Obamacare 2023 Rates for Wilson County

Obamacare > Rates > Tennessee > Wilson 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 Wilson 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, 138 Plans and 2023 Rates for Wilson County, Tennessee

Below, you’ll find a summary of the 138 plans for Wilson 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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Wilson 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 		$421.65
$478.57
$538.87
$753.07
$1,144.36 		$744.21
$801.13
$861.43
$1,075.63 		$1,066.77
$1,123.69
$1,183.99
$1,398.19 		$1,389.33
$1,446.25
$1,506.55
$1,720.75 		$322.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.30
$957.14
$1,077.74
$1,506.14
$2,288.72 		$1,165.86
$1,279.70
$1,400.30
$1,828.70 		$1,488.42
$1,602.26
$1,722.86
$2,151.26 		$1,810.98
$1,924.82
$2,045.42
$2,473.82 		$322.56
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 		$379.18
$430.37
$484.59
$677.22
$1,029.09 		$669.25
$720.44
$774.66
$967.29 		$959.32
$1,010.51
$1,064.73
$1,257.36 		$1,249.39
$1,300.58
$1,354.80
$1,547.43 		$290.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.36
$860.74
$969.18
$1,354.44
$2,058.18 		$1,048.43
$1,150.81
$1,259.25
$1,644.51 		$1,338.50
$1,440.88
$1,549.32
$1,934.58 		$1,628.57
$1,730.95
$1,839.39
$2,224.65 		$290.07
Toc - Plan #3 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B11S $25 PCP Copay at Blue of TN + Free Telehealth

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

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 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 		$419.62
$476.27
$536.27
$749.44
$1,138.85 		$740.63
$797.28
$857.28
$1,070.45 		$1,061.64
$1,118.29
$1,178.29
$1,391.46 		$1,382.65
$1,439.30
$1,499.30
$1,712.47 		$321.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.24
$952.54
$1,072.54
$1,498.88
$2,277.70 		$1,160.25
$1,273.55
$1,393.55
$1,819.89 		$1,481.26
$1,594.56
$1,714.56
$2,140.90 		$1,802.27
$1,915.57
$2,035.57
$2,461.91 		$321.01
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 		$441.32
$500.90
$564.01
$788.20
$1,197.74 		$778.93
$838.51
$901.62
$1,125.81 		$1,116.54
$1,176.12
$1,239.23
$1,463.42 		$1,454.15
$1,513.73
$1,576.84
$1,801.03 		$337.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.64
$1,001.80
$1,128.02
$1,576.40
$2,395.48 		$1,220.25
$1,339.41
$1,465.63
$1,914.01 		$1,557.86
$1,677.02
$1,803.24
$2,251.62 		$1,895.47
$2,014.63
$2,140.85
$2,589.23 		$337.61
Toc - Plan #5 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B07E 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 		$340.79
$386.80
$435.53
$608.65
$924.90 		$601.49
$647.50
$696.23
$869.35 		$862.19
$908.20
$956.93
$1,130.05 		$1,122.89
$1,168.90
$1,217.63
$1,390.75 		$260.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.58
$773.60
$871.06
$1,217.30
$1,849.80 		$942.28
$1,034.30
$1,131.76
$1,478.00 		$1,202.98
$1,295.00
$1,392.46
$1,738.70 		$1,463.68
$1,555.70
$1,653.16
$1,999.40 		$260.70
Toc - Plan #6 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B08E 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 		$306.47
$347.84
$391.67
$547.36
$831.76 		$540.92
$582.29
$626.12
$781.81 		$775.37
$816.74
$860.57
$1,016.26 		$1,009.82
$1,051.19
$1,095.02
$1,250.71 		$234.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$612.94
$695.68
$783.34
$1,094.72
$1,663.52 		$847.39
$930.13
$1,017.79
$1,329.17 		$1,081.84
$1,164.58
$1,252.24
$1,563.62 		$1,316.29
$1,399.03
$1,486.69
$1,798.07 		$234.45
Toc - Plan #7 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 		$415.11
$471.15
$530.51
$741.39
$1,126.61 		$732.67
$788.71
$848.07
$1,058.95 		$1,050.23
$1,106.27
$1,165.63
$1,376.51 		$1,367.79
$1,423.83
$1,483.19
$1,694.07 		$317.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.22
$942.30
$1,061.02
$1,482.78
$2,253.22 		$1,147.78
$1,259.86
$1,378.58
$1,800.34 		$1,465.34
$1,577.42
$1,696.14
$2,117.90 		$1,782.90
$1,894.98
$2,013.70
$2,435.46 		$317.56
Toc - Plan #8 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B10E 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 		$335.51
$380.80
$428.78
$599.22
$910.57 		$592.18
$637.47
$685.45
$855.89 		$848.85
$894.14
$942.12
$1,112.56 		$1,105.52
$1,150.81
$1,198.79
$1,369.23 		$256.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.02
$761.60
$857.56
$1,198.44
$1,821.14 		$927.69
$1,018.27
$1,114.23
$1,455.11 		$1,184.36
$1,274.94
$1,370.90
$1,711.78 		$1,441.03
$1,531.61
$1,627.57
$1,968.45 		$256.67
Toc - Plan #9 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B11E $25 PCP Copay at Blue of TN + Free Telehealth

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

Annual Out of Pocket Expenses:

Individual Family
$6,400 $12,800 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 		$352.65
$400.26
$450.69
$629.83
$957.09 		$622.43
$670.04
$720.47
$899.61 		$892.21
$939.82
$990.25
$1,169.39 		$1,161.99
$1,209.60
$1,260.03
$1,439.17 		$269.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.30
$800.52
$901.38
$1,259.66
$1,914.18 		$975.08
$1,070.30
$1,171.16
$1,529.44 		$1,244.86
$1,340.08
$1,440.94
$1,799.22 		$1,514.64
$1,609.86
$1,710.72
$2,069.00 		$269.78
Toc - Plan #10 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B13E 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 		$356.69
$404.84
$455.85
$637.05
$968.06 		$629.56
$677.71
$728.72
$909.92 		$902.43
$950.58
$1,001.59
$1,182.79 		$1,175.30
$1,223.45
$1,274.46
$1,455.66 		$272.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.38
$809.68
$911.70
$1,274.10
$1,936.12 		$986.25
$1,082.55
$1,184.57
$1,546.97 		$1,259.12
$1,355.42
$1,457.44
$1,819.84 		$1,531.99
$1,628.29
$1,730.31
$2,092.71 		$272.87
Toc - Plan #11 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 		$385.82
$437.91
$493.08
$689.07
$1,047.12 		$680.97
$733.06
$788.23
$984.22 		$976.12
$1,028.21
$1,083.38
$1,279.37 		$1,271.27
$1,323.36
$1,378.53
$1,574.52 		$295.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.64
$875.82
$986.16
$1,378.14
$2,094.24 		$1,066.79
$1,170.97
$1,281.31
$1,673.29 		$1,361.94
$1,466.12
$1,576.46
$1,968.44 		$1,657.09
$1,761.27
$1,871.61
$2,263.59 		$295.15
Toc - Plan #12 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B14E $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 		$311.83
$353.93
$398.52
$556.93
$846.31 		$550.38
$592.48
$637.07
$795.48 		$788.93
$831.03
$875.62
$1,034.03 		$1,027.48
$1,069.58
$1,114.17
$1,272.58 		$238.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.66
$707.86
$797.04
$1,113.86
$1,692.62 		$862.21
$946.41
$1,035.59
$1,352.41 		$1,100.76
$1,184.96
$1,274.14
$1,590.96 		$1,339.31
$1,423.51
$1,512.69
$1,829.51 		$238.55
Toc - Plan #13 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 		$375.38
$426.06
$479.74
$670.43
$1,018.78 		$662.55
$713.23
$766.91
$957.60 		$949.72
$1,000.40
$1,054.08
$1,244.77 		$1,236.89
$1,287.57
$1,341.25
$1,531.94 		$287.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.76
$852.12
$959.48
$1,340.86
$2,037.56 		$1,037.93
$1,139.29
$1,246.65
$1,628.03 		$1,325.10
$1,426.46
$1,533.82
$1,915.20 		$1,612.27
$1,713.63
$1,820.99
$2,202.37 		$287.17
Toc - Plan #14 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 		$541.03
$614.07
$691.44
$966.28
$1,468.36 		$954.92
$1,027.96
$1,105.33
$1,380.17 		$1,368.81
$1,441.85
$1,519.22
$1,794.06 		$1,782.70
$1,855.74
$1,933.11
$2,207.95 		$413.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,082.06
$1,228.14
$1,382.88
$1,932.56
$2,936.72 		$1,495.95
$1,642.03
$1,796.77
$2,346.45 		$1,909.84
$2,055.92
$2,210.66
$2,760.34 		$2,323.73
$2,469.81
$2,624.55
$3,174.23 		$413.89
Toc - Plan #15 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 		$533.76
$605.82
$682.15
$953.30
$1,448.62 		$942.09
$1,014.15
$1,090.48
$1,361.63 		$1,350.42
$1,422.48
$1,498.81
$1,769.96 		$1,758.75
$1,830.81
$1,907.14
$2,178.29 		$408.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,067.52
$1,211.64
$1,364.30
$1,906.60
$2,897.24 		$1,475.85
$1,619.97
$1,772.63
$2,314.93 		$1,884.18
$2,028.30
$2,180.96
$2,723.26 		$2,292.51
$2,436.63
$2,589.29
$3,131.59 		$408.33
Toc - Plan #16 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S21S $10 PCP Copay at Blue of TN + Free Telehealth

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

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$536.68
$609.13
$685.88
$958.51
$1,456.55 		$947.24
$1,019.69
$1,096.44
$1,369.07 		$1,357.80
$1,430.25
$1,507.00
$1,779.63 		$1,768.36
$1,840.81
$1,917.56
$2,190.19 		$410.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,073.36
$1,218.26
$1,371.76
$1,917.02
$2,913.10 		$1,483.92
$1,628.82
$1,782.32
$2,327.58 		$1,894.48
$2,039.38
$2,192.88
$2,738.14 		$2,305.04
$2,449.94
$2,603.44
$3,148.70 		$410.56
Toc - Plan #17 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 		$530.17
$601.74
$677.56
$946.88
$1,438.88 		$935.75
$1,007.32
$1,083.14
$1,352.46 		$1,341.33
$1,412.90
$1,488.72
$1,758.04 		$1,746.91
$1,818.48
$1,894.30
$2,163.62 		$405.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,060.34
$1,203.48
$1,355.12
$1,893.76
$2,877.76 		$1,465.92
$1,609.06
$1,760.70
$2,299.34 		$1,871.50
$2,014.64
$2,166.28
$2,704.92 		$2,277.08
$2,420.22
$2,571.86
$3,110.50 		$405.58
Toc - Plan #18 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S01E 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 		$437.28
$496.31
$558.84
$780.98
$1,186.78 		$771.80
$830.83
$893.36
$1,115.50 		$1,106.32
$1,165.35
$1,227.88
$1,450.02 		$1,440.84
$1,499.87
$1,562.40
$1,784.54 		$334.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.56
$992.62
$1,117.68
$1,561.96
$2,373.56 		$1,209.08
$1,327.14
$1,452.20
$1,896.48 		$1,543.60
$1,661.66
$1,786.72
$2,231.00 		$1,878.12
$1,996.18
$2,121.24
$2,565.52 		$334.52
Toc - Plan #19 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S04E 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 		$431.40
$489.64
$551.33
$770.48
$1,170.82 		$761.42
$819.66
$881.35
$1,100.50 		$1,091.44
$1,149.68
$1,211.37
$1,430.52 		$1,421.46
$1,479.70
$1,541.39
$1,760.54 		$330.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.80
$979.28
$1,102.66
$1,540.96
$2,341.64 		$1,192.82
$1,309.30
$1,432.68
$1,870.98 		$1,522.84
$1,639.32
$1,762.70
$2,201.00 		$1,852.86
$1,969.34
$2,092.72
$2,531.02 		$330.02
Toc - Plan #20 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S21E $10 PCP Copay at Blue of TN + Free Telehealth

