25
$1,734.55
$1,898.01
$2,478.67 		$2,017.46
$2,171.76
$2,335.22
$2,915.88 		$2,454.67
$2,608.97
$2,772.43
$3,353.09 		$437.21
Toc - Plan #37 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 		$570.60
$647.63
$729.23
$1,019.09
$1,548.61 		$1,007.11
$1,084.14
$1,165.74
$1,455.60 		$1,443.62
$1,520.65
$1,602.25
$1,892.11 		$1,880.13
$1,957.16
$2,038.76
$2,328.62 		$436.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,141.20
$1,295.26
$1,458.46
$2,038.18
$3,097.22 		$1,577.71
$1,731.77
$1,894.97
$2,474.69 		$2,014.22
$2,168.28
$2,331.48
$2,911.20 		$2,450.73
$2,604.79
$2,767.99
$3,347.71 		$436.51
Toc - Plan #38 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 		$403.16
$457.58
$515.24
$720.04
$1,094.17 		$711.58
$766.00
$823.66
$1,028.46 		$1,020.00
$1,074.42
$1,132.08
$1,336.88 		$1,328.42
$1,382.84
$1,440.50
$1,645.30 		$308.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$806.32
$915.16
$1,030.48
$1,440.08
$2,188.34 		$1,114.74
$1,223.58
$1,338.90
$1,748.50 		$1,423.16
$1,532.00
$1,647.32
$2,056.92 		$1,731.58
$1,840.42
$1,955.74
$2,365.34 		$308.42
Toc - Plan #39 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 		$601.30
$682.47
$768.46
$1,073.91
$1,631.92 		$1,061.29
$1,142.46
$1,228.45
$1,533.90 		$1,521.28
$1,602.45
$1,688.44
$1,993.89 		$1,981.27
$2,062.44
$2,148.43
$2,453.88 		$459.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,202.60
$1,364.94
$1,536.92
$2,147.82
$3,263.84 		$1,662.59
$1,824.93
$1,996.91
$2,607.81 		$2,122.58
$2,284.92
$2,456.90
$3,067.80 		$2,582.57
$2,744.91
$2,916.89
$3,527.79 		$459.99
Toc - Plan #40 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 		$623.66
$707.85
$797.03
$1,113.85
$1,692.60 		$1,100.76
$1,184.95
$1,274.13
$1,590.95 		$1,577.86
$1,662.05
$1,751.23
$2,068.05 		$2,054.96
$2,139.15
$2,228.33
$2,545.15 		$477.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,247.32
$1,415.70
$1,594.06
$2,227.70
$3,385.20 		$1,724.42
$1,892.80
$2,071.16
$2,704.80 		$2,201.52
$2,369.90
$2,548.26
$3,181.90 		$2,678.62
$2,847.00
$3,025.36
$3,659.00 		$477.10
Toc - Plan #41 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 		$428.77
$486.66
$547.97
$765.79
$1,163.69 		$756.78
$814.67
$875.98
$1,093.80 		$1,084.79
$1,142.68
$1,203.99
$1,421.81 		$1,412.80
$1,470.69
$1,532.00
$1,749.82 		$328.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.54
$973.32
$1,095.94
$1,531.58
$2,327.38 		$1,185.55
$1,301.33
$1,423.95
$1,859.59 		$1,513.56
$1,629.34
$1,751.96
$2,187.60 		$1,841.57
$1,957.35
$2,079.97
$2,515.61 		$328.01
Toc - Plan #42 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 		$570.96
$648.04
$729.69
$1,019.74
$1,549.60 		$1,007.75
$1,084.83
$1,166.48
$1,456.53 		$1,444.54
$1,521.62
$1,603.27
$1,893.32 		$1,881.33
$1,958.41
$2,040.06
$2,330.11 		$436.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,141.92
$1,296.08
$1,459.38
$2,039.48
$3,099.20 		$1,578.71
$1,732.87
$1,896.17
$2,476.27 		$2,015.50
$2,169.66
$2,332.96
$2,913.06 		$2,452.29
$2,606.45
$2,769.75
$3,349.85 		$436.79
Toc - Plan #43 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 		$408.10
$463.20
$521.55
$728.87
$1,107.59 		$720.30
$775.40
$833.75
$1,041.07 		$1,032.50
$1,087.60
$1,145.95
$1,353.27 		$1,344.70
$1,399.80
$1,458.15
$1,665.47 		$312.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.20
$926.40
$1,043.10
$1,457.74
$2,215.18 		$1,128.40
$1,238.60
$1,355.30
$1,769.94 		$1,440.60
$1,550.80
$1,667.50
$2,082.14 		$1,752.80
$1,863.00
$1,979.70
$2,394.34 		$312.20
Toc - Plan #44 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 		$589.24
$668.79
$753.05
$1,052.39
$1,599.20 		$1,040.01
$1,119.56
$1,203.82
$1,503.16 		$1,490.78
$1,570.33
$1,654.59
$1,953.93 		$1,941.55
$2,021.10
$2,105.36
$2,404.70 		$450.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,178.48
$1,337.58
$1,506.10
$2,104.78
$3,198.40 		$1,629.25
$1,788.35
$1,956.87
$2,555.55 		$2,080.02
