Obamacare 2023 Rates for Wayne County

Obamacare > Rates > Tennessee > Wayne 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 Wayne County, TN.

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, 67 Plans and 2023 Rates for Wayne County, Tennessee

Below, you’ll find a summary of the 67 plans for Wayne County, Tennessee 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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Wayne County Resources

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BlueCross BlueShield of Tennessee

Local: 1-423-535-5600 | Toll Free: 1-800-565-9140

Toc - Plan #1 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B07S HSA + Free Preventive Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,950 $11,900 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 		$417.86
$474.27
$534.03
$746.30
$1,134.07 		$737.52
$793.93
$853.69
$1,065.96 		$1,057.18
$1,113.59
$1,173.35
$1,385.62 		$1,376.84
$1,433.25
$1,493.01
$1,705.28 		$319.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.72
$948.54
$1,068.06
$1,492.60
$2,268.14 		$1,155.38
$1,268.20
$1,387.72
$1,812.26 		$1,475.04
$1,587.86
$1,707.38
$2,131.92 		$1,794.70
$1,907.52
$2,027.04
$2,451.58 		$319.66
Toc - Plan #2 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B08S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$375.77
$426.50
$480.23
$671.13
$1,019.84 		$663.23
$713.96
$767.69
$958.59 		$950.69
$1,001.42
$1,055.15
$1,246.05 		$1,238.15
$1,288.88
$1,342.61
$1,533.51 		$287.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.54
$853.00
$960.46
$1,342.26
$2,039.68 		$1,039.00
$1,140.46
$1,247.92
$1,629.72 		$1,326.46
$1,427.92
$1,535.38
$1,917.18 		$1,613.92
$1,715.38
$1,822.84
$2,204.64 		$287.46
Toc - Plan #3 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B10S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$6,600 $13,200 Annual Deductible
$8,150 $16,300 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 		$411.38
$466.92
$525.74
$734.72
$1,116.49 		$726.09
$781.63
$840.45
$1,049.43 		$1,040.80
$1,096.34
$1,155.16
$1,364.14 		$1,355.51
$1,411.05
$1,469.87
$1,678.85 		$314.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.76
$933.84
$1,051.48
$1,469.44
$2,232.98 		$1,137.47
$1,248.55
$1,366.19
$1,784.15 		$1,452.18
$1,563.26
$1,680.90
$2,098.86 		$1,766.89
$1,877.97
$1,995.61
$2,413.57 		$314.71
Toc - Plan #4 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B13S 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$437.34
$496.38
$558.92
$781.09
$1,186.94 		$771.91
$830.95
$893.49
$1,115.66 		$1,106.48
$1,165.52
$1,228.06
$1,450.23 		$1,441.05
$1,500.09
$1,562.63
$1,784.80 		$334.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.68
$992.76
$1,117.84
$1,562.18
$2,373.88 		$1,209.25
$1,327.33
$1,452.41
$1,896.75 		$1,543.82
$1,661.90
$1,786.98
$2,231.32 		$1,878.39
$1,996.47
$2,121.55
$2,565.89 		$334.57
Toc - Plan #5 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B14S $70 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$382.35
$433.97
$488.64
$682.88
$1,037.70 		$674.85
$726.47
$781.14
$975.38 		$967.35
$1,018.97
$1,073.64
$1,267.88 		$1,259.85
$1,311.47
$1,366.14
$1,560.38 		$292.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.70
$867.94
$977.28
$1,365.76
$2,075.40 		$1,057.20
$1,160.44
$1,269.78
$1,658.26 		$1,349.70
$1,452.94
$1,562.28
$1,950.76 		$1,642.20
$1,745.44
$1,854.78
$2,243.26 		$292.50
Toc - Plan #6 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B15S + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$372.00
$422.22
$475.42
$664.39
$1,009.61 		$656.58
$706.80
$760.00
$948.97 		$941.16
$991.38
$1,044.58
$1,233.55 		$1,225.74
$1,275.96
$1,329.16
$1,518.13 		$284.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.00
$844.44
$950.84
$1,328.78
$2,019.22 		$1,028.58
$1,129.02
$1,235.42
$1,613.36 		$1,313.16
$1,413.60
$1,520.00
$1,897.94 		$1,597.74
$1,698.18
$1,804.58
$2,182.52 		$284.58
Toc - Plan #7 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S01S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$536.16
$608.54
$685.21
$957.58
$1,455.14 		$946.32
$1,018.70
$1,095.37
$1,367.74 		$1,356.48
$1,428.86
$1,505.53
$1,777.90 		$1,766.64
$1,839.02
$1,915.69
$2,188.06 		$410.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,072.32
$1,217.08
$1,370.42
$1,915.16
$2,910.28 		$1,482.48
$1,627.24
$1,780.58
$2,325.32 		$1,892.64
$2,037.40
$2,190.74
$2,735.48 		$2,302.80
$2,447.56
$2,600.90
$3,145.64 		$410.16
Toc - Plan #8 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S04S Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,200 $12,400 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 		$528.96
$600.37
$676.01
$944.72
$1,435.60 		$933.61
$1,005.02
$1,080.66
$1,349.37 		$1,338.26
$1,409.67
$1,485.31
$1,754.02 		$1,742.91
$1,814.32
$1,889.96
$2,158.67 		$404.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,057.92
$1,200.74
$1,352.02
$1,889.44
$2,871.20 		$1,462.57
$1,605.39
$1,756.67
$2,294.09 		$1,867.22
$2,010.04
$2,161.32
$2,698.74 		$2,271.87
$2,414.69
$2,565.97
$3,103.39 		$404.65
Toc - Plan #9 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S23S 2 Free PCP Visits + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 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 		$525.40
$596.33
$671.46
$938.36
$1,425.94 		$927.33
$998.26
$1,073.39
$1,340.29 		$1,329.26
$1,400.19
$1,475.32
$1,742.22 		$1,731.19
$1,802.12
$1,877.25
$2,144.15 		$401.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,050.80
$1,192.66
$1,342.92
$1,876.72
$2,851.88 		$1,452.73
$1,594.59
$1,744.85
$2,278.65 		$1,854.66
$1,996.52
$2,146.78
$2,680.58 		$2,256.59
$2,398.45
$2,548.71
$3,082.51 		$401.93
Toc - Plan #10 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S24S $35 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,150 $10,300 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 		$491.56
$557.92
$628.21
$877.93
$1,334.09 		$867.60
$933.96
$1,004.25
$1,253.97 		$1,243.64
$1,310.00
$1,380.29
$1,630.01 		$1,619.68
$1,686.04
$1,756.33
$2,006.05 		$376.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.12
$1,115.84
$1,256.42
$1,755.86
$2,668.18 		$1,359.16
$1,491.88
$1,632.46
$2,131.90 		$1,735.20
$1,867.92
$2,008.50
$2,507.94 		$2,111.24
$2,243.96
$2,384.54
$2,883.98 		$376.04
Toc - Plan #11 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S25S $45 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$504.81
$572.96
$645.15
$901.59
$1,370.05 		$890.99
$959.14
$1,031.33
$1,287.77 		$1,277.17
$1,345.32
$1,417.51
$1,673.95 		$1,663.35
$1,731.50
$1,803.69
$2,060.13 		$386.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,009.62
$1,145.92
$1,290.30
$1,803.18
$2,740.10 		$1,395.80
$1,532.10
$1,676.48
$2,189.36 		$1,781.98
$1,918.28
$2,062.66
$2,575.54 		$2,168.16
$2,304.46
$2,448.84
$2,961.72 		$386.18
Toc - Plan #12 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G06S $35 PCP Copay + Free Telehealth + Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$6,350 $12,700 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 		$641.52
$728.13
$819.86
$1,145.75
$1,741.09 		$1,132.28
$1,218.89
$1,310.62
$1,636.51 		$1,623.04
$1,709.65
$1,801.38
$2,127.27 		$2,113.80
$2,200.41
$2,292.14
$2,618.03 		$490.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,283.04
$1,456.26
$1,639.72
$2,291.50
$3,482.18 		$1,773.80
$1,947.02
$2,130.48
$2,782.26 		$2,264.56
$2,437.78
$2,621.24
$3,273.02 		$2,755.32
$2,928.54
$3,112.00
$3,763.78 		$490.76
Toc - Plan #13 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G08S $30 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$634.07
$719.67
$810.34
$1,132.45
$1,720.87 		$1,119.13
$1,204.73
$1,295.40
$1,617.51 		$1,604.19
$1,689.79
$1,780.46
$2,102.57 		$2,089.25
$2,174.85
$2,265.52
$2,587.63 		$485.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,268.14
$1,439.34
$1,620.68
$2,264.90
$3,441.74 		$1,753.20
$1,924.40
$2,105.74
$2,749.96 		$2,238.26
$2,409.46
$2,590.80
$3,235.02 		$2,723.32
$2,894.52
$3,075.86
$3,720.08 		$485.06
Toc - Plan #14 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B16S $50 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$408.34
$463.47
$521.86
$729.30
$1,108.23 		$720.72
$775.85
$834.24
$1,041.68 		$1,033.10
$1,088.23
$1,146.62
$1,354.06 		$1,345.48
$1,400.61
$1,459.00
$1,666.44 		$312.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.68
$926.94
$1,043.72
$1,458.60
$2,216.46 		$1,129.06
$1,239.32
$1,356.10
$1,770.98 		$1,441.44
$1,551.70
$1,668.48
$2,083.36 		$1,753.82
$1,864.08
$1,980.86
$2,395.74 		$312.38
Toc - Plan #15 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S26S $40 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