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

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 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 		$446.28
$506.53
$570.35
$797.06
$1,211.20 		$787.68
$847.93
$911.75
$1,138.46 		$1,129.08
$1,189.33
$1,253.15
$1,479.86 		$1,470.48
$1,530.73
$1,594.55
$1,821.26 		$341.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.56
$1,013.06
$1,140.70
$1,594.12
$2,422.40 		$1,233.96
$1,354.46
$1,482.10
$1,935.52 		$1,575.36
$1,695.86
$1,823.50
$2,276.92 		$1,916.76
$2,037.26
$2,164.90
$2,618.32 		$341.40
Toc - Plan #21 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S23E 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 		$428.50
$486.35
$547.62
$765.30
$1,162.95 		$756.30
$814.15
$875.42
$1,093.10 		$1,084.10
$1,141.95
$1,203.22
$1,420.90 		$1,411.90
$1,469.75
$1,531.02
$1,748.70 		$327.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$857.00
$972.70
$1,095.24
$1,530.60
$2,325.90 		$1,184.80
$1,300.50
$1,423.04
$1,858.40 		$1,512.60
$1,628.30
$1,750.84
$2,186.20 		$1,840.40
$1,956.10
$2,078.64
$2,514.00 		$327.80
Toc - Plan #22 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 		$496.02
$562.98
$633.91
$885.89
$1,346.20 		$875.48
$942.44
$1,013.37
$1,265.35 		$1,254.94
$1,321.90
$1,392.83
$1,644.81 		$1,634.40
$1,701.36
$1,772.29
$2,024.27 		$379.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$992.04
$1,125.96
$1,267.82
$1,771.78
$2,692.40 		$1,371.50
$1,505.42
$1,647.28
$2,151.24 		$1,750.96
$1,884.88
$2,026.74
$2,530.70 		$2,130.42
$2,264.34
$2,406.20
$2,910.16 		$379.46
Toc - Plan #23 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S24E $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 		$400.90
$455.02
$512.35
$716.01
$1,088.04 		$707.59
$761.71
$819.04
$1,022.70 		$1,014.28
$1,068.40
$1,125.73
$1,329.39 		$1,320.97
$1,375.09
$1,432.42
$1,636.08 		$306.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.80
$910.04
$1,024.70
$1,432.02
$2,176.08 		$1,108.49
$1,216.73
$1,331.39
$1,738.71 		$1,415.18
$1,523.42
$1,638.08
$2,045.40 		$1,721.87
$1,830.11
$1,944.77
$2,352.09 		$306.69
Toc - Plan #24 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 		$509.40
$578.17
$651.01
$909.79
$1,382.51 		$899.09
$967.86
$1,040.70
$1,299.48 		$1,288.78
$1,357.55
$1,430.39
$1,689.17 		$1,678.47
$1,747.24
$1,820.08
$2,078.86 		$389.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,018.80
$1,156.34
$1,302.02
$1,819.58
$2,765.02 		$1,408.49
$1,546.03
$1,691.71
$2,209.27 		$1,798.18
$1,935.72
$2,081.40
$2,598.96 		$2,187.87
$2,325.41
$2,471.09
$2,988.65 		$389.69
Toc - Plan #25 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 		$647.35
$734.74
$827.31
$1,156.17
$1,756.91 		$1,142.57
$1,229.96
$1,322.53
$1,651.39 		$1,637.79
$1,725.18
$1,817.75
$2,146.61 		$2,133.01
$2,220.40
$2,312.97
$2,641.83 		$495.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,294.70
$1,469.48
$1,654.62
$2,312.34
$3,513.82 		$1,789.92
$1,964.70
$2,149.84
$2,807.56 		$2,285.14
$2,459.92
$2,645.06
$3,302.78 		$2,780.36
$2,955.14
$3,140.28
$3,798.00 		$495.22
Toc - Plan #26 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G07S $10 PCP Copay at Blue of TN + Free Telehealth

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$4,200 $8,400 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 		$613.36
$696.16
$783.87
$1,095.46
$1,664.66 		$1,082.58
$1,165.38
$1,253.09
$1,564.68 		$1,551.80
$1,634.60
$1,722.31
$2,033.90 		$2,021.02
$2,103.82
$2,191.53
$2,503.12 		$469.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,226.72
$1,392.32
$1,567.74
$2,190.92
$3,329.32 		$1,695.94
$1,861.54
$2,036.96
$2,660.14 		$2,165.16
$2,330.76
$2,506.18
$3,129.36 		$2,634.38
$2,799.98
$2,975.40
$3,598.58 		$469.22
Toc - Plan #27 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G06E $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 		$523.21
$593.84
$668.66
$934.45
$1,419.99 		$923.47
$994.10
$1,068.92
$1,334.71 		$1,323.73
$1,394.36
$1,469.18
$1,734.97 		$1,723.99
$1,794.62
$1,869.44
$2,135.23 		$400.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,046.42
$1,187.68
$1,337.32
$1,868.90
$2,839.98 		$1,446.68
$1,587.94
$1,737.58
$2,269.16 		$1,846.94
$1,988.20
$2,137.84
$2,669.42 		$2,247.20
$2,388.46
$2,538.10
$3,069.68 		$400.26
Toc - Plan #28 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G07E $10 PCP Copay at Blue of TN + Free Telehealth

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$485.14
$550.63
$620.01
$866.46
$1,316.67 		$856.27
$921.76
$991.14
$1,237.59 		$1,227.40
$1,292.89
$1,362.27
$1,608.72 		$1,598.53
$1,664.02
$1,733.40
$1,979.85 		$371.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$970.28
$1,101.26
$1,240.02
$1,732.92
$2,633.34 		$1,341.41
$1,472.39
$1,611.15
$2,104.05 		$1,712.54
$1,843.52
$1,982.28
$2,475.18 		$2,083.67
$2,214.65
$2,353.41
$2,846.31 		$371.13
Toc - Plan #29 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 		$639.83
$726.21
$817.70
$1,142.74
$1,736.50 		$1,129.30
$1,215.68
$1,307.17
$1,632.21 		$1,618.77
$1,705.15
$1,796.64
$2,121.68 		$2,108.24
$2,194.62
$2,286.11
$2,611.15 		$489.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,279.66
$1,452.42
$1,635.40
$2,285.48
$3,473.00 		$1,769.13
$1,941.89
$2,124.87
$2,774.95 		$2,258.60
$2,431.36
$2,614.34
$3,264.42 		$2,748.07
$2,920.83
$3,103.81
$3,753.89 		$489.47
Toc - Plan #30 BlueCross BlueShield of Tennessee
Gold

(EPO) Gold G08E $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 		$517.13
$586.94
$660.89
$923.59
$1,403.49 		$912.73
$982.54
$1,056.49
$1,319.19 		$1,308.33
$1,378.14
$1,452.09
$1,714.79 		$1,703.93
$1,773.74
$1,847.69
$2,110.39 		$395.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,034.26
$1,173.88
$1,321.78
$1,847.18
$2,806.98 		$1,429.86
$1,569.48
$1,717.38
$2,242.78 		$1,825.46
$1,965.08
$2,112.98
$2,638.38 		$2,221.06
$2,360.68
$2,508.58
$3,033.98 		$395.60
Toc - Plan #31 BlueCross BlueShield of Tennessee
Bronze

(EPO) Bronze B15E + 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 		$303.40
$344.36
$387.75
$541.87
$823.43 		$535.50
$576.46
$619.85
$773.97 		$767.60
$808.56
$851.95
$1,006.07 		$999.70
$1,040.66
$1,084.05
$1,238.17 		$232.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.80
$688.72
$775.50
$1,083.74
$1,646.86 		$838.90
$920.82
$1,007.60
$1,315.84 		$1,071.00
$1,152.92
$1,239.70
$1,547.94 		$1,303.10
$1,385.02
$1,471.80
$1,780.04 		$232.10
Toc - Plan #32 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 		$412.04
$467.67
$526.59
$735.90
$1,118.28 		$727.25
$782.88
$841.80
$1,051.11 		$1,042.46
$1,098.09
$1,157.01
$1,366.32 		$1,357.67
$1,413.30
$1,472.22
$1,681.53 		$315.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.08
$935.34
$1,053.18
$1,471.80
$2,236.56 		$1,139.29
$1,250.55
$1,368.39
$1,787.01 		$1,454.50
$1,565.76
$1,683.60
$2,102.22 		$1,769.71
$1,880.97
$1,998.81
$2,417.43 		$315.21
Toc - Plan #33 BlueCross BlueShield of Tennessee
Expanded Bronze