$2,239.12
$2,407.64
$3,006.32 		$2,530.79
$2,689.89
$2,858.41
$3,457.09 		$450.77
Toc - Plan #45 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 		$579.51
$657.75
$740.62
$1,035.01
$1,572.80 		$1,022.84
$1,101.08
$1,183.95
$1,478.34 		$1,466.17
$1,544.41
$1,627.28
$1,921.67 		$1,909.50
$1,987.74
$2,070.61
$2,365.00 		$443.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,159.02
$1,315.50
$1,481.24
$2,070.02
$3,145.60 		$1,602.35
$1,758.83
$1,924.57
$2,513.35 		$2,045.68
$2,202.16
$2,367.90
$2,956.68 		$2,489.01
$2,645.49
$2,811.23
$3,400.01 		$443.33
Toc - Plan #46 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 		$565.84
$642.23
$723.14
$1,010.59
$1,535.69 		$998.71
$1,075.10
$1,156.01
$1,443.46 		$1,431.58
$1,507.97
$1,588.88
$1,876.33 		$1,864.45
$1,940.84
$2,021.75
$2,309.20 		$432.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,131.68
$1,284.46
$1,446.28
$2,021.18
$3,071.38 		$1,564.55
$1,717.33
$1,879.15
$2,454.05 		$1,997.42
$2,150.20
$2,312.02
$2,886.92 		$2,430.29
$2,583.07
$2,744.89
$3,319.79 		$432.87
Toc - Plan #47 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 		$596.59
$677.13
$762.44
$1,065.51
$1,619.15 		$1,052.98
$1,133.52
$1,218.83
$1,521.90 		$1,509.37
$1,589.91
$1,675.22
$1,978.29 		$1,965.76
$2,046.30
$2,131.61
$2,434.68 		$456.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,193.18
$1,354.26
$1,524.88
$2,131.02
$3,238.30 		$1,649.57
$1,810.65
$1,981.27
$2,587.41 		$2,105.96
$2,267.04
$2,437.66
$3,043.80 		$2,562.35
$2,723.43
$2,894.05
$3,500.19 		$456.39
Toc - Plan #48 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 		$569.01
$645.83
$727.20
$1,016.26
$1,544.30 		$1,004.31
$1,081.13
$1,162.50
$1,451.56 		$1,439.61
$1,516.43
$1,597.80
$1,886.86 		$1,874.91
$1,951.73
$2,033.10
$2,322.16 		$435.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,138.02
$1,291.66
$1,454.40
$2,032.52
$3,088.60 		$1,573.32
$1,726.96
$1,889.70
$2,467.82 		$2,008.62
$2,162.26
$2,325.00
$2,903.12 		$2,443.92
$2,597.56
$2,760.30
$3,338.42 		$435.30
Toc - Plan #49 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 		$389.96
$442.60
$498.37
$696.47
$1,058.35 		$688.28
$740.92
$796.69
$994.79 		$986.60
$1,039.24
$1,095.01
$1,293.11 		$1,284.92
$1,337.56
$1,393.33
$1,591.43 		$298.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.92
$885.20
$996.74
$1,392.94
$2,116.70 		$1,078.24
$1,183.52
$1,295.06
$1,691.26 		$1,376.56
$1,481.84
$1,593.38
$1,989.58 		$1,674.88
$1,780.16
$1,891.70
$2,287.90 		$298.32
Toc - Plan #50 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 		$388.61
$441.07
$496.64
$694.06
$1,054.69 		$685.90
$738.36
$793.93
$991.35 		$983.19
$1,035.65
$1,091.22
$1,288.64 		$1,280.48
$1,332.94
$1,388.51
$1,585.93 		$297.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.22
$882.14
$993.28
$1,388.12
$2,109.38 		$1,074.51
$1,179.43
$1,290.57
$1,685.41 		$1,371.80
$1,476.72
$1,587.86
$1,982.70 		$1,669.09
$1,774.01
$1,885.15
$2,279.99 		$297.29
Toc - Plan #51 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 		$408.77
$463.96
$522.41
$730.06
$1,109.40 		$721.48
$776.67
$835.12
$1,042.77 		$1,034.19
$1,089.38
$1,147.83
$1,355.48 		$1,346.90
$1,402.09
$1,460.54
$1,668.19 		$312.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$817.54
$927.92
$1,044.82
$1,460.12
$2,218.80 		$1,130.25
$1,240.63
$1,357.53
$1,772.83 		$1,442.96
$1,553.34
$1,670.24
$2,085.54 		$1,755.67
$1,866.05
$1,982.95
$2,398.25 		$312.71
Toc - Plan #52 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 		$398.04
$451.78
$508.70
$710.91
$1,080.29 		$702.54
$756.28
$813.20
$1,015.41 		$1,007.04
$1,060.78
$1,117.70
$1,319.91 		$1,311.54
$1,365.28
$1,422.20
$1,624.41 		$304.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.08
$903.56
$1,017.40
$1,421.82
$2,160.58 		$1,100.58
$1,208.06
$1,321.90
$1,726.32 		$1,405.08
$1,512.56
$1,626.40
$2,030.82 		$1,709.58
$1,817.06
$1,930.90
$2,335.32 		$304.50