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 		$501.90
$569.66
$641.43
$896.39
$1,362.16 		$885.85
$953.61
$1,025.38
$1,280.34 		$1,269.80
$1,337.56
$1,409.33
$1,664.29 		$1,653.75
$1,721.51
$1,793.28
$2,048.24 		$383.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.80
$1,139.32
$1,282.86
$1,792.78
$2,724.32 		$1,387.75
$1,523.27
$1,666.81
$2,176.73 		$1,771.70
$1,907.22
$2,050.76
$2,560.68 		$2,155.65
$2,291.17
$2,434.71
$2,944.63 		$383.95
Toc - Plan #16 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S27S $60 PCP Copay + Free Telehealth

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-565-9140

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$6,300 $12,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$485.19
$550.69
$620.07
$866.55
$1,316.81 		$856.36
$921.86
$991.24
$1,237.72 		$1,227.53
$1,293.03
$1,362.41
$1,608.89 		$1,598.70
$1,664.20
$1,733.58
$1,980.06 		$371.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$970.38
$1,101.38
$1,240.14
$1,733.10
$2,633.62 		$1,341.55
$1,472.55
$1,611.31
$2,104.27 		$1,712.72
$1,843.72
$1,982.48
$2,475.44 		$2,083.89
$2,214.89
$2,353.65
$2,846.61 		$371.17

ADVERTISEMENT

US Health and Life

Local: 1-833-600-1311 | Toll Free: 