(EPO) Bronze B16E $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 		$333.03
$377.99
$425.61
$594.79
$903.84 		$587.80
$632.76
$680.38
$849.56 		$842.57
$887.53
$935.15
$1,104.33 		$1,097.34
$1,142.30
$1,189.92
$1,359.10 		$254.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.06
$755.98
$851.22
$1,189.58
$1,807.68 		$920.83
$1,010.75
$1,105.99
$1,444.35 		$1,175.60
$1,265.52
$1,360.76
$1,699.12 		$1,430.37
$1,520.29
$1,615.53
$1,953.89 		$254.77
Toc - Plan #34 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S25E $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 		$411.71
$467.29
$526.17
$735.31
$1,117.38 		$726.67
$782.25
$841.13
$1,050.27 		$1,041.63
$1,097.21
$1,156.09
$1,365.23 		$1,356.59
$1,412.17
$1,471.05
$1,680.19 		$314.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.42
$934.58
$1,052.34
$1,470.62
$2,234.76 		$1,138.38
$1,249.54
$1,367.30
$1,785.58 		$1,453.34
$1,564.50
$1,682.26
$2,100.54 		$1,768.30
$1,879.46
$1,997.22
$2,415.50 		$314.96
Toc - Plan #35 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 		$506.46
$574.83
$647.26
$904.54
$1,374.53 		$893.90
$962.27
$1,034.70
$1,291.98 		$1,281.34
$1,349.71
$1,422.14
$1,679.42 		$1,668.78
$1,737.15
$1,809.58
$2,066.86 		$387.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.92
$1,149.66
$1,294.52
$1,809.08
$2,749.06 		$1,400.36
$1,537.10
$1,681.96
$2,196.52 		$1,787.80
$1,924.54
$2,069.40
$2,583.96 		$2,175.24
$2,311.98
$2,456.84
$2,971.40 		$387.44
Toc - Plan #36 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S26E $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 		$409.34
$464.60
$523.14
$731.08
$1,110.95 		$722.49
$777.75
$836.29
$1,044.23 		$1,035.64
$1,090.90
$1,149.44
$1,357.38 		$1,348.79
$1,404.05
$1,462.59
$1,670.53 		$313.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.68
$929.20
$1,046.28
$1,462.16
$2,221.90 		$1,131.83
$1,242.35
$1,359.43
$1,775.31 		$1,444.98
$1,555.50
$1,672.58
$2,088.46 		$1,758.13
$1,868.65
$1,985.73
$2,401.61 		$313.15
Toc - Plan #37 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 		$489.60
$555.70
$625.71
$874.43
$1,328.77 		$864.14
$930.24
$1,000.25
$1,248.97 		$1,238.68
$1,304.78
$1,374.79
$1,623.51 		$1,613.22
$1,679.32
$1,749.33
$1,998.05 		$374.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$979.20
$1,111.40
$1,251.42
$1,748.86
$2,657.54 		$1,353.74
$1,485.94
$1,625.96
$2,123.40 		$1,728.28
$1,860.48
$2,000.50
$2,497.94 		$2,102.82
$2,235.02
$2,375.04
$2,872.48 		$374.54
Toc - Plan #38 BlueCross BlueShield of Tennessee
Silver

(EPO) Silver S28E $30 PCP Copay at Blue of TN + Free Telehealth

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$6,500 $13,000 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 		$393.83
$447.00
$503.31
$703.38
$1,068.85 		$695.11
$748.28
$804.59
$1,004.66 		$996.39
$1,049.56
$1,105.87
$1,305.94 		$1,297.67
$1,350.84
$1,407.15
$1,607.22 		$301.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.66
$894.00
$1,006.62
$1,406.76
$2,137.70 		$1,088.94
$1,195.28
$1,307.90
$1,708.04 		$1,390.22
$1,496.56
$1,609.18
$2,009.32 		$1,691.50
$1,797.84
$1,910.46
$2,310.60 		$301.28

ADVERTISEMENT

Oscar Insurance Company

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755 | TTY: 1-855-672-2755
Toc - Plan #39 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.90
$373.30
$420.33
$587.41
$892.62 		$580.50
$624.90
$671.93
$839.01 		$832.10
$876.50
$923.53
$1,090.61 		$1,083.70
$1,128.10
$1,175.13
$1,342.21 		$251.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.80
$746.60
$840.66
$1,174.82
$1,785.24 		$909.40
$998.20
$1,092.26
$1,426.42 		$1,161.00
$1,249.80
$1,343.86
$1,678.02 		$1,412.60
$1,501.40
$1,595.46
$1,929.62 		$251.60
Toc - Plan #40 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.06
$385.96
$434.59
$607.33
$922.90 		$600.20
$646.10
$694.73
$867.47 		$860.34
$906.24
$954.87
$1,127.61 		$1,120.48
$1,166.38
$1,215.01
$1,387.75 		$260.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.12
$771.92
$869.18
$1,214.66
$1,845.80 		$940.26
$1,032.06
$1,129.32
$1,474.80 		$1,200.40
$1,292.20
$1,389.46
$1,734.94 		$1,460.54
$1,552.34
$1,649.60
$1,995.08 		$260.14
Toc - Plan #41 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic

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

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331.87
$376.66
$424.12
$592.71
$900.68 		$585.74
$630.53
$677.99
$846.58 		$839.61
$884.40
$931.86
$1,100.45 		$1,093.48
$1,138.27
$1,185.73
$1,354.32 		$253.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.74
$753.32
$848.24
$1,185.42
$1,801.36 		$917.61
$1,007.19
$1,102.11
$1,439.29 		$1,171.48
$1,261.06
$1,355.98
$1,693.16 		$1,425.35
$1,514.93
$1,609.85
$1,947.03 		$253.87
Toc - Plan #42 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.36
$450.99
$507.81
$709.66
$1,078.40 		$701.33
$754.96
$811.78
$1,013.63 		$1,005.30
$1,058.93
$1,115.75
$1,317.60 		$1,309.27
$1,362.90
$1,419.72
$1,621.57 		$303.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.72
$901.98
$1,015.62
$1,419.32
$2,156.80 		$1,098.69
$1,205.95
$1,319.59
$1,723.29 		$1,402.66
$1,509.92
$1,623.56
$2,027.26 		$1,706.63
$1,813.89
$1,927.53
$2,331.23 		$303.97
Toc - Plan #43 Oscar Insurance Company
Silver

(EPO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$431.78
$490.06
$551.80
$771.14
$1,171.82 		$762.08
$820.36
$882.10
$1,101.44 		$1,092.38
$1,150.66
$1,212.40
$1,431.74 		$1,422.68
$1,480.96
$1,542.70
$1,762.04 		$330.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.56
$980.12
$1,103.60
$1,542.28
$2,343.64 		$1,193.86
$1,310.42
$1,433.90
$1,872.58 		$1,524.16
$1,640.72
$1,764.20
$2,202.88 		$1,854.46
$1,971.02
$2,094.50
$2,533.18 		$330.30
Toc - Plan #44 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.45
$484.01
$544.99
$761.63
$1,157.37 		$752.68
$810.24
$871.22
$1,087.86 		$1,078.91
$1,136.47
$1,197.45
$1,414.09 		$1,405.14
$1,462.70
$1,523.68
$1,740.32 		$326.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.90
$968.02
$1,089.98
$1,523.26
$2,314.74 		$1,179.13
$1,294.25
$1,416.21
$1,849.49 		$1,505.36
$1,620.48
$1,742.44
$2,175.72 		$1,831.59
$1,946.71
$2,068.67
$2,501.95 		$326.23
Toc - Plan #45 Oscar Insurance Company
Catastrophic

(EPO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$258.31
$293.17
$330.11
$461.33
$701.03 		$455.91
$490.77
$527.71
$658.93 		$653.51
$688.37
$725.31
$856.53 		$851.11
$885.97
$922.91
$1,054.13 		$197.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$516.62
$586.34
$660.22
$922.66
$1,402.06 		$714.22
$783.94
$857.82
$1,120.26 		$911.82
$981.54
$1,055.42
$1,317.86 		$1,109.42
$1,179.14
$1,253.02
$1,515.46 		$197.60
Toc - Plan #46 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.80
$449.22
$505.82
$706.88
$1,074.17 		$698.58
$752.00
$808.60
$1,009.66 		$1,001.36
$1,054.78
$1,111.38
$1,312.44 		$1,304.14
$1,357.56
$1,414.16
$1,615.22 		$302.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.60
$898.44
$1,011.64
$1,413.76
$2,148.34 		$1,094.38
$1,201.22
$1,314.42
$1,716.54 		$1,397.16
$1,504.00
$1,617.20
$2,019.32 		$1,699.94
$1,806.78
$1,919.98
$2,322.10 		$302.78
Toc - Plan #47 Oscar Insurance Company
Gold

(EPO) Gold Classic

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$506.28
$574.61
$647.01
$904.19
$1,374.00 		$893.57
$961.90
$1,034.30
$1,291.48 		$1,280.86
$1,349.19
$1,421.59
$1,678.77 		$1,668.15
$1,736.48
$1,808.88
$2,066.06 		$387.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.56
$1,149.22
$1,294.02
$1,808.38
$2,748.00 		$1,399.85
$1,536.51
$1,681.31
$2,195.67 		$1,787.14
$1,923.80
$2,068.60
$2,582.96 		$2,174.43
$2,311.09
$2,455.89
$2,970.25 		$387.29
Toc - Plan #48 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$356.31
$404.40
$455.35
$636.35
$966.99 		$628.88
$676.97
$727.92
$908.92 		$901.45
$949.54
$1,000.49
$1,181.49 		$1,174.02
$1,222.11
$1,273.06
$1,454.06 		$272.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.62
$808.80
$910.70
$1,272.70
$1,933.98 		$985.19
$1,081.37
$1,183.27
$1,545.27 		$1,257.76
$1,353.94
$1,455.84
$1,817.84 		$1,530.33
$1,626.51
$1,728.41
$2,090.41 		$272.57
Toc - Plan #49 Oscar Insurance Company
Silver

(EPO) Silver Elite

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$440.54
$500.00
$563.00
$786.79
$1,195.60 		$777.55
$837.01
$900.01
$1,123.80 		$1,114.56
$1,174.02
$1,237.02
$1,460.81 		$1,451.57
$1,511.03
$1,574.03
$1,797.82 		$337.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.08
$1,000.00
$1,126.00
$1,573.58
$2,391.20 		$1,218.09
$1,337.01
$1,463.01
$1,910.59 		$1,555.10
$1,674.02
$1,800.02
$2,247.60 		$1,892.11
$2,011.03
$2,137.03
$2,584.61 		$337.01
Toc - Plan #50 Oscar Insurance Company
Silver

(EPO) Silver Classic- $0 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $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 		$455.80
$517.33
$582.51
$814.05
$1,237.03 		$804.48
$866.01
$931.19
$1,162.73 		$1,153.16
$1,214.69
$1,279.87
$1,511.41 		$1,501.84
$1,563.37
$1,628.55
$1,860.09 		$348.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.60
$1,034.66
$1,165.02
$1,628.10
$2,474.06 		$1,260.28
$1,383.34
$1,513.70
$1,976.78 		$1,608.96
$1,732.02
$1,862.38
$2,325.46 		$1,957.64
$2,080.70
$2,211.06
$2,674.14 		$348.68
Toc - Plan #51 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$354.66
$402.53
$453.25
$633.41
$962.53 		$625.97
$673.84
$724.56
$904.72 		$897.28
$945.15
$995.87
$1,176.03 		$1,168.59
$1,216.46
$1,267.18
$1,447.34 		$271.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$709.32
$805.06
$906.50
$1,266.82
$1,925.06 		$980.63
$1,076.37
$1,177.81
$1,538.13 		$1,251.94
$1,347.68
$1,449.12
$1,809.44 		$1,523.25
$1,618.99
$1,720.43
$2,080.75 		$271.31
Toc - Plan #52 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$357.62
$405.89
$457.03
$638.69
$970.55 		$631.19
$679.46
$730.60
$912.26 		$904.76
$953.03
$1,004.17
$1,185.83 		$1,178.33
$1,226.60
$1,277.74
$1,459.40 		$273.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.24
$811.78
$914.06
$1,277.38
$1,941.10 		$988.81
$1,085.35
$1,187.63
$1,550.95 		$1,262.38
$1,358.92
$1,461.20
$1,824.52 		$1,535.95
$1,632.49
$1,734.77
$2,098.09 		$273.57
Toc - Plan #53 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.54
$471.62
$531.04
$742.13
$1,127.74 		$733.42
$789.50
$848.92
$1,060.01 		$1,051.30
$1,107.38
$1,166.80
$1,377.89 		$1,369.18
$1,425.26
$1,484.68
$1,695.77 		$317.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.08
$943.24
$1,062.08
$1,484.26
$2,255.48 		$1,148.96
$1,261.12
$1,379.96
$1,802.14 		$1,466.84
$1,579.00
$1,697.84
$2,120.02 		$1,784.72
$1,896.88
$2,015.72
$2,437.90 		$317.88
Toc - Plan #54 Oscar Insurance Company
Gold