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #53 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 		$289.64
$328.74
$370.15
$517.29
$786.07 		$511.21
$550.31
$591.72
$738.86 		$732.78
$771.88
$813.29
$960.43 		$954.35
$993.45
$1,034.86
$1,182.00 		$221.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.28
$657.48
$740.30
$1,034.58
$1,572.14 		$800.85
$879.05
$961.87
$1,256.15 		$1,022.42
$1,100.62
$1,183.44
$1,477.72 		$1,243.99
$1,322.19
$1,405.01
$1,699.29 		$221.57
Toc - Plan #54 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 		$260.63
$295.81
$333.08
$465.48
$707.35 		$460.01
$495.19
$532.46
$664.86 		$659.39
$694.57
$731.84
$864.24 		$858.77
$893.95
$931.22
$1,063.62 		$199.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.26
$591.62
$666.16
$930.96
$1,414.70 		$720.64
$791.00
$865.54
$1,130.34 		$920.02
$990.38
$1,064.92
$1,329.72 		$1,119.40
$1,189.76
$1,264.30
$1,529.10 		$199.38
Toc - Plan #55 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 		$427.43
$485.14
$546.26
$763.40
$1,160.06 		$754.42
$812.13
$873.25
$1,090.39 		$1,081.41
$1,139.12
$1,200.24
$1,417.38 		$1,408.40
$1,466.11
$1,527.23
$1,744.37 		$326.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.86
$970.28
$1,092.52
$1,526.80
$2,320.12 		$1,181.85
$1,297.27
$1,419.51
$1,853.79 		$1,508.84
$1,624.26
$1,746.50
$2,180.78 		$1,835.83
$1,951.25
$2,073.49
$2,507.77 		$326.99
Toc - Plan #56 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 		$401.12
$455.27
$512.63
$716.40
$1,088.63 		$707.97
$762.12
$819.48
$1,023.25 		$1,014.82
$1,068.97
$1,126.33
$1,330.10 		$1,321.67
$1,375.82
$1,433.18
$1,636.95 		$306.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.24
$910.54
$1,025.26
$1,432.80
$2,177.26 		$1,109.09
$1,217.39
$1,332.11
$1,739.65 		$1,415.94
$1,524.24
$1,638.96
$2,046.50 		$1,722.79
$1,831.09
$1,945.81
$2,353.35 		$306.85
Toc - Plan #57 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 		$380.73
$432.12
$486.57
$679.98
$1,033.29 		$671.99
$723.38
$777.83
$971.24 		$963.25
$1,014.64
$1,069.09
$1,262.50 		$1,254.51
$1,305.90
$1,360.35
$1,553.76 		$291.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.46
$864.24
$973.14
$1,359.96
$2,066.58 		$1,052.72
$1,155.50
$1,264.40
$1,651.22 		$1,343.98
$1,446.76
$1,555.66
$1,942.48 		$1,635.24
$1,738.02
$1,846.92
$2,233.74 		$291.26
Toc - Plan #58 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 		$270.13
$306.59
$345.22
$482.44
$733.12 		$476.78
$513.24
$551.87
$689.09 		$683.43
$719.89
$758.52
$895.74 		$890.08
$926.54
$965.17
$1,102.39 		$206.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.26
$613.18
$690.44
$964.88
$1,466.24 		$746.91
$819.83
$897.09
$1,171.53 		$953.56
$1,026.48
$1,103.74
$1,378.18 		$1,160.21
$1,233.13
$1,310.39
$1,584.83 		$206.65
Toc - Plan #59 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 		$419.56
$476.20
$536.20
$749.34
$1,138.69 		$740.53
$797.17
$857.17
$1,070.31 		$1,061.50
$1,118.14
$1,178.14
$1,391.28 		$1,382.47
$1,439.11
$1,499.11
$1,712.25 		$320.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.12
$952.40
$1,072.40
$1,498.68
$2,277.38 		$1,160.09
$1,273.37
$1,393.37
$1,819.65 		$1,481.06
$1,594.34
$1,714.34
$2,140.62 		$1,802.03
$1,915.31
$2,035.31
$2,461.59 		$320.97
Toc - Plan #60 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 		$393.81
$446.98
$503.29
$703.35
$1,068.81 		$695.08
$748.25
$804.56
$1,004.62 		$996.35
$1,049.52
$1,105.83
$1,305.89 		$1,297.62
$1,350.79
$1,407.10
$1,607.16 		$301.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.62
$893.96
$1,006.58
$1,406.70
$2,137.62 		$1,088.89
$1,195.23
$1,307.85
$1,707.97 		$1,390.16
$1,496.50
$1,609.12
$2,009.24 		$1,691.43
$1,797.77
$1,910.39
$2,310.51 		$301.27
Toc - Plan #61 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 		$371.82
$422.02
$475.19
$664.08
$1,009.13 		$656.27
$706.47
$759.64
$948.53 		$940.72
$990.92
$1,044.09
$1,232.98 		$1,225.17
$1,275.37
$1,328.54
$1,517.43 		$284.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.64
$844.04
$950.38
$1,328.16
$2,018.26 		$1,028.09
$1,128.49
$1,234.83
$1,612.61 		$1,312.54
$1,412.94
$1,519.28
$1,897.06 		$1,596.99
$1,697.39
$1,803.73
$2,181.51 		$284.45