Toc - Plan #17 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$312.67
$354.88
$399.59
$558.43
$848.58 		$551.86
$594.07
$638.78
$797.62 		$791.05
$833.26
$877.97
$1,036.81 		$1,030.24
$1,072.45
$1,117.16
$1,276.00 		$239.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.34
$709.76
$799.18
$1,116.86
$1,697.16 		$864.53
$948.95
$1,038.37
$1,356.05 		$1,103.72
$1,188.14
$1,277.56
$1,595.24 		$1,342.91
$1,427.33
$1,516.75
$1,834.43 		$239.19
Toc - Plan #18 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Balanced Bronze 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.43
$352.33
$396.73
$554.42
$842.50 		$547.91
$589.81
$634.21
$791.90 		$785.39
$827.29
$871.69
$1,029.38 		$1,022.87
$1,064.77
$1,109.17
$1,266.86 		$237.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620.86
$704.66
$793.46
$1,108.84
$1,685.00 		$858.34
$942.14
$1,030.94
$1,346.32 		$1,095.82
$1,179.62
$1,268.42
$1,583.80 		$1,333.30
$1,417.10
$1,505.90
$1,821.28 		$237.48
Toc - Plan #19 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care No Deductible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$350.31
$397.61
$447.70
$625.66
$950.75 		$618.30
$665.60
$715.69
$893.65 		$886.29
$933.59
$983.68
$1,161.64 		$1,154.28
$1,201.58
$1,251.67
$1,429.63 		$267.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.62
$795.22
$895.40
$1,251.32
$1,901.50 		$968.61
$1,063.21
$1,163.39
$1,519.31 		$1,236.60
$1,331.20
$1,431.38
$1,787.30 		$1,504.59
$1,599.19
$1,699.37
$2,055.29 		$267.99
Toc - Plan #20 US Health and Life
Silver

(EPO) Ascension Personalized Care Balanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$456.71
$518.36
$583.67
$815.68
$1,239.50 		$806.09
$867.74
$933.05
$1,165.06 		$1,155.47
$1,217.12
$1,282.43
$1,514.44 		$1,504.85
$1,566.50
$1,631.81
$1,863.82 		$349.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$913.42
$1,036.72
$1,167.34
$1,631.36
$2,479.00 		$1,262.80
$1,386.10
$1,516.72
$1,980.74 		$1,612.18
$1,735.48
$1,866.10
$2,330.12 		$1,961.56
$2,084.86
$2,215.48
$2,679.50 		$349.38
Toc - Plan #21 US Health and Life
Silver

(EPO) Ascension Personalized Care No Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$452.94
$514.08
$578.85
$808.94
$1,229.27 		$799.44
$860.58
$925.35
$1,155.44 		$1,145.94
$1,207.08
$1,271.85
$1,501.94 		$1,492.44
$1,553.58
$1,618.35
$1,848.44 		$346.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$905.88
$1,028.16
$1,157.70
$1,617.88
$2,458.54 		$1,252.38
$1,374.66
$1,504.20
$1,964.38 		$1,598.88
$1,721.16
$1,850.70
$2,310.88 		$1,945.38
$2,067.66
$2,197.20
$2,657.38 		$346.50
Toc - Plan #22 US Health and Life
Silver

(EPO) Ascension Personalized Care Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$422.16
$479.16
$539.52
$753.98
$1,145.75 		$745.12
$802.12
$862.48
$1,076.94 		$1,068.08
$1,125.08
$1,185.44
$1,399.90 		$1,391.04
$1,448.04
$1,508.40
$1,722.86 		$322.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$844.32
$958.32
$1,079.04
$1,507.96
$2,291.50 		$1,167.28
$1,281.28
$1,402.00
$1,830.92 		$1,490.24
$1,604.24
$1,724.96
$2,153.88 		$1,813.20
$1,927.20
$2,047.92
$2,476.84 		$322.96
Toc - Plan #23 US Health and Life
Expanded Bronze

(EPO) Ascension Personalized Care Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$314.46
$356.91
$401.88
$561.62
$853.44 		$555.02
$597.47
$642.44
$802.18 		$795.58
$838.03
$883.00
$1,042.74 		$1,036.14
$1,078.59
$1,123.56
$1,283.30 		$240.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$628.92
$713.82
$803.76
$1,123.24
$1,706.88 		$869.48
$954.38
$1,044.32
$1,363.80 		$1,110.04
$1,194.94
$1,284.88
$1,604.36 		$1,350.60
$1,435.50
$1,525.44
$1,844.92 		$240.56
Toc - Plan #24 US Health and Life
Silver

(EPO) Ascension Personalized Care Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$425.34
$482.77
$543.59
$759.67
$1,154.39 		$750.73
$808.16
$868.98
$1,085.06 		$1,076.12
$1,133.55
$1,194.37
$1,410.45 		$1,401.51
$1,458.94
$1,519.76
$1,735.84 		$325.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.68
$965.54
$1,087.18
$1,519.34
$2,308.78 		$1,176.07
$1,290.93
$1,412.57
$1,844.73 		$1,501.46
$1,616.32
$1,737.96
$2,170.12 		$1,826.85
$1,941.71
$2,063.35
$2,495.51 		$325.39
Toc - Plan #25 US Health and Life
Gold