(EPO) Gold Elite- $0 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$561.15
$636.90
$717.14
$1,002.20
$1,522.94 		$990.42
$1,066.17
$1,146.41
$1,431.47 		$1,419.69
$1,495.44
$1,575.68
$1,860.74 		$1,848.96
$1,924.71
$2,004.95
$2,290.01 		$429.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,122.30
$1,273.80
$1,434.28
$2,004.40
$3,045.88 		$1,551.57
$1,703.07
$1,863.55
$2,433.67 		$1,980.84
$2,132.34
$2,292.82
$2,862.94 		$2,410.11
$2,561.61
$2,722.09
$3,292.21 		$429.27
Toc - Plan #55 Oscar Insurance Company
Gold

(EPO) Gold Elite

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$526.46
$597.52
$672.80
$940.24
$1,428.79 		$929.19
$1,000.25
$1,075.53
$1,342.97 		$1,331.92
$1,402.98
$1,478.26
$1,745.70 		$1,734.65
$1,805.71
$1,880.99
$2,148.43 		$402.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,052.92
$1,195.04
$1,345.60
$1,880.48
$2,857.58 		$1,455.65
$1,597.77
$1,748.33
$2,283.21 		$1,858.38
$2,000.50
$2,151.06
$2,685.94 		$2,261.11
$2,403.23
$2,553.79
$3,088.67 		$402.73
Toc - Plan #56 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.43
$397.72
$447.83
$625.85
$951.04 		$618.50
$665.79
$715.90
$893.92 		$886.57
$933.86
$983.97
$1,161.99 		$1,154.64
$1,201.93
$1,252.04
$1,430.06 		$268.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.86
$795.44
$895.66
$1,251.70
$1,902.08 		$968.93
$1,063.51
$1,163.73
$1,519.77 		$1,237.00
$1,331.58
$1,431.80
$1,787.84 		$1,505.07
$1,599.65
$1,699.87
$2,055.91 		$268.07
Toc - Plan #57 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$315.54
$358.12
$403.24
$563.53
$856.34 		$556.92
$599.50
$644.62
$804.91 		$798.30
$840.88
$886.00
$1,046.29 		$1,039.68
$1,082.26
$1,127.38
$1,287.67 		$241.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.08
$716.24
$806.48
$1,127.06
$1,712.68 		$872.46
$957.62
$1,047.86
$1,368.44 		$1,113.84
$1,199.00
$1,289.24
$1,609.82 		$1,355.22
$1,440.38
$1,530.62
$1,851.20 		$241.38
Toc - Plan #58 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$418.95
$475.49
$535.40
$748.22
$1,136.99 		$739.44
$795.98
$855.89
$1,068.71 		$1,059.93
$1,116.47
$1,176.38
$1,389.20 		$1,380.42
$1,436.96
$1,496.87
$1,709.69 		$320.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.90
$950.98
$1,070.80
$1,496.44
$2,273.98 		$1,158.39
$1,271.47
$1,391.29
$1,816.93 		$1,478.88
$1,591.96
$1,711.78
$2,137.42 		$1,799.37
$1,912.45
$2,032.27
$2,457.91 		$320.49
Toc - Plan #59 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$480.77
$545.66
$614.41
$858.63
$1,304.78 		$848.55
$913.44
$982.19
$1,226.41 		$1,216.33
$1,281.22
$1,349.97
$1,594.19 		$1,584.11
$1,649.00
$1,717.75
$1,961.97 		$367.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$961.54
$1,091.32
$1,228.82
$1,717.26
$2,609.56 		$1,329.32
$1,459.10
$1,596.60
$2,085.04 		$1,697.10
$1,826.88
$1,964.38
$2,452.82 		$2,064.88
$2,194.66
$2,332.16
$2,820.60 		$367.78

ADVERTISEMENT

US Health and Life

Local: 1-833-600-1311 | Toll Free: 

Toc - Plan #60 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 		$269.73
$306.14
$344.71
$481.73
$732.03 		$476.07
$512.48
$551.05
$688.07 		$682.41
$718.82
$757.39
$894.41 		$888.75
$925.16
$963.73
$1,100.75 		$206.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.46
$612.28
$689.42
$963.46
$1,464.06 		$745.80
$818.62
$895.76
$1,169.80 		$952.14
$1,024.96
$1,102.10
$1,376.14 		$1,158.48
$1,231.30
$1,308.44
$1,582.48 		$206.34
Toc - Plan #61 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 		$267.79
$303.94
$342.24
$478.28
$726.79 		$472.65
$508.80
$547.10
$683.14 		$677.51
$713.66
$751.96
$888.00 		$882.37
$918.52
$956.82
$1,092.86 		$204.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$535.58
$607.88
$684.48
$956.56
$1,453.58 		$740.44
$812.74
$889.34
$1,161.42 		$945.30
$1,017.60
$1,094.20
$1,366.28 		$1,150.16
$1,222.46
$1,299.06
$1,571.14 		$204.86
Toc - Plan #62 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 		$302.20
$343.00
$386.21
$539.73
$820.17 		$533.38
$574.18
$617.39
$770.91 		$764.56
$805.36
$848.57
$1,002.09 		$995.74
$1,036.54
$1,079.75
$1,233.27 		$231.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.40
$686.00
$772.42
$1,079.46
$1,640.34 		$835.58
$917.18
$1,003.60
$1,310.64 		$1,066.76
$1,148.36
$1,234.78
$1,541.82 		$1,297.94
$1,379.54
$1,465.96
$1,773.00 		$231.18
Toc - Plan #63 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 		$393.98
$447.17
$503.51
$703.65
$1,069.27 		$695.38
$748.57
$804.91
$1,005.05 		$996.78
$1,049.97
$1,106.31
$1,306.45 		$1,298.18
$1,351.37
$1,407.71
$1,607.85 		$301.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.96
$894.34
$1,007.02
$1,407.30
$2,138.54 		$1,089.36
$1,195.74
$1,308.42
$1,708.70 		$1,390.76
$1,497.14
$1,609.82
$2,010.10 		$1,692.16
$1,798.54
$1,911.22
$2,311.50 		$301.40
Toc - Plan #64 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 		$390.73
$443.48
$499.35
$697.84
$1,060.44 		$689.64
$742.39
$798.26
$996.75 		$988.55
$1,041.30
$1,097.17
$1,295.66 		$1,287.46
$1,340.21
$1,396.08
$1,594.57 		$298.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$781.46
$886.96
$998.70
$1,395.68
$2,120.88 		$1,080.37
$1,185.87
$1,297.61
$1,694.59 		$1,379.28
$1,484.78
$1,596.52
$1,993.50 		$1,678.19
$1,783.69
$1,895.43
$2,292.41 		$298.91
Toc - Plan #65 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 		$364.18
$413.35
$465.42
$650.43
$988.39 		$642.78
$691.95
$744.02
$929.03 		$921.38
$970.55
$1,022.62
$1,207.63 		$1,199.98
$1,249.15
$1,301.22
$1,486.23 		$278.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$728.36
$826.70
$930.84
$1,300.86
$1,976.78 		$1,006.96
$1,105.30
$1,209.44
$1,579.46 		$1,285.56
$1,383.90
$1,488.04
$1,858.06 		$1,564.16
$1,662.50
$1,766.64
$2,136.66 		$278.60
Toc - Plan #66 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 		$271.27
$307.89
$346.68
$484.49
$736.22 		$478.79
$515.41
$554.20
$692.01 		$686.31
$722.93
$761.72
$899.53 		$893.83
$930.45
$969.24
$1,107.05 		$207.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.54
$615.78
$693.36
$968.98
$1,472.44 		$750.06
$823.30
$900.88
$1,176.50 		$957.58
$1,030.82
$1,108.40
$1,384.02 		$1,165.10
$1,238.34
$1,315.92
$1,591.54 		$207.52
Toc - Plan #67 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 		$366.93
$416.46
$468.93
$655.33
$995.84 		$647.63
$697.16
$749.63
$936.03 		$928.33
$977.86
$1,030.33
$1,216.73 		$1,209.03
$1,258.56
$1,311.03
$1,497.43 		$280.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.86
$832.92
$937.86
$1,310.66
$1,991.68 		$1,014.56
$1,113.62
$1,218.56
$1,591.36 		$1,295.26
$1,394.32
$1,499.26
$1,872.06 		$1,575.96
$1,675.02
$1,779.96
$2,152.76 		$280.70
Toc - Plan #68 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 		$433.07
$491.53
$553.46
$773.46
$1,175.35 		$764.37
$822.83
$884.76
$1,104.76 		$1,095.67
$1,154.13
$1,216.06
$1,436.06 		$1,426.97
$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 		$866.14
$983.06
$1,106.92
$1,546.92
$2,350.70 		$1,197.44
$1,314.36
$1,438.22
$1,878.22 		$1,528.74
$1,645.66
$1,769.52
$2,209.52 		$1,860.04
$1,976.96
$2,100.82
$2,540.82 		$331.30