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310 | TTY: 1-833-863-1310
Toc - Plan #62 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze with Atrium Health

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 		$280.75
$318.65
$358.79
$501.41
$761.94 		$495.52
$533.42
$573.56
$716.18 		$710.29
$748.19
$788.33
$930.95 		$925.06
$962.96
$1,003.10
$1,145.72 		$214.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.50
$637.30
$717.58
$1,002.82
$1,523.88 		$776.27
$852.07
$932.35
$1,217.59 		$991.04
$1,066.84
$1,147.12
$1,432.36 		$1,205.81
$1,281.61
$1,361.89
$1,647.13 		$214.77
Toc - Plan #63 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA with Atrium Health

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 		$308.74
$350.41
$394.55
$551.39
$837.89 		$544.92
$586.59
$630.73
$787.57 		$781.10
$822.77
$866.91
$1,023.75 		$1,017.28
$1,058.95
$1,103.09
$1,259.93 		$236.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.48
$700.82
$789.10
$1,102.78
$1,675.78 		$853.66
$937.00
$1,025.28
$1,338.96 		$1,089.84
$1,173.18
$1,261.46
$1,575.14 		$1,326.02
$1,409.36
$1,497.64
$1,811.32 		$236.18
Toc - Plan #64 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze with Atrium Health