(EPO) Ascension Personalized Care Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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 		$502.02
$569.79
$641.58
$896.60
$1,362.48 		$886.06
$953.83
$1,025.62
$1,280.64 		$1,270.10
$1,337.87
$1,409.66
$1,664.68 		$1,654.14
$1,721.91
$1,793.70
$2,048.72 		$384.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,004.04
$1,139.58
$1,283.16
$1,793.20
$2,724.96 		$1,388.08
$1,523.62
$1,667.20
$2,177.24 		$1,772.12
$1,907.66
$2,051.24
$2,561.28 		$2,156.16
$2,291.70
$2,435.28
$2,945.32 		$384.04

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-250-8188 | Toll Free: 1-877-250-8188 | TTY: 1-877-250-8188
Toc - Plan #26 UnitedHealthcare
Silver

(EPO) UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$482.30
$547.41
$616.38
$861.39
$1,308.97 		$851.26
$916.37
$985.34
$1,230.35 		$1,220.22
$1,285.33
$1,354.30
$1,599.31 		$1,589.18
$1,654.29
$1,723.26
$1,968.27 		$368.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.60
$1,094.82
$1,232.76
$1,722.78
$2,617.94 		$1,333.56
$1,463.78
$1,601.72
$2,091.74 		$1,702.52
$1,832.74
$1,970.68
$2,460.70 		$2,071.48
$2,201.70
$2,339.64
$2,829.66 		$368.96
Toc - Plan #27 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value $7,500 Deductible 1 (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$371.04
$421.13
$474.19
$662.68
$1,007.00 		$654.88
$704.97
$758.03
$946.52 		$938.72
$988.81
$1,041.87
$1,230.36 		$1,222.56
$1,272.65
$1,325.71
$1,514.20 		$283.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.08
$842.26
$948.38
$1,325.36
$2,014.00 		$1,025.92
$1,126.10
$1,232.22
$1,609.20 		$1,309.76
$1,409.94
$1,516.06
$1,893.04 		$1,593.60
$1,693.78
$1,799.90
$2,176.88 		$283.84
Toc - Plan #28 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 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 		$640.74
$727.24
$818.86
$1,144.36
$1,738.96 		$1,130.90
$1,217.40
$1,309.02
$1,634.52 		$1,621.06
$1,707.56
$1,799.18
$2,124.68 		$2,111.22
$2,197.72
$2,289.34
$2,614.84 		$490.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,281.48
$1,454.48
$1,637.72
$2,288.72
$3,477.92 		$1,771.64
$1,944.64
$2,127.88
$2,778.88 		$2,261.80
$2,434.80
$2,618.04
$3,269.04 		$2,751.96
$2,924.96
$3,108.20
$3,759.20 		$490.16
Toc - Plan #29 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$703.24
$798.18
$898.74
$1,255.99
$1,908.59 		$1,241.22
$1,336.16
$1,436.72
$1,793.97 		$1,779.20
$1,874.14
$1,974.70
$2,331.95 		$2,317.18
$2,412.12
$2,512.68
$2,869.93 		$537.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,406.48
$1,596.36
$1,797.48
$2,511.98
$3,817.18 		$1,944.46
$2,134.34
$2,335.46
$3,049.96 		$2,482.44
$2,672.32
$2,873.44
$3,587.94 		$3,020.42
$3,210.30
$3,411.42
$4,125.92 		$537.98
Toc - Plan #30 UnitedHealthcare
Gold

(EPO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$683.23
$775.47
$873.17
$1,220.25
$1,854.29 		$1,205.90
$1,298.14
$1,395.84
$1,742.92 		$1,728.57
$1,820.81
$1,918.51
$2,265.59 		$2,251.24
$2,343.48
$2,441.18
$2,788.26 		$522.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,366.46
$1,550.94
$1,746.34
$2,440.50
$3,708.58 		$1,889.13
$2,073.61
$2,269.01
$2,963.17 		$2,411.80
$2,596.28
$2,791.68
$3,485.84 		$2,934.47
$3,118.95
$3,314.35
$4,008.51 		$522.67
Toc - Plan #31 UnitedHealthcare
Silver

(EPO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$483.14
$548.37
$617.46
$862.89
$1,311.25 		$852.74
$917.97
$987.06
$1,232.49 		$1,222.34
$1,287.57
$1,356.66
$1,602.09 		$1,591.94
$1,657.17
$1,726.26
$1,971.69 		$369.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$966.28
$1,096.74
$1,234.92
$1,725.78
$2,622.50 		$1,335.88
$1,466.34
$1,604.52
$2,095.38 		$1,705.48
$1,835.94
$1,974.12
$2,464.98 		$2,075.08
$2,205.54
$2,343.72
$2,834.58 		$369.60
Toc - Plan #32 UnitedHealthcare
Silver

(EPO) UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$482.12
$547.21
$616.15
$861.07
$1,308.48 		$850.94
$916.03
$984.97
$1,229.89 		$1,219.76
$1,284.85
$1,353.79
$1,598.71 		$1,588.58
$1,653.67
$1,722.61
$1,967.53 		$368.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.24
$1,094.42
$1,232.30
$1,722.14
$2,616.96 		$1,333.06
$1,463.24
$1,601.12
$2,090.96 		$1,701.88
$1,832.06
$1,969.94
$2,459.78 		$2,070.70
$2,200.88
$2,338.76
$2,828.60 		$368.82
Toc - Plan #33 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$497.80
$565.00
$636.18
$889.06
$1,351.02 		$878.61
$945.81
$1,016.99
$1,269.87 		$1,259.42
$1,326.62
$1,397.80
$1,650.68 		$1,640.23
$1,707.43
$1,778.61
$2,031.49 		$380.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.60
$1,130.00
$1,272.36
$1,778.12
$2,702.04 		$1,376.41
$1,510.81
$1,653.17
$2,158.93 		$1,757.22
$1,891.62
$2,033.98
$2,539.74 		$2,138.03
$2,272.43
$2,414.79
$2,920.55 		$380.81
Toc - Plan #34 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage $0 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$489.77
$555.89
$625.93
$874.74
$1,329.25 		$864.45
$930.57
$1,000.61
$1,249.42 		$1,239.13
$1,305.25
$1,375.29
$1,624.10 		$1,613.81
$1,679.93
$1,749.97
$1,998.78 		$374.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$979.54
$1,111.78
$1,251.86
$1,749.48
$2,658.50 		$1,354.22
$1,486.46
$1,626.54
$2,124.16 		$1,728.90
$1,861.14
$2,001.22
$2,498.84 		$2,103.58
$2,235.82
$2,375.90
$2,873.52 		$374.68
Toc - Plan #35 UnitedHealthcare
Silver