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-250-8188 | Toll Free: 1-877-250-8188 | TTY: 1-877-250-8188
Toc - Plan #69 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 		$495.87
$562.82
$633.73
$885.63
$1,345.80 		$875.21
$942.16
$1,013.07
$1,264.97 		$1,254.55
$1,321.50
$1,392.41
$1,644.31 		$1,633.89
$1,700.84
$1,771.75
$2,023.65 		$379.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.74
$1,125.64
$1,267.46
$1,771.26
$2,691.60 		$1,371.08
$1,504.98
$1,646.80
$2,150.60 		$1,750.42
$1,884.32
$2,026.14
$2,529.94 		$2,129.76
$2,263.66
$2,405.48
$2,909.28 		$379.34
Toc - Plan #70 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 		$381.48
$432.98
$487.53
$681.32
$1,035.33 		$673.31
$724.81
$779.36
$973.15 		$965.14
$1,016.64
$1,071.19
$1,264.98 		$1,256.97
$1,308.47
$1,363.02
$1,556.81 		$291.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.96
$865.96
$975.06
$1,362.64
$2,070.66 		$1,054.79
$1,157.79
$1,266.89
$1,654.47 		$1,346.62
$1,449.62
$1,558.72
$1,946.30 		$1,638.45
$1,741.45
$1,850.55
$2,238.13 		$291.83
Toc - Plan #71 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 		$658.77
$747.70
$841.90
$1,176.56
$1,787.89 		$1,162.73
$1,251.66
$1,345.86
$1,680.52 		$1,666.69
$1,755.62
$1,849.82
$2,184.48 		$2,170.65
$2,259.58
$2,353.78
$2,688.44 		$503.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,317.54
$1,495.40
$1,683.80
$2,353.12
$3,575.78 		$1,821.50
$1,999.36
$2,187.76
$2,857.08 		$2,325.46
$2,503.32
$2,691.72
$3,361.04 		$2,829.42
$3,007.28
$3,195.68
$3,865.00 		$503.96
Toc - Plan #72 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 		$723.03
$820.64
$924.03
$1,291.33
$1,962.30 		$1,276.15
$1,373.76
$1,477.15
$1,844.45 		$1,829.27
$1,926.88
$2,030.27
$2,397.57 		$2,382.39
$2,480.00
$2,583.39
$2,950.69 		$553.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,446.06
$1,641.28
$1,848.06
$2,582.66
$3,924.60 		$1,999.18
$2,194.40
$2,401.18
$3,135.78 		$2,552.30
$2,747.52
$2,954.30
$3,688.90 		$3,105.42
$3,300.64
$3,507.42
$4,242.02 		$553.12
Toc - Plan #73 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 		$702.46
$797.29
$897.74
$1,254.59
$1,906.46 		$1,239.84
$1,334.67
$1,435.12
$1,791.97 		$1,777.22
$1,872.05
$1,972.50
$2,329.35 		$2,314.60
$2,409.43
$2,509.88
$2,866.73 		$537.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,404.92
$1,594.58
$1,795.48
$2,509.18
$3,812.92 		$1,942.30
$2,131.96
$2,332.86
$3,046.56 		$2,479.68
$2,669.34
$2,870.24
$3,583.94 		$3,017.06
$3,206.72
$3,407.62
$4,121.32 		$537.38
Toc - Plan #74 UnitedHealthcare
Silver

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

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

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 		$496.74
$563.80
$634.83
$887.17
$1,348.15 		$876.74
$943.80
$1,014.83
$1,267.17 		$1,256.74
$1,323.80
$1,394.83
$1,647.17 		$1,636.74
$1,703.80
$1,774.83
$2,027.17 		$380.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$993.48
$1,127.60
$1,269.66
$1,774.34
$2,696.30 		$1,373.48
$1,507.60
$1,649.66
$2,154.34 		$1,753.48
$1,887.60
$2,029.66
$2,534.34 		$2,133.48
$2,267.60
$2,409.66
$2,914.34 		$380.00
Toc - Plan #75 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 		$495.69
$562.61
$633.49
$885.30
$1,345.30 		$874.89
$941.81
$1,012.69
$1,264.50 		$1,254.09
$1,321.01
$1,391.89
$1,643.70 		$1,633.29
$1,700.21
$1,771.09
$2,022.90 		$379.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.38
$1,125.22
$1,266.98
$1,770.60
$2,690.60 		$1,370.58
$1,504.42
$1,646.18
$2,149.80 		$1,749.78
$1,883.62
$2,025.38
$2,529.00 		$2,128.98
$2,262.82
$2,404.58
$2,908.20 		$379.20
Toc - Plan #76 UnitedHealthcare
Silver

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

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

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 		$511.80
$580.90
$654.08
$914.08
$1,389.03 		$903.33
$972.43
$1,045.61
$1,305.61 		$1,294.86
$1,363.96
$1,437.14
$1,697.14 		$1,686.39
$1,755.49
$1,828.67
$2,088.67 		$391.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,023.60
$1,161.80
$1,308.16
$1,828.16
$2,778.06 		$1,415.13
$1,553.33
$1,699.69
$2,219.69 		$1,806.66
$1,944.86
$2,091.22
$2,611.22 		$2,198.19
$2,336.39
$2,482.75
$3,002.75 		$391.53
Toc - Plan #77 UnitedHealthcare
Silver

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

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

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 		$503.56
$571.54
$643.54
$899.35
$1,366.65 		$888.78
$956.76
$1,028.76
$1,284.57 		$1,274.00
$1,341.98
$1,413.98
$1,669.79 		$1,659.22
$1,727.20
$1,799.20
$2,055.01 		$385.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,007.12
$1,143.08
$1,287.08
$1,798.70
$2,733.30 		$1,392.34
$1,528.30
$1,672.30
$2,183.92 		$1,777.56
$1,913.52
$2,057.52
$2,569.14 		$2,162.78
$2,298.74
$2,442.74
$2,954.36 		$385.22
Toc - Plan #78 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 		$497.51
$564.68
$635.82
$888.56
$1,350.25 		$878.11
$945.28
$1,016.42
$1,269.16 		$1,258.71
$1,325.88
$1,397.02
$1,649.76 		$1,639.31
$1,706.48
$1,777.62
$2,030.36 		$380.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.02
$1,129.36
$1,271.64
$1,777.12
$2,700.50 		$1,375.62
$1,509.96
$1,652.24
$2,157.72 		$1,756.22
$1,890.56
$2,032.84
$2,538.32 		$2,136.82
$2,271.16
$2,413.44
$2,918.92 		$380.60
Toc - Plan #79 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 		$387.99
$440.37
$495.85
$692.95
$1,053.01 		$684.80
$737.18
$792.66
$989.76 		$981.61
$1,033.99
$1,089.47
$1,286.57 		$1,278.42
$1,330.80
$1,386.28
$1,583.38 		$296.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$775.98
$880.74
$991.70
$1,385.90
$2,106.02 		$1,072.79
$1,177.55
$1,288.51
$1,682.71 		$1,369.60
$1,474.36
$1,585.32
$1,979.52 		$1,666.41
$1,771.17
$1,882.13
$2,276.33 		$296.81
Toc - Plan #80 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 		$396.00
$449.46
$506.09
$707.25
$1,074.74 		$698.94
$752.40
$809.03
$1,010.19 		$1,001.88
$1,055.34
$1,111.97
$1,313.13 		$1,304.82
$1,358.28
$1,414.91
$1,616.07 		$302.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$792.00
$898.92
$1,012.18
$1,414.50
$2,149.48 		$1,094.94
$1,201.86
$1,315.12
$1,717.44 		$1,397.88
$1,504.80
$1,618.06
$2,020.38 		$1,700.82
$1,807.74
$1,921.00
$2,323.32 		$302.94
Toc - Plan #81 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 		$362.51
$411.45
$463.29
$647.45
$983.86 		$639.83
$688.77
$740.61
$924.77 		$917.15
$966.09
$1,017.93
$1,202.09 		$1,194.47
$1,243.41
$1,295.25
$1,479.41 		$277.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.02
$822.90
$926.58
$1,294.90
$1,967.72 		$1,002.34
$1,100.22
$1,203.90
$1,572.22 		$1,279.66
$1,377.54
$1,481.22
$1,849.54 		$1,556.98
$1,654.86
$1,758.54
$2,126.86 		$277.32
Toc - Plan #82 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 		$384.84
$436.80
$491.83
$687.33
$1,044.47 		$679.25
$731.21
$786.24
$981.74 		$973.66
$1,025.62
$1,080.65
$1,276.15 		$1,268.07
$1,320.03
$1,375.06
$1,570.56 		$294.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.68
$873.60
$983.66
$1,374.66
$2,088.94 		$1,064.09
$1,168.01
$1,278.07
$1,669.07 		$1,358.50
$1,462.42
$1,572.48
$1,963.48 		$1,652.91
$1,756.83
$1,866.89
$2,257.89 		$294.41
Toc - Plan #83 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 		$362.56
$411.50
$463.35
$647.53
$983.98 		$639.92
$688.86
$740.71
$924.89 		$917.28
$966.22
$1,018.07
$1,202.25 		$1,194.64
$1,243.58
$1,295.43
$1,479.61 		$277.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.12
$823.00
$926.70
$1,295.06
$1,967.96 		$1,002.48
$1,100.36
$1,204.06
$1,572.42 		$1,279.84
$1,377.72
$1,481.42
$1,849.78 		$1,557.20
$1,655.08
$1,758.78
$2,127.14 		$277.36
Toc - Plan #84 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 		$375.36
$426.03
$479.71
$670.40
$1,018.73 		$662.51
$713.18
$766.86
$957.55 		$949.66
$1,000.33
$1,054.01
$1,244.70 		$1,236.81
$1,287.48
$1,341.16
$1,531.85 		$287.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.72
$852.06
$959.42
$1,340.80
$2,037.46 		$1,037.87
$1,139.21
$1,246.57
$1,627.95 		$1,325.02
$1,426.36
$1,533.72
$1,915.10 		$1,612.17
$1,713.51
$1,820.87
$2,202.25 		$287.15