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 		$299.56
$339.99
$382.83
$535.00
$812.99 		$528.72
$569.15
$611.99
$764.16 		$757.88
$798.31
$841.15
$993.32 		$987.04
$1,027.47
$1,070.31
$1,222.48 		$229.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.12
$679.98
$765.66
$1,070.00
$1,625.98 		$828.28
$909.14
$994.82
$1,299.16 		$1,057.44
$1,138.30
$1,223.98
$1,528.32 		$1,286.60
$1,367.46
$1,453.14
$1,757.48 		$229.16
Toc - Plan #65 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze with Atrium Health

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 		$337.10
$382.60
$430.80
$602.05
$914.87 		$594.98
$640.48
$688.68
$859.93 		$852.86
$898.36
$946.56
$1,117.81 		$1,110.74
$1,156.24
$1,204.44
$1,375.69 		$257.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.20
$765.20
$861.60
$1,204.10
$1,829.74 		$932.08
$1,023.08
$1,119.48
$1,461.98 		$1,189.96
$1,280.96
$1,377.36
$1,719.86 		$1,447.84
$1,538.84
$1,635.24
$1,977.74 		$257.88
Toc - Plan #66 Ambetter of North Carolina
Silver

(HMO) Complete Silver with Atrium Health

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 		$380.73
$432.12
$486.56
$679.97
$1,033.28 		$671.98
$723.37
$777.81
$971.22 		$963.23
$1,014.62
$1,069.06
$1,262.47 		$1,254.48
$1,305.87
$1,360.31
$1,553.72 		$291.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.46
$864.24
$973.12
$1,359.94
$2,066.56 		$1,052.71
$1,155.49
$1,264.37
$1,651.19 		$1,343.96
$1,446.74
$1,555.62
$1,942.44 		$1,635.21
$1,737.99
$1,846.87
$2,233.69 		$291.25
Toc - Plan #67 Ambetter of North Carolina
Silver

(HMO) Everyday Silver with Atrium Health

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 		$377.19
$428.10
$482.04
$673.65
$1,023.67 		$665.73
$716.64
$770.58
$962.19 		$954.27
$1,005.18
$1,059.12
$1,250.73 		$1,242.81
$1,293.72
$1,347.66
$1,539.27 		$288.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.38
$856.20
$964.08
$1,347.30
$2,047.34 		$1,042.92
$1,144.74
$1,252.62
$1,635.84 		$1,331.46
$1,433.28
$1,541.16
$1,924.38 		$1,620.00
$1,721.82
$1,829.70
$2,212.92 		$288.54
Toc - Plan #68 Ambetter of North Carolina
Silver

(HMO) Clear Silver with Atrium Health

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 		$376.20
$426.98
$480.77
$671.88
$1,020.99 		$663.99
$714.77
$768.56
$959.67 		$951.78
$1,002.56
$1,056.35
$1,247.46 		$1,239.57
$1,290.35
$1,344.14
$1,535.25 		$287.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.40
$853.96
$961.54
$1,343.76
$2,041.98 		$1,040.19
$1,141.75
$1,249.33
$1,631.55 		$1,327.98
$1,429.54
$1,537.12
$1,919.34 		$1,615.77
$1,717.33
$1,824.91
$2,207.13 		$287.79
Toc - Plan #69 Ambetter of North Carolina
Silver

(HMO) Focused Silver with Atrium Health

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 		$376.35
$427.15
$480.97
$672.15
$1,021.40 		$664.25
$715.05
$768.87
$960.05 		$952.15
$1,002.95
$1,056.77
$1,247.95 		$1,240.05
$1,290.85
$1,344.67
$1,535.85 		$287.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$752.70
$854.30
$961.94
$1,344.30
$2,042.80 		$1,040.60
$1,142.20
$1,249.84
$1,632.20 		$1,328.50
$1,430.10
$1,537.74
$1,920.10 		$1,616.40
$1,718.00
$1,825.64
$2,208.00 		$287.90
Toc - Plan #70 Ambetter of North Carolina
Gold

(HMO) Complete Gold with Atrium Health

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 		$397.18
$450.79
$507.58
$709.35
$1,077.92 		$701.01
$754.62
$811.41
$1,013.18 		$1,004.84
$1,058.45
$1,115.24
$1,317.01 		$1,308.67
$1,362.28
$1,419.07
$1,620.84 		$303.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.36
$901.58
$1,015.16
$1,418.70
$2,155.84 		$1,098.19
$1,205.41
$1,318.99
$1,722.53 		$1,402.02
$1,509.24
$1,622.82
$2,026.36 		$1,705.85
$1,813.07
$1,926.65
$2,330.19 		$303.83
Toc - Plan #71 Ambetter of North Carolina
Expanded Bronze