(EPO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$483.90
$549.22
$618.42
$864.24
$1,313.30 		$854.08
$919.40
$988.60
$1,234.42 		$1,224.26
$1,289.58
$1,358.78
$1,604.60 		$1,594.44
$1,659.76
$1,728.96
$1,974.78 		$370.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$967.80
$1,098.44
$1,236.84
$1,728.48
$2,626.60 		$1,337.98
$1,468.62
$1,607.02
$2,098.66 		$1,708.16
$1,838.80
$1,977.20
$2,468.84 		$2,078.34
$2,208.98
$2,347.38
$2,839.02 		$370.18
Toc - Plan #36 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value $7,500 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$377.37
$428.32
$482.28
$673.99
$1,024.19 		$666.06
$717.01
$770.97
$962.68 		$954.75
$1,005.70
$1,059.66
$1,251.37 		$1,243.44
$1,294.39
$1,348.35
$1,540.06 		$288.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.74
$856.64
$964.56
$1,347.98
$2,048.38 		$1,043.43
$1,145.33
$1,253.25
$1,636.67 		$1,332.12
$1,434.02
$1,541.94
$1,925.36 		$1,620.81
$1,722.71
$1,830.63
$2,214.05 		$288.69
Toc - Plan #37 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$385.16
$437.16
$492.24
$687.90
$1,045.33 		$679.81
$731.81
$786.89
$982.55 		$974.46
$1,026.46
$1,081.54
$1,277.20 		$1,269.11
$1,321.11
$1,376.19
$1,571.85 		$294.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.32
$874.32
$984.48
$1,375.80
$2,090.66 		$1,064.97
$1,168.97
$1,279.13
$1,670.45 		$1,359.62
$1,463.62
$1,573.78
$1,965.10 		$1,654.27
$1,758.27
$1,868.43
$2,259.75 		$294.65
Toc - Plan #38 UnitedHealthcare
Bronze

(EPO) UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.59
$400.19
$450.61
$629.73
$956.93 		$622.32
$669.92
$720.34
$899.46 		$892.05
$939.65
$990.07
$1,169.19 		$1,161.78
$1,209.38
$1,259.80
$1,438.92 		$269.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.18
$800.38
$901.22
$1,259.46
$1,913.86 		$974.91
$1,070.11
$1,170.95
$1,529.19 		$1,244.64
$1,339.84
$1,440.68
$1,798.92 		$1,514.37
$1,609.57
$1,710.41
$2,068.65 		$269.73
Toc - Plan #39 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$374.31
$424.84
$478.37
$668.52
$1,015.88 		$660.66
$711.19
$764.72
$954.87 		$947.01
$997.54
$1,051.07
$1,241.22 		$1,233.36
$1,283.89
$1,337.42
$1,527.57 		$286.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.62
$849.68
$956.74
$1,337.04
$2,031.76 		$1,034.97
$1,136.03
$1,243.09
$1,623.39 		$1,321.32
$1,422.38
$1,529.44
$1,909.74 		$1,607.67
$1,708.73
$1,815.79
$2,196.09 		$286.35
Toc - Plan #40 UnitedHealthcare
Bronze

(EPO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$352.63
$400.24
$450.67
$629.81
$957.05 		$622.40
$670.01
$720.44
$899.58 		$892.17
$939.78
$990.21
$1,169.35 		$1,161.94
$1,209.55
$1,259.98
$1,439.12 		$269.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.26
$800.48
$901.34
$1,259.62
$1,914.10 		$975.03
$1,070.25
$1,171.11
$1,529.39 		$1,244.80
$1,340.02
$1,440.88
$1,799.16 		$1,514.57
$1,609.79
$1,710.65
$2,068.93 		$269.77
Toc - Plan #41 UnitedHealthcare
Bronze

(EPO) UHC Bronze Essential $6,350 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-250-8188

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 		$365.09
$414.38
$466.58
$652.05
$990.85 		$644.38
$693.67
$745.87
$931.34 		$923.67
$972.96
$1,025.16
$1,210.63 		$1,202.96
$1,252.25
$1,304.45
$1,489.92 		$279.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.18
$828.76
$933.16
$1,304.10
$1,981.70 		$1,009.47
$1,108.05
$1,212.45
$1,583.39 		$1,288.76
$1,387.34
$1,491.74
$1,862.68 		$1,568.05
$1,666.63
$1,771.03
$2,141.97 		$279.29