ADVERTISEMENT

Ambetter of Tennessee

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

Toc - Plan #85 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 		$289.96
$329.09
$370.55
$517.85
$786.92 		$511.77
$550.90
$592.36
$739.66 		$733.58
$772.71
$814.17
$961.47 		$955.39
$994.52
$1,035.98
$1,183.28 		$221.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.92
$658.18
$741.10
$1,035.70
$1,573.84 		$801.73
$879.99
$962.91
$1,257.51 		$1,023.54
$1,101.80
$1,184.72
$1,479.32 		$1,245.35
$1,323.61
$1,406.53
$1,701.13 		$221.81
Toc - Plan #86 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 		$399.77
$453.73
$510.90
$713.98
$1,084.96 		$705.59
$759.55
$816.72
$1,019.80 		$1,011.41
$1,065.37
$1,122.54
$1,325.62 		$1,317.23
$1,371.19
$1,428.36
$1,631.44 		$305.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.54
$907.46
$1,021.80
$1,427.96
$2,169.92 		$1,105.36
$1,213.28
$1,327.62
$1,733.78 		$1,411.18
$1,519.10
$1,633.44
$2,039.60 		$1,717.00
$1,824.92
$1,939.26
$2,345.42 		$305.82
Toc - Plan #87 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 		$413.58
$469.41
$528.55
$738.64
$1,122.44 		$729.96
$785.79
$844.93
$1,055.02 		$1,046.34
$1,102.17
$1,161.31
$1,371.40 		$1,362.72
$1,418.55
$1,477.69
$1,687.78 		$316.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.16
$938.82
$1,057.10
$1,477.28
$2,244.88 		$1,143.54
$1,255.20
$1,373.48
$1,793.66 		$1,459.92
$1,571.58
$1,689.86
$2,110.04 		$1,776.30
$1,887.96
$2,006.24
$2,426.42 		$316.38
Toc - Plan #88 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 		$317.82
$360.71
$406.16
$567.60
$862.53 		$560.94
$603.83
$649.28
$810.72 		$804.06
$846.95
$892.40
$1,053.84 		$1,047.18
$1,090.07
$1,135.52
$1,296.96 		$243.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$635.64
$721.42
$812.32
$1,135.20
$1,725.06 		$878.76
$964.54
$1,055.44
$1,378.32 		$1,121.88
$1,207.66
$1,298.56
$1,621.44 		$1,365.00
$1,450.78
$1,541.68
$1,864.56 		$243.12
Toc - Plan #89 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 		$395.74
$449.15
$505.74
$706.77
$1,074.00 		$698.47
$751.88
$808.47
$1,009.50 		$1,001.20
$1,054.61
$1,111.20
$1,312.23 		$1,303.93
$1,357.34
$1,413.93
$1,614.96 		$302.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.48
$898.30
$1,011.48
$1,413.54
$2,148.00 		$1,094.21
$1,201.03
$1,314.21
$1,716.27 		$1,396.94
$1,503.76
$1,616.94
$2,019.00 		$1,699.67
$1,806.49
$1,919.67
$2,321.73 		$302.73
Toc - Plan #90 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 		$311.09
$353.08
$397.56
$555.59
$844.27 		$549.07
$591.06
$635.54
$793.57 		$787.05
$829.04
$873.52
$1,031.55 		$1,025.03
$1,067.02
$1,111.50
$1,269.53 		$237.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.18
$706.16
$795.12
$1,111.18
$1,688.54 		$860.16
$944.14
$1,033.10
$1,349.16 		$1,098.14
$1,182.12
$1,271.08
$1,587.14 		$1,336.12
$1,420.10
$1,509.06
$1,825.12 		$237.98
Toc - Plan #91 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 		$350.31
$397.59
$447.68
$625.63
$950.71 		$618.29
$665.57
$715.66
$893.61 		$886.27
$933.55
$983.64
$1,161.59 		$1,154.25
$1,201.53
$1,251.62
$1,429.57 		$267.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.62
$795.18
$895.36
$1,251.26
$1,901.42 		$968.60
$1,063.16
$1,163.34
$1,519.24 		$1,236.58
$1,331.14
$1,431.32
$1,787.22 		$1,504.56
$1,599.12
$1,699.30
$2,055.20 		$267.98
Toc - Plan #92 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 		$389.80
$442.41
$498.15
$696.17
$1,057.89 		$687.99
$740.60
$796.34
$994.36 		$986.18
$1,038.79
$1,094.53
$1,292.55 		$1,284.37
$1,336.98
$1,392.72
$1,590.74 		$298.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.60
$884.82
$996.30
$1,392.34
$2,115.78 		$1,077.79
$1,183.01
$1,294.49
$1,690.53 		$1,375.98
$1,481.20
$1,592.68
$1,988.72 		$1,674.17
$1,779.39
$1,890.87
$2,286.91 		$298.19
Toc - Plan #93 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 		$394.11
$447.31
$503.66
$703.87
$1,069.60 		$695.60
$748.80
$805.15
$1,005.36 		$997.09
$1,050.29
$1,106.64
$1,306.85 		$1,298.58
$1,351.78
$1,408.13
$1,608.34 		$301.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.22
$894.62
$1,007.32
$1,407.74
$2,139.20 		$1,089.71
$1,196.11
$1,308.81
$1,709.23 		$1,391.20
$1,497.60
$1,610.30
$2,010.72 		$1,692.69
$1,799.09
$1,911.79
$2,312.21 		$301.49
Toc - Plan #94 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 		$395.82
$449.24
$505.84
$706.91
$1,074.22 		$698.61
$752.03
$808.63
$1,009.70 		$1,001.40
$1,054.82
$1,111.42
$1,312.49 		$1,304.19
$1,357.61
$1,414.21
$1,615.28 		$302.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.64
$898.48
$1,011.68
$1,413.82
$2,148.44 		$1,094.43
$1,201.27
$1,314.47
$1,716.61 		$1,397.22
$1,504.06
$1,617.26
$2,019.40 		$1,700.01
$1,806.85
$1,920.05
$2,322.19 		$302.79
Toc - Plan #95 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 		$455.25
$516.70
$581.80
$813.06
$1,235.53 		$803.51
$864.96
$930.06
$1,161.32 		$1,151.77
$1,213.22
$1,278.32
$1,509.58 		$1,500.03
$1,561.48
$1,626.58
$1,857.84 		$348.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.50
$1,033.40
$1,163.60
$1,626.12
$2,471.06 		$1,258.76
$1,381.66
$1,511.86
$1,974.38 		$1,607.02
$1,729.92
$1,860.12
$2,322.64 		$1,955.28
$2,078.18
$2,208.38
$2,670.90 		$348.26
Toc - Plan #96 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 		$276.50
$313.82
$353.36
$493.82
$750.40 		$488.02
$525.34
$564.88
$705.34 		$699.54
$736.86
$776.40
$916.86 		$911.06
$948.38
$987.92
$1,128.38 		$211.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.00
$627.64
$706.72
$987.64
$1,500.80 		$764.52
$839.16
$918.24
$1,199.16 		$976.04
$1,050.68
$1,129.76
$1,410.68 		$1,187.56
$1,262.20
$1,341.28
$1,622.20 		$211.52
Toc - Plan #97 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 		$304.64
$345.75
$389.32
$544.07
$826.77 		$537.68
$578.79
$622.36
$777.11 		$770.72
$811.83
$855.40
$1,010.15 		$1,003.76
$1,044.87
$1,088.44
$1,243.19 		$233.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.28
$691.50
$778.64
$1,088.14
$1,653.54 		$842.32
$924.54
$1,011.68
$1,321.18 		$1,075.36
$1,157.58
$1,244.72
$1,554.22 		$1,308.40
$1,390.62
$1,477.76
$1,787.26 		$233.04
Toc - Plan #98 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 		$390.43
$443.13
$498.96
$697.30
$1,059.61 		$689.10
$741.80
$797.63
$995.97 		$987.77
$1,040.47
$1,096.30
$1,294.64 		$1,286.44
$1,339.14
$1,394.97
$1,593.31 		$298.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.86
$886.26
$997.92
$1,394.60
$2,119.22 		$1,079.53
$1,184.93
$1,296.59
$1,693.27 		$1,378.20
$1,483.60
$1,595.26
$1,991.94 		$1,676.87
$1,782.27
$1,893.93
$2,290.61 		$298.67
Toc - Plan #99 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 		$391.26
$444.07
$500.02
$698.78
$1,061.86 		$690.57
$743.38
$799.33
$998.09 		$989.88
$1,042.69
$1,098.64
$1,297.40 		$1,289.19
$1,342.00
$1,397.95
$1,596.71 		$299.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.52
$888.14
$1,000.04
$1,397.56
$2,123.72 		$1,081.83
$1,187.45
$1,299.35
$1,696.87 		$1,381.14
$1,486.76
$1,598.66
$1,996.18 		$1,680.45
$1,786.07
$1,897.97
$2,295.49 		$299.31
Toc - Plan #100 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 		$301.11
$341.75
$384.81
$537.77
$817.19 		$531.45
$572.09
$615.15
$768.11 		$761.79
$802.43
$845.49
$998.45 		$992.13
$1,032.77
$1,075.83
$1,228.79 		$230.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.22
$683.50
$769.62
$1,075.54
$1,634.38 		$832.56
$913.84
$999.96
$1,305.88 		$1,062.90
$1,144.18
$1,230.30
$1,536.22 		$1,293.24
$1,374.52
$1,460.64
$1,766.56 		$230.34
Toc - Plan #101 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 		$415.15
$471.18
$530.55
$741.44
$1,126.69 		$732.73
$788.76
$848.13
$1,059.02 		$1,050.31
$1,106.34
$1,165.71
$1,376.60 		$1,367.89
$1,423.92
$1,483.29
$1,694.18 		$317.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.30
$942.36
$1,061.10
$1,482.88
$2,253.38 		$1,147.88
$1,259.94
$1,378.68
$1,800.46 		$1,465.46
$1,577.52
$1,696.26
$2,118.04 		$1,783.04
$1,895.10
$2,013.84
$2,435.62 		$317.58
Toc - Plan #102 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 		$429.49
$487.46
$548.88
$767.05
$1,165.61 		$758.04
$816.01
$877.43
$1,095.60 		$1,086.59
$1,144.56
$1,205.98
$1,424.15 		$1,415.14
$1,473.11
$1,534.53
$1,752.70 		$328.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.98
$974.92
$1,097.76
$1,534.10
$2,331.22 		$1,187.53
$1,303.47
$1,426.31
$1,862.65 		$1,516.08
$1,632.02
$1,754.86
$2,191.20 		$1,844.63
$1,960.57
$2,083.41
$2,519.75 		$328.55
Toc - Plan #103 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 		$330.04
$374.59
$421.78
$589.44
$895.71 		$582.51
$627.06
$674.25
$841.91 		$834.98
$879.53
$926.72
$1,094.38 		$1,087.45
$1,132.00
$1,179.19
$1,346.85 		$252.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.08
$749.18
$843.56
$1,178.88
$1,791.42 		$912.55
$1,001.65
$1,096.03
$1,431.35 		$1,165.02
$1,254.12
$1,348.50
$1,683.82 		$1,417.49
$1,506.59
$1,600.97
$1,936.29 		$252.47
Toc - Plan #104 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 		$410.96
$466.43
$525.19
$733.95
$1,115.31 		$725.34
$780.81
$839.57
$1,048.33 		$1,039.72
$1,095.19
$1,153.95
$1,362.71 		$1,354.10
$1,409.57
$1,468.33
$1,677.09 		$314.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.92
$932.86
$1,050.38
$1,467.90
$2,230.62 		$1,136.30
$1,247.24
$1,364.76
$1,782.28 		$1,450.68
$1,561.62
$1,679.14
$2,096.66 		$1,765.06
$1,876.00
$1,993.52
$2,411.04 		$314.38
Toc - Plan #105 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 		$323.06
$366.66
$412.85
$576.96
$876.75 		$570.19
$613.79
$659.98
$824.09 		$817.32
$860.92
$907.11
$1,071.22 		$1,064.45
$1,108.05
$1,154.24
$1,318.35 		$247.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.12
$733.32
$825.70
$1,153.92
$1,753.50 		$893.25
$980.45
$1,072.83
$1,401.05 		$1,140.38
$1,227.58
$1,319.96
$1,648.18 		$1,387.51
$1,474.71
$1,567.09
$1,895.31 		$247.13
Toc - Plan #106 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 		$363.78
$412.88
$464.90
$649.70
$987.27 		$642.06
$691.16
$743.18
$927.98 		$920.34
$969.44
$1,021.46
$1,206.26 		$1,198.62
$1,247.72
$1,299.74
$1,484.54 		$278.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.56
$825.76
$929.80
$1,299.40
$1,974.54 		$1,005.84
$1,104.04
$1,208.08
$1,577.68 		$1,284.12
$1,382.32
$1,486.36
$1,855.96 		$1,562.40
$1,660.60
$1,764.64
$2,134.24 		$278.28
Toc - Plan #107 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 		$409.27
$464.51
$523.04
$730.94
$1,110.74 		$722.36
$777.60
$836.13
$1,044.03 		$1,035.45
$1,090.69
$1,149.22
$1,357.12 		$1,348.54
$1,403.78
$1,462.31
$1,670.21 		$313.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.54
$929.02
$1,046.08
$1,461.88
$2,221.48 		$1,131.63
$1,242.11
$1,359.17
$1,774.97 		$1,444.72
$1,555.20
$1,672.26
$2,088.06 		$1,757.81
$1,868.29
$1,985.35
$2,401.15 		$313.09
Toc - Plan #108 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 		$411.04
$466.52
$525.30
$734.10
$1,115.54 		$725.48
$780.96
$839.74
$1,048.54 		$1,039.92
$1,095.40
$1,154.18
$1,362.98 		$1,354.36
$1,409.84
$1,468.62
$1,677.42 		$314.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.08
$933.04
$1,050.60
$1,468.20
$2,231.08 		$1,136.52
$1,247.48
$1,365.04
$1,782.64 		$1,450.96
$1,561.92
$1,679.48
$2,097.08 		$1,765.40
$1,876.36
$1,993.92
$2,411.52 		$314.44
Toc - Plan #109 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 		$404.79
$459.43
$517.31
$722.94
$1,098.58 		$714.45
$769.09
$826.97
$1,032.60 		$1,024.11
$1,078.75
$1,136.63
$1,342.26 		$1,333.77
$1,388.41
$1,446.29
$1,651.92 		$309.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.58
$918.86
$1,034.62
$1,445.88
$2,197.16 		$1,119.24
$1,228.52
$1,344.28
$1,755.54 		$1,428.90
$1,538.18
$1,653.94
$2,065.20 		$1,738.56
$1,847.84
$1,963.60
$2,374.86 		$309.66
Toc - Plan #110 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 		$472.76
$536.58
$604.18
$844.34
$1,283.06 		$834.42
$898.24
$965.84
$1,206.00 		$1,196.08
$1,259.90
$1,327.50
$1,567.66 		$1,557.74
$1,621.56
$1,689.16
$1,929.32 		$361.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$945.52
$1,073.16
$1,208.36
$1,688.68
$2,566.12 		$1,307.18
$1,434.82
$1,570.02
$2,050.34 		$1,668.84
$1,796.48
$1,931.68
$2,412.00 		$2,030.50
$2,158.14
$2,293.34
$2,773.66 		$361.66
Toc - Plan #111 Ambetter of Tennessee
Expanded Bronze