(HMO) CMS Standard Expanded Bronze with Atrium Health

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 		$293.74
$333.38
$375.38
$524.60
$797.18 		$518.44
$558.08
$600.08
$749.30 		$743.14
$782.78
$824.78
$974.00 		$967.84
$1,007.48
$1,049.48
$1,198.70 		$224.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.48
$666.76
$750.76
$1,049.20
$1,594.36 		$812.18
$891.46
$975.46
$1,273.90 		$1,036.88
$1,116.16
$1,200.16
$1,498.60 		$1,261.58
$1,340.86
$1,424.86
$1,723.30 		$224.70
Toc - Plan #72 Ambetter of North Carolina
Silver

(HMO) CMS Standard Silver with Atrium Health

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 		$372.51
$422.79
$476.05
$665.28
$1,010.96 		$657.47
$707.75
$761.01
$950.24 		$942.43
$992.71
$1,045.97
$1,235.20 		$1,227.39
$1,277.67
$1,330.93
$1,520.16 		$284.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.02
$845.58
$952.10
$1,330.56
$2,021.92 		$1,029.98
$1,130.54
$1,237.06
$1,615.52 		$1,314.94
$1,415.50
$1,522.02
$1,900.48 		$1,599.90
$1,700.46
$1,806.98
$2,185.44 		$284.96
Toc - Plan #73 Ambetter of North Carolina
Gold

(HMO) CMS Standard Gold with Atrium Health

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 		$376.96
$427.84
$481.75
$673.24
$1,023.05 		$665.33
$716.21
$770.12
$961.61 		$953.70
$1,004.58
$1,058.49
$1,249.98 		$1,242.07
$1,292.95
$1,346.86
$1,538.35 		$288.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.92
$855.68
$963.50
$1,346.48
$2,046.10 		$1,042.29
$1,144.05
$1,251.87
$1,634.85 		$1,330.66
$1,432.42
$1,540.24
$1,923.22 		$1,619.03
$1,720.79
$1,828.61
$2,211.59 		$288.37
Toc - Plan #74 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze with Atrium Health + 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 		$292.58
$332.07
$373.90
$522.53
$794.03 		$516.40
$555.89
$597.72
$746.35 		$740.22
$779.71
$821.54
$970.17 		$964.04
$1,003.53
$1,045.36
$1,193.99 		$223.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.16
$664.14
$747.80
$1,045.06
$1,588.06 		$808.98
$887.96
$971.62
$1,268.88 		$1,032.80
$1,111.78
$1,195.44
$1,492.70 		$1,256.62
$1,335.60
$1,419.26
$1,716.52 		$223.82
Toc - Plan #75 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA with Atrium Health + 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 		$321.74
$365.17
$411.17
$574.61
$873.18 		$567.86
$611.29
$657.29
$820.73 		$813.98
$857.41
$903.41
$1,066.85 		$1,060.10
$1,103.53
$1,149.53
$1,312.97 		$246.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.48
$730.34
$822.34
$1,149.22
$1,746.36 		$889.60
$976.46
$1,068.46
$1,395.34 		$1,135.72
$1,222.58
$1,314.58
$1,641.46 		$1,381.84
$1,468.70
$1,560.70
$1,887.58 		$246.12
Toc - Plan #76 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze with Atrium Health + 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 		$312.18
$354.31
$398.95
$557.54
$847.23 		$550.99
$593.12
$637.76
$796.35 		$789.80
$831.93
$876.57
$1,035.16 		$1,028.61
$1,070.74
$1,115.38
$1,273.97 		$238.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.36
$708.62
$797.90
$1,115.08
$1,694.46 		$863.17
$947.43
$1,036.71
$1,353.89 		$1,101.98
$1,186.24
$1,275.52
$1,592.70 		$1,340.79
$1,425.05
$1,514.33
$1,831.51 		$238.81
Toc - Plan #77 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze with Atrium Health + 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 		$351.30
$398.71
$448.95
$627.40
$953.40 		$620.04
$667.45
$717.69
$896.14 		$888.78
$936.19
$986.43
$1,164.88 		$1,157.52
$1,204.93
$1,255.17
$1,433.62 		$268.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.60
$797.42
$897.90
$1,254.80
$1,906.80 		$971.34
$1,066.16
$1,166.64
$1,523.54 		$1,240.08
$1,334.90
$1,435.38
$1,792.28 		$1,508.82
$1,603.64
$1,704.12
$2,061.02 		$268.74
Toc - Plan #78 Ambetter of North Carolina
Silver