ADVERTISEMENT

Ambetter of Tennessee

Local: 1-833-709-4735 | Toll Free: 1-833-709-4735

Toc - Plan #42 Ambetter of Tennessee
Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$310.22
$352.09
$396.45
$554.03
$841.91 		$547.53
$589.40
$633.76
$791.34 		$784.84
$826.71
$871.07
$1,028.65 		$1,022.15
$1,064.02
$1,108.38
$1,265.96 		$237.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620.44
$704.18
$792.90
$1,108.06
$1,683.82 		$857.75
$941.49
$1,030.21
$1,345.37 		$1,095.06
$1,178.80
$1,267.52
$1,582.68 		$1,332.37
$1,416.11
$1,504.83
$1,819.99 		$237.31
Toc - Plan #43 Ambetter of Tennessee
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$427.71
$485.44
$546.60
$763.87
$1,160.77 		$754.90
$812.63
$873.79
$1,091.06 		$1,082.09
$1,139.82
$1,200.98
$1,418.25 		$1,409.28
$1,467.01
$1,528.17
$1,745.44 		$327.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.42
$970.88
$1,093.20
$1,527.74
$2,321.54 		$1,182.61
$1,298.07
$1,420.39
$1,854.93 		$1,509.80
$1,625.26
$1,747.58
$2,182.12 		$1,836.99
$1,952.45
$2,074.77
$2,509.31 		$327.19
Toc - Plan #44 Ambetter of Tennessee
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$442.48
$502.21
$565.48
$790.26
$1,200.87 		$780.97
$840.70
$903.97
$1,128.75 		$1,119.46
$1,179.19
$1,242.46
$1,467.24 		$1,457.95
$1,517.68
$1,580.95
$1,805.73 		$338.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.96
$1,004.42
$1,130.96
$1,580.52
$2,401.74 		$1,223.45
$1,342.91
$1,469.45
$1,919.01 		$1,561.94
$1,681.40
$1,807.94
$2,257.50 		$1,900.43
$2,019.89
$2,146.43
$2,595.99 		$338.49
Toc - Plan #45 Ambetter of Tennessee
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$340.03
$385.92
$434.54
$607.27
$922.80 		$600.14
$646.03
$694.65
$867.38 		$860.25
$906.14
$954.76
$1,127.49 		$1,120.36
$1,166.25
$1,214.87
$1,387.60 		$260.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.06
$771.84
$869.08
$1,214.54
$1,845.60 		$940.17
$1,031.95
$1,129.19
$1,474.65 		$1,200.28
$1,292.06
$1,389.30
$1,734.76 		$1,460.39
$1,552.17
$1,649.41
$1,994.87 		$260.11
Toc - Plan #46 Ambetter of Tennessee
Silver

(EPO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$423.39
$480.53
$541.08
$756.15
$1,149.05 		$747.27
$804.41
$864.96
$1,080.03 		$1,071.15
$1,128.29
$1,188.84
$1,403.91 		$1,395.03
$1,452.17
$1,512.72
$1,727.79 		$323.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.78
$961.06
$1,082.16
$1,512.30
$2,298.10 		$1,170.66
$1,284.94
$1,406.04
$1,836.18 		$1,494.54
$1,608.82
$1,729.92
$2,160.06 		$1,818.42
$1,932.70
$2,053.80
$2,483.94 		$323.88
Toc - Plan #47 Ambetter of Tennessee
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$332.83
$377.75
$425.34
$594.41
$903.27 		$587.44
$632.36
$679.95
$849.02 		$842.05
$886.97
$934.56
$1,103.63 		$1,096.66
$1,141.58
$1,189.17
$1,358.24 		$254.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.66
$755.50
$850.68
$1,188.82
$1,806.54 		$920.27
$1,010.11
$1,105.29
$1,443.43 		$1,174.88
$1,264.72
$1,359.90
$1,698.04 		$1,429.49
$1,519.33
$1,614.51
$1,952.65 		$254.61
Toc - Plan #48 Ambetter of Tennessee
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$374.78
$425.37
$478.96
$669.35
$1,017.14 		$661.48
$712.07
$765.66
$956.05 		$948.18
$998.77
$1,052.36
$1,242.75 		$1,234.88
$1,285.47
$1,339.06
$1,529.45 		$286.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.56
$850.74
$957.92
$1,338.70
$2,034.28 		$1,036.26
$1,137.44
$1,244.62
$1,625.40 		$1,322.96
$1,424.14
$1,531.32
$1,912.10 		$1,609.66
$1,710.84
$1,818.02
$2,198.80 		$286.70
Toc - Plan #49 Ambetter of Tennessee
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$417.04
$473.33
$532.96
$744.81
$1,131.81 		$736.07
$792.36
$851.99
$1,063.84 		$1,055.10
$1,111.39
$1,171.02
$1,382.87 		$1,374.13
$1,430.42
$1,490.05
$1,701.90 		$319.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.08
$946.66
$1,065.92
$1,489.62
$2,263.62 		$1,153.11
$1,265.69
$1,384.95
$1,808.65 		$1,472.14
$1,584.72
$1,703.98
$2,127.68 		$1,791.17
$1,903.75
$2,023.01
$2,446.71 		$319.03
Toc - Plan #50 Ambetter of Tennessee
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$421.65
$478.56
$538.86
$753.05
$1,144.34 		$744.21
$801.12
$861.42
$1,075.61 		$1,066.77
$1,123.68
$1,183.98
$1,398.17 		$1,389.33
$1,446.24
$1,506.54
$1,720.73 		$322.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.30
$957.12
$1,077.72
$1,506.10
$2,288.68 		$1,165.86
$1,279.68
$1,400.28
$1,828.66 		$1,488.42
$1,602.24
$1,722.84
$2,151.22 		$1,810.98
$1,924.80
$2,045.40
$2,473.78 		$322.56
Toc - Plan #51 Ambetter of Tennessee
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$423.47
$480.63
$541.19
$756.30
$1,149.28 		$747.42
$804.58
$865.14
$1,080.25 		$1,071.37
$1,128.53
$1,189.09
$1,404.20 		$1,395.32
$1,452.48
$1,513.04
$1,728.15 		$323.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.94
$961.26
$1,082.38
$1,512.60
$2,298.56 		$1,170.89
$1,285.21
$1,406.33
$1,836.55 		$1,494.84
$1,609.16
$1,730.28
$2,160.50 		$1,818.79
$1,933.11
$2,054.23
$2,484.45 		$323.95
Toc - Plan #52 Ambetter of Tennessee
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 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 		$487.06
$552.81
$622.46
$869.88
$1,321.87 		$859.66
$925.41
$995.06
$1,242.48 		$1,232.26
$1,298.01
$1,367.66
$1,615.08 		$1,604.86
$1,670.61
$1,740.26
$1,987.68 		$372.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$974.12
$1,105.62
$1,244.92
$1,739.76
$2,643.74 		$1,346.72
$1,478.22
$1,617.52
$2,112.36 		$1,719.32
$1,850.82
$1,990.12
$2,484.96 		$2,091.92
$2,223.42
$2,362.72
$2,857.56 		$372.60
Toc - Plan #53 Ambetter of Tennessee
Bronze