(EPO) Elite SELECT Bronze with Select Providers

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 		$322.84
$366.42
$412.58
$576.58
$876.17 		$569.81
$613.39
$659.55
$823.55 		$816.78
$860.36
$906.52
$1,070.52 		$1,063.75
$1,107.33
$1,153.49
$1,317.49 		$246.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.68
$732.84
$825.16
$1,153.16
$1,752.34 		$892.65
$979.81
$1,072.13
$1,400.13 		$1,139.62
$1,226.78
$1,319.10
$1,647.10 		$1,386.59
$1,473.75
$1,566.07
$1,894.07 		$246.97
Toc - Plan #112 Ambetter of Tennessee
Silver

(EPO) Clear SELECT Silver with Select Providers

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 		$359.25
$407.74
$459.11
$641.60
$974.98 		$634.07
$682.56
$733.93
$916.42 		$908.89
$957.38
$1,008.75
$1,191.24 		$1,183.71
$1,232.20
$1,283.57
$1,466.06 		$274.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.50
$815.48
$918.22
$1,283.20
$1,949.96 		$993.32
$1,090.30
$1,193.04
$1,558.02 		$1,268.14
$1,365.12
$1,467.86
$1,832.84 		$1,542.96
$1,639.94
$1,742.68
$2,107.66 		$274.82
Toc - Plan #113 Ambetter of Tennessee
Silver

(EPO) Focused SELECT Silver with Select Providers

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 		$363.25
$412.27
$464.22
$648.74
$985.83 		$641.13
$690.15
$742.10
$926.62 		$919.01
$968.03
$1,019.98
$1,204.50 		$1,196.89
$1,245.91
$1,297.86
$1,482.38 		$277.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.50
$824.54
$928.44
$1,297.48
$1,971.66 		$1,004.38
$1,102.42
$1,206.32
$1,575.36 		$1,282.26
$1,380.30
$1,484.20
$1,853.24 		$1,560.14
$1,658.18
$1,762.08
$2,131.12 		$277.88
Toc - Plan #114 Ambetter of Tennessee
Silver

(EPO) Enhanced SELECT Silver with Select Providers

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

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 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 		$363.37
$412.41
$464.37
$648.95
$986.15 		$641.34
$690.38
$742.34
$926.92 		$919.31
$968.35
$1,020.31
$1,204.89 		$1,197.28
$1,246.32
$1,298.28
$1,482.86 		$277.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.74
$824.82
$928.74
$1,297.90
$1,972.30 		$1,004.71
$1,102.79
$1,206.71
$1,575.87 		$1,282.68
$1,380.76
$1,484.68
$1,853.84 		$1,560.65
$1,658.73
$1,762.65
$2,131.81 		$277.97
Toc - Plan #115 Ambetter of Tennessee
Gold

(EPO) Complete SELECT Gold with Select Providers

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 		$381.17
$432.62
$487.13
$680.76
$1,034.48 		$672.76
$724.21
$778.72
$972.35 		$964.35
$1,015.80
$1,070.31
$1,263.94 		$1,255.94
$1,307.39
$1,361.90
$1,555.53 		$291.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.34
$865.24
$974.26
$1,361.52
$2,068.96 		$1,053.93
$1,156.83
$1,265.85
$1,653.11 		$1,345.52
$1,448.42
$1,557.44
$1,944.70 		$1,637.11
$1,740.01
$1,849.03
$2,236.29 		$291.59
Toc - Plan #116 Ambetter of Tennessee
Gold

(EPO) Everyday SELECT Gold with Select Providers

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 		$364.83
$414.07
$466.24
$651.57
$990.12 		$643.92
$693.16
$745.33
$930.66 		$923.01
$972.25
$1,024.42
$1,209.75 		$1,202.10
$1,251.34
$1,303.51
$1,488.84 		$279.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.66
$828.14
$932.48
$1,303.14
$1,980.24 		$1,008.75
$1,107.23
$1,211.57
$1,582.23 		$1,287.84
$1,386.32
$1,490.66
$1,861.32 		$1,566.93
$1,665.41
$1,769.75
$2,140.41 		$279.09
Toc - Plan #117 Ambetter of Tennessee
Expanded Bronze

(EPO) CMS Standard Expanded Bronze SELECT

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 		$280.78
$318.67
$358.82
$501.45
$762.00 		$495.57
$533.46
$573.61
$716.24 		$710.36
$748.25
$788.40
$931.03 		$925.15
$963.04
$1,003.19
$1,145.82 		$214.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.56
$637.34
$717.64
$1,002.90
$1,524.00 		$776.35
$852.13
$932.43
$1,217.69 		$991.14
$1,066.92
$1,147.22
$1,432.48 		$1,205.93
$1,281.71
$1,362.01
$1,647.27 		$214.79
Toc - Plan #118 Ambetter of Tennessee
Silver

(EPO) CMS Standard Silver SELECT

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 		$359.84
$408.41
$459.87
$642.66
$976.59 		$635.11
$683.68
$735.14
$917.93 		$910.38
$958.95
$1,010.41
$1,193.20 		$1,185.65
$1,234.22
$1,285.68
$1,468.47 		$275.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.68
$816.82
$919.74
$1,285.32
$1,953.18 		$994.95
$1,092.09
$1,195.01
$1,560.59 		$1,270.22
$1,367.36
$1,470.28
$1,835.86 		$1,545.49
$1,642.63
$1,745.55
$2,111.13 		$275.27
Toc - Plan #119 Ambetter of Tennessee
Gold

(EPO) CMS Standard Gold SELECT

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 		$360.60
$409.26
$460.83
$644.01
$978.63 		$636.45
$685.11
$736.68
$919.86 		$912.30
$960.96
$1,012.53
$1,195.71 		$1,188.15
$1,236.81
$1,288.38
$1,471.56 		$275.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.20
$818.52
$921.66
$1,288.02
$1,957.26 		$997.05
$1,094.37
$1,197.51
$1,563.87 		$1,272.90
$1,370.22
$1,473.36
$1,839.72 		$1,548.75
$1,646.07
$1,749.21
$2,115.57 		$275.85

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #120 Cigna Healthcare
Silver

(EPO) Cigna Connect 4100

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

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$406.63
$461.52
$519.67
$726.23
$1,103.58 		$717.70
$772.59
$830.74
$1,037.30 		$1,028.77
$1,083.66
$1,141.81
$1,348.37 		$1,339.84
$1,394.73
$1,452.88
$1,659.44 		$311.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.26
$923.04
$1,039.34
$1,452.46
$2,207.16 		$1,124.33
$1,234.11
$1,350.41
$1,763.53 		$1,435.40
$1,545.18
$1,661.48
$2,074.60 		$1,746.47
$1,856.25
$1,972.55
$2,385.67 		$311.07
Toc - Plan #121 Cigna Healthcare
Gold

(EPO) Cigna Connect 1000

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

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$6,500 $13,000 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 		$617.95
$701.38
$789.75
$1,103.67
$1,677.13 		$1,090.69
$1,174.12
$1,262.49
$1,576.41 		$1,563.43
$1,646.86
$1,735.23
$2,049.15 		$2,036.17
$2,119.60
$2,207.97
$2,521.89 		$472.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,235.90
$1,402.76
$1,579.50
$2,207.34
$3,354.26 		$1,708.64
$1,875.50
$2,052.24
$2,680.08 		$2,181.38
$2,348.24
$2,524.98
$3,152.82 		$2,654.12
$2,820.98
$2,997.72
$3,625.56 		$472.74
Toc - Plan #122 Cigna Healthcare
Bronze