(HMO) Complete Silver with Atrium Health + 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 		$396.77
$450.32
$507.06
$708.61
$1,076.80 		$700.29
$753.84
$810.58
$1,012.13 		$1,003.81
$1,057.36
$1,114.10
$1,315.65 		$1,307.33
$1,360.88
$1,417.62
$1,619.17 		$303.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.54
$900.64
$1,014.12
$1,417.22
$2,153.60 		$1,097.06
$1,204.16
$1,317.64
$1,720.74 		$1,400.58
$1,507.68
$1,621.16
$2,024.26 		$1,704.10
$1,811.20
$1,924.68
$2,327.78 		$303.52
Toc - Plan #79 Ambetter of North Carolina
Silver

(HMO) Everyday Silver with Atrium Health + 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 		$393.08
$446.13
$502.34
$702.02
$1,066.79 		$693.78
$746.83
$803.04
$1,002.72 		$994.48
$1,047.53
$1,103.74
$1,303.42 		$1,295.18
$1,348.23
$1,404.44
$1,604.12 		$300.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$786.16
$892.26
$1,004.68
$1,404.04
$2,133.58 		$1,086.86
$1,192.96
$1,305.38
$1,704.74 		$1,387.56
$1,493.66
$1,606.08
$2,005.44 		$1,688.26
$1,794.36
$1,906.78
$2,306.14 		$300.70
Toc - Plan #80 Ambetter of North Carolina
Silver

(HMO) Clear Silver with Atrium Health + 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 		$392.05
$444.96
$501.02
$700.18
$1,063.99 		$691.96
$744.87
$800.93
$1,000.09 		$991.87
$1,044.78
$1,100.84
$1,300.00 		$1,291.78
$1,344.69
$1,400.75
$1,599.91 		$299.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.10
$889.92
$1,002.04
$1,400.36
$2,127.98 		$1,084.01
$1,189.83
$1,301.95
$1,700.27 		$1,383.92
$1,489.74
$1,601.86
$2,000.18 		$1,683.83
$1,789.65
$1,901.77
$2,300.09 		$299.91
Toc - Plan #81 Ambetter of North Carolina
Silver

(HMO) Focused Silver with Atrium Health + 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 		$392.21
$445.14
$501.23
$700.46
$1,064.42 		$692.24
$745.17
$801.26
$1,000.49 		$992.27
$1,045.20
$1,101.29
$1,300.52 		$1,292.30
$1,345.23
$1,401.32
$1,600.55 		$300.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$784.42
$890.28
$1,002.46
$1,400.92
$2,128.84 		$1,084.45
$1,190.31
$1,302.49
$1,700.95 		$1,384.48
$1,490.34
$1,602.52
$2,000.98 		$1,684.51
$1,790.37
$1,902.55
$2,301.01 		$300.03
Toc - Plan #82 Ambetter of North Carolina
Gold

(HMO) Complete Gold with Atrium Health + 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 		$413.91
$469.77
$528.96
$739.22
$1,123.32 		$730.54
$786.40
$845.59
$1,055.85 		$1,047.17
$1,103.03
$1,162.22
$1,372.48 		$1,363.80
$1,419.66
$1,478.85
$1,689.11 		$316.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.82
$939.54
$1,057.92
$1,478.44
$2,246.64 		$1,144.45
$1,256.17
$1,374.55
$1,795.07 		$1,461.08
$1,572.80
$1,691.18
$2,111.70 		$1,777.71
$1,889.43
$2,007.81
$2,428.33 		$316.63

‡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 Mecklenburg County here.

Mecklenburg County is in “Rating Area 4” of North Carolina.

Currently, there are 82 plans offered in Rating Area 4.

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2023 Obamacare Plans for Mecklenburg County, NC

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