(EPO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$295.82
$335.75
$378.05
$528.32
$802.84 		$522.12
$562.05
$604.35
$754.62 		$748.42
$788.35
$830.65
$980.92 		$974.72
$1,014.65
$1,056.95
$1,207.22 		$226.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$591.64
$671.50
$756.10
$1,056.64
$1,605.68 		$817.94
$897.80
$982.40
$1,282.94 		$1,044.24
$1,124.10
$1,208.70
$1,509.24 		$1,270.54
$1,350.40
$1,435.00
$1,735.54 		$226.30
Toc - Plan #54 Ambetter of Tennessee
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$325.93
$369.92
$416.52
$582.09
$884.54 		$575.26
$619.25
$665.85
$831.42 		$824.59
$868.58
$915.18
$1,080.75 		$1,073.92
$1,117.91
$1,164.51
$1,330.08 		$249.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.86
$739.84
$833.04
$1,164.18
$1,769.08 		$901.19
$989.17
$1,082.37
$1,413.51 		$1,150.52
$1,238.50
$1,331.70
$1,662.84 		$1,399.85
$1,487.83
$1,581.03
$1,912.17 		$249.33
Toc - Plan #55 Ambetter of Tennessee
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$417.72
$474.10
$533.83
$746.02
$1,133.65 		$737.26
$793.64
$853.37
$1,065.56 		$1,056.80
$1,113.18
$1,172.91
$1,385.10 		$1,376.34
$1,432.72
$1,492.45
$1,704.64 		$319.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.44
$948.20
$1,067.66
$1,492.04
$2,267.30 		$1,154.98
$1,267.74
$1,387.20
$1,811.58 		$1,474.52
$1,587.28
$1,706.74
$2,131.12 		$1,794.06
$1,906.82
$2,026.28
$2,450.66 		$319.54
Toc - Plan #56 Ambetter of Tennessee
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$418.60
$475.10
$534.96
$747.61
$1,136.06 		$738.82
$795.32
$855.18
$1,067.83 		$1,059.04
$1,115.54
$1,175.40
$1,388.05 		$1,379.26
$1,435.76
$1,495.62
$1,708.27 		$320.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.20
$950.20
$1,069.92
$1,495.22
$2,272.12 		$1,157.42
$1,270.42
$1,390.14
$1,815.44 		$1,477.64
$1,590.64
$1,710.36
$2,135.66 		$1,797.86
$1,910.86
$2,030.58
$2,455.88 		$320.22
Toc - Plan #57 Ambetter of Tennessee
Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$322.15
$365.63
$411.70
$575.34
$874.29 		$568.59
$612.07
$658.14
$821.78 		$815.03
$858.51
$904.58
$1,068.22 		$1,061.47
$1,104.95
$1,151.02
$1,314.66 		$246.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.30
$731.26
$823.40
$1,150.68
$1,748.58 		$890.74
$977.70
$1,069.84
$1,397.12 		$1,137.18
$1,224.14
$1,316.28
$1,643.56 		$1,383.62
$1,470.58
$1,562.72
$1,890.00 		$246.44
Toc - Plan #58 Ambetter of Tennessee
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$444.16
$504.11
$567.62
$793.25
$1,205.42 		$783.93
$843.88
$907.39
$1,133.02 		$1,123.70
$1,183.65
$1,247.16
$1,472.79 		$1,463.47
$1,523.42
$1,586.93
$1,812.56 		$339.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.32
$1,008.22
$1,135.24
$1,586.50
$2,410.84 		$1,228.09
$1,347.99
$1,475.01
$1,926.27 		$1,567.86
$1,687.76
$1,814.78
$2,266.04 		$1,907.63
$2,027.53
$2,154.55
$2,605.81 		$339.77
Toc - Plan #59 Ambetter of Tennessee
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$459.50
$521.52
$587.23
$820.65
$1,247.06 		$811.01
$873.03
$938.74
$1,172.16 		$1,162.52
$1,224.54
$1,290.25
$1,523.67 		$1,514.03
$1,576.05
$1,641.76
$1,875.18 		$351.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919.00
$1,043.04
$1,174.46
$1,641.30
$2,494.12 		$1,270.51
$1,394.55
$1,525.97
$1,992.81 		$1,622.02
$1,746.06
$1,877.48
$2,344.32 		$1,973.53
$2,097.57
$2,228.99
$2,695.83 		$351.51
Toc - Plan #60 Ambetter of Tennessee
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$353.10
$400.76
$451.25
$630.63
$958.30 		$623.22
$670.88
$721.37
$900.75 		$893.34
$941.00
$991.49
$1,170.87 		$1,163.46
$1,211.12
$1,261.61
$1,440.99 		$270.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.20
$801.52
$902.50
$1,261.26
$1,916.60 		$976.32
$1,071.64
$1,172.62
$1,531.38 		$1,246.44
$1,341.76
$1,442.74
$1,801.50 		$1,516.56
$1,611.88
$1,712.86
$2,071.62 		$270.12
Toc - Plan #61 Ambetter of Tennessee
Silver