(EPO) Cigna Connect 6500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$346.01
$392.72
$442.20
$617.97
$939.06 		$610.71
$657.42
$706.90
$882.67 		$875.41
$922.12
$971.60
$1,147.37 		$1,140.11
$1,186.82
$1,236.30
$1,412.07 		$264.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$692.02
$785.44
$884.40
$1,235.94
$1,878.12 		$956.72
$1,050.14
$1,149.10
$1,500.64 		$1,221.42
$1,314.84
$1,413.80
$1,765.34 		$1,486.12
$1,579.54
$1,678.50
$2,030.04 		$264.70
Toc - Plan #123 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 5900

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.69
$408.24
$459.68
$642.40
$976.19 		$634.85
$683.40
$734.84
$917.56 		$910.01
$958.56
$1,010.00
$1,192.72 		$1,185.17
$1,233.72
$1,285.16
$1,467.88 		$275.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.38
$816.48
$919.36
$1,284.80
$1,952.38 		$994.54
$1,091.64
$1,194.52
$1,559.96 		$1,269.70
$1,366.80
$1,469.68
$1,835.12 		$1,544.86
$1,641.96
$1,744.84
$2,110.28 		$275.16
Toc - Plan #124 Cigna Healthcare
Silver

(EPO) Cigna Connect 3200

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

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.47
$465.88
$524.58
$733.09
$1,114.00 		$724.48
$779.89
$838.59
$1,047.10 		$1,038.49
$1,093.90
$1,152.60
$1,361.11 		$1,352.50
$1,407.91
$1,466.61
$1,675.12 		$314.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.94
$931.76
$1,049.16
$1,466.18
$2,228.00 		$1,134.95
$1,245.77
$1,363.17
$1,780.19 		$1,448.96
$1,559.78
$1,677.18
$2,094.20 		$1,762.97
$1,873.79
$1,991.19
$2,408.21 		$314.01
Toc - Plan #125 Cigna Healthcare
Bronze

(EPO) Cigna Connect 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.89
$390.32
$439.50
$614.20
$933.33 		$606.97
$653.40
$702.58
$877.28 		$870.05
$916.48
$965.66
$1,140.36 		$1,133.13
$1,179.56
$1,228.74
$1,403.44 		$263.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.78
$780.64
$879.00
$1,228.40
$1,866.66 		$950.86
$1,043.72
$1,142.08
$1,491.48 		$1,213.94
$1,306.80
$1,405.16
$1,754.56 		$1,477.02
$1,569.88
$1,668.24
$2,017.64 		$263.08
Toc - Plan #126 Cigna Healthcare
Silver

(EPO) Cigna Connect 5450

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

Annual Out of Pocket Expenses:

Individual Family
$5,450 $10,900 Annual Deductible
$8,950 $17,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.35
$463.48
$521.88
$729.32
$1,108.27 		$720.74
$775.87
$834.27
$1,041.71 		$1,033.13
$1,088.26
$1,146.66
$1,354.10 		$1,345.52
$1,400.65
$1,459.05
$1,666.49 		$312.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.70
$926.96
$1,043.76
$1,458.64
$2,216.54 		$1,129.09
$1,239.35
$1,356.15
$1,771.03 		$1,441.48
$1,551.74
$1,668.54
$2,083.42 		$1,753.87
$1,864.13
$1,980.93
$2,395.81 		$312.39
Toc - Plan #127 Cigna Healthcare
Silver

(EPO) Cigna Connect 3800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.07
$464.30
$522.80
$730.61
$1,110.23 		$722.01
$777.24
$835.74
$1,043.55 		$1,034.95
$1,090.18
$1,148.68
$1,356.49 		$1,347.89
$1,403.12
$1,461.62
$1,669.43 		$312.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$818.14
$928.60
$1,045.60
$1,461.22
$2,220.46 		$1,131.08
$1,241.54
$1,358.54
$1,774.16 		$1,444.02
$1,554.48
$1,671.48
$2,087.10 		$1,756.96
$1,867.42
$1,984.42
$2,400.04 		$312.94
Toc - Plan #128 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.64
$408.19
$459.62
$642.31
$976.06 		$634.76
$683.31
$734.74
$917.43 		$909.88
$958.43
$1,009.86
$1,192.55 		$1,185.00
$1,233.55
$1,284.98
$1,467.67 		$275.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.28
$816.38
$919.24
$1,284.62
$1,952.12 		$994.40
$1,091.50
$1,194.36
$1,559.74 		$1,269.52
$1,366.62
$1,469.48
$1,834.86 		$1,544.64
$1,641.74
$1,744.60
$2,109.98 		$275.12
Toc - Plan #129 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.97
$408.57
$460.05
$642.91
$976.97 		$635.35
$683.95
$735.43
$918.29 		$910.73
$959.33
$1,010.81
$1,193.67 		$1,186.11
$1,234.71
$1,286.19
$1,469.05 		$275.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.94
$817.14
$920.10
$1,285.82
$1,953.94 		$995.32
$1,092.52
$1,195.48
$1,561.20 		$1,270.70
$1,367.90
$1,470.86
$1,836.58 		$1,546.08
$1,643.28
$1,746.24
$2,111.96 		$275.38
Toc - Plan #130 Cigna Healthcare
Silver

(EPO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$408.40
$463.54
$521.94
$729.41
$1,108.40 		$720.83
$775.97
$834.37
$1,041.84 		$1,033.26
$1,088.40
$1,146.80
$1,354.27 		$1,345.69
$1,400.83
$1,459.23
$1,666.70 		$312.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.80
$927.08
$1,043.88
$1,458.82
$2,216.80 		$1,129.23
$1,239.51
$1,356.31
$1,771.25 		$1,441.66
$1,551.94
$1,668.74
$2,083.68 		$1,754.09
$1,864.37
$1,981.17
$2,396.11 		$312.43
Toc - Plan #131 Cigna Healthcare
Silver

(EPO) Cigna Connect 0B

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$412.72
$468.44
$527.46
$737.12
$1,120.13 		$728.45
$784.17
$843.19
$1,052.85 		$1,044.18
$1,099.90
$1,158.92
$1,368.58 		$1,359.91
$1,415.63
$1,474.65
$1,684.31 		$315.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.44
$936.88
$1,054.92
$1,474.24
$2,240.26 		$1,141.17
$1,252.61
$1,370.65
$1,789.97 		$1,456.90
$1,568.34
$1,686.38
$2,105.70 		$1,772.63
$1,884.07
$2,002.11
$2,421.43 		$315.73
Toc - Plan #132 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect HSA 6000

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.70
$410.53
$462.25
$646.00
$981.66 		$638.40
$687.23
$738.95
$922.70 		$915.10
$963.93
$1,015.65
$1,199.40 		$1,191.80
$1,240.63
$1,292.35
$1,476.10 		$276.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.40
$821.06
$924.50
$1,292.00
$1,963.32 		$1,000.10
$1,097.76
$1,201.20
$1,568.70 		$1,276.80
$1,374.46
$1,477.90
$1,845.40 		$1,553.50
$1,651.16
$1,754.60
$2,122.10 		$276.70
Toc - Plan #133 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 0A

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$384.50
$436.41
$491.39
$686.72
$1,043.53 		$678.64
$730.55
$785.53
$980.86 		$972.78
$1,024.69
$1,079.67
$1,275.00 		$1,266.92
$1,318.83
$1,373.81
$1,569.14 		$294.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.00
$872.82
$982.78
$1,373.44
$2,087.06 		$1,063.14
$1,166.96
$1,276.92
$1,667.58 		$1,357.28
$1,461.10
$1,571.06
$1,961.72 		$1,651.42
$1,755.24
$1,865.20
$2,255.86 		$294.14
Toc - Plan #134 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Connect 7600 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.88
$408.46
$459.92
$642.74
$976.71 		$635.19
$683.77
$735.23
$918.05 		$910.50
$959.08
$1,010.54
$1,193.36 		$1,185.81
$1,234.39
$1,285.85
$1,468.67 		$275.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.76
$816.92
$919.84
$1,285.48
$1,953.42 		$995.07
$1,092.23
$1,195.15
$1,560.79 		$1,270.38
$1,367.54
$1,470.46
$1,836.10 		$1,545.69
$1,642.85
$1,745.77
$2,111.41 		$275.31
Toc - Plan #135 Cigna Healthcare
Bronze

(EPO) Cigna Simple Choice 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.89
$390.32
$439.50
$614.20
$933.33 		$606.97
$653.40
$702.58
$877.28 		$870.05
$916.48
$965.66
$1,140.36 		$1,133.13
$1,179.56
$1,228.74
$1,403.44 		$263.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.78
$780.64
$879.00
$1,228.40
$1,866.66 		$950.86
$1,043.72
$1,142.08
$1,491.48 		$1,213.94
$1,306.80
$1,405.16
$1,754.56 		$1,477.02
$1,569.88
$1,668.24
$2,017.64 		$263.08
Toc - Plan #136 Cigna Healthcare
Expanded Bronze

(EPO) Cigna Simple Choice 7500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.39
$406.77
$458.02
$640.08
$972.67 		$632.56
$680.94
$732.19
$914.25 		$906.73
$955.11
$1,006.36
$1,188.42 		$1,180.90
$1,229.28
$1,280.53
$1,462.59 		$274.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$716.78
$813.54
$916.04
$1,280.16
$1,945.34 		$990.95
$1,087.71
$1,190.21
$1,554.33 		$1,265.12
$1,361.88
$1,464.38
$1,828.50 		$1,539.29
$1,636.05
$1,738.55
$2,102.67 		$274.17
Toc - Plan #137 Cigna Healthcare
Silver

(EPO) Cigna Simple Choice 5800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.73
$462.77
$521.08
$728.21
$1,106.58 		$719.64
$774.68
$832.99
$1,040.12 		$1,031.55
$1,086.59
$1,144.90
$1,352.03 		$1,343.46
$1,398.50
$1,456.81
$1,663.94 		$311.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$815.46
$925.54
$1,042.16
$1,456.42
$2,213.16 		$1,127.37
$1,237.45
$1,354.07
$1,768.33 		$1,439.28
$1,549.36
$1,665.98
$2,080.24 		$1,751.19
$1,861.27
$1,977.89
$2,392.15 		$311.91
Toc - Plan #138 Cigna Healthcare
Gold

(EPO) Cigna Simple Choice 2000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$595.78
$676.21
$761.41
$1,064.06
$1,616.95 		$1,051.55
$1,131.98
$1,217.18
$1,519.83 		$1,507.32
$1,587.75
$1,672.95
$1,975.60 		$1,963.09
$2,043.52
$2,128.72
$2,431.37 		$455.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,191.56
$1,352.42
$1,522.82
$2,128.12
$3,233.90 		$1,647.33
$1,808.19
$1,978.59
$2,583.89 		$2,103.10
$2,263.96
$2,434.36
$3,039.66 		$2,558.87
$2,719.73
$2,890.13
$3,495.43 		$455.77

‡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 Wilson County here.

Wilson County is in “Rating Area 4” of Tennessee.

Currently, there are 138 plans offered in Rating Area 4.

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2023 Obamacare Plans for Wilson County, TN

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