(EPO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$439.67
$499.02
$561.89
$785.24
$1,193.25 		$776.01
$835.36
$898.23
$1,121.58 		$1,112.35
$1,171.70
$1,234.57
$1,457.92 		$1,448.69
$1,508.04
$1,570.91
$1,794.26 		$336.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.34
$998.04
$1,123.78
$1,570.48
$2,386.50 		$1,215.68
$1,334.38
$1,460.12
$1,906.82 		$1,552.02
$1,670.72
$1,796.46
$2,243.16 		$1,888.36
$2,007.06
$2,132.80
$2,579.50 		$336.34
Toc - Plan #62 Ambetter of Tennessee
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$345.63
$392.28
$441.70
$617.28
$938.01 		$610.03
$656.68
$706.10
$881.68 		$874.43
$921.08
$970.50
$1,146.08 		$1,138.83
$1,185.48
$1,234.90
$1,410.48 		$264.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$691.26
$784.56
$883.40
$1,234.56
$1,876.02 		$955.66
$1,048.96
$1,147.80
$1,498.96 		$1,220.06
$1,313.36
$1,412.20
$1,763.36 		$1,484.46
$1,577.76
$1,676.60
$2,027.76 		$264.40
Toc - Plan #63 Ambetter of Tennessee
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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 		$389.20
$441.73
$497.39
$695.09
$1,056.26 		$686.93
$739.46
$795.12
$992.82 		$984.66
$1,037.19
$1,092.85
$1,290.55 		$1,282.39
$1,334.92
$1,390.58
$1,588.28 		$297.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.40
$883.46
$994.78
$1,390.18
$2,112.52 		$1,076.13
$1,181.19
$1,292.51
$1,687.91 		$1,373.86
$1,478.92
$1,590.24
$1,985.64 		$1,671.59
$1,776.65
$1,887.97
$2,283.37 		$297.73
Toc - Plan #64 Ambetter of Tennessee
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$437.87
$496.97
$559.59
$782.02
$1,188.36 		$772.83
$831.93
$894.55
$1,116.98 		$1,107.79
$1,166.89
$1,229.51
$1,451.94 		$1,442.75
$1,501.85
$1,564.47
$1,786.90 		$334.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$875.74
$993.94
$1,119.18
$1,564.04
$2,376.72 		$1,210.70
$1,328.90
$1,454.14
$1,899.00 		$1,545.66
$1,663.86
$1,789.10
$2,233.96 		$1,880.62
$1,998.82
$2,124.06
$2,568.92 		$334.96
Toc - Plan #65 Ambetter of Tennessee
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439.76
$499.12
$562.00
$785.40
$1,193.49 		$776.17
$835.53
$898.41
$1,121.81 		$1,112.58
$1,171.94
$1,234.82
$1,458.22 		$1,448.99
$1,508.35
$1,571.23
$1,794.63 		$336.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.52
$998.24
$1,124.00
$1,570.80
$2,386.98 		$1,215.93
$1,334.65
$1,460.41
$1,907.21 		$1,552.34
$1,671.06
$1,796.82
$2,243.62 		$1,888.75
$2,007.47
$2,133.23
$2,580.03 		$336.41
Toc - Plan #66 Ambetter of Tennessee
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

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 		$433.08
$491.53
$553.46
$773.46
$1,175.35 		$764.38
$822.83
$884.76
$1,104.76 		$1,095.68
$1,154.13
$1,216.06
$1,436.06 		$1,426.98
$1,485.43
$1,547.36
$1,767.36 		$331.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.16
$983.06
$1,106.92
$1,546.92
$2,350.70 		$1,197.46
$1,314.36
$1,438.22
$1,878.22 		$1,528.76
$1,645.66
$1,769.52
$2,209.52 		$1,860.06
$1,976.96
$2,100.82
$2,540.82 		$331.30
Toc - Plan #67 Ambetter of Tennessee
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-709-4735

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 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 		$505.80
$574.07
$646.40
$903.34
$1,372.71 		$892.73
$961.00
$1,033.33
$1,290.27 		$1,279.66
$1,347.93
$1,420.26
$1,677.20 		$1,666.59
$1,734.86
$1,807.19
$2,064.13 		$386.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,011.60
$1,148.14
$1,292.80
$1,806.68
$2,745.42 		$1,398.53
$1,535.07
$1,679.73
$2,193.61 		$1,785.46
$1,922.00
$2,066.66
$2,580.54 		$2,172.39
$2,308.93
$2,453.59
$2,967.47 		$386.93

‡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 Wayne County here.

Wayne County is in “Rating Area 8” of Tennessee.

Currently, there are 67 plans offered in Rating Area 8.

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