Obamacare 2023 Rates for Louisa County

Obamacare > Rates > Virginia > Louisa 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 Louisa County, VA.

The health insurance rates listed below are for calendar year 2023.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 75 Plans and 2023 Rates for Louisa County, Virginia

Below, you’ll find a summary of the 75 plans for Louisa County, Virginia 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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Louisa County Resources

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Optima Health Plan

Local: 1-866-946-6034 | Toll Free: 1-866-946-6034 | TTY: 1-800-828-1140
Toc - Plan #1 Optima Health Plan
Expanded Bronze

(HMO) OptimaFit Bronze 6250 20% HSA Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$6,250 $12,500 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 		$267.27
$303.35
$341.57
$477.34
$725.36 		$471.73
$507.81
$546.03
$681.80 		$676.19
$712.27
$750.49
$886.26 		$880.65
$916.73
$954.95
$1,090.72 		$204.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$534.54
$606.70
$683.14
$954.68
$1,450.72 		$739.00
$811.16
$887.60
$1,159.14 		$943.46
$1,015.62
$1,092.06
$1,363.60 		$1,147.92
$1,220.08
$1,296.52
$1,568.06 		$204.46
Toc - Plan #2 Optima Health Plan
Gold

(HMO) OptimaFit Gold 1300 20% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$1,300 $2,600 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 		$319.81
$362.98
$408.71
$571.17
$867.95 		$564.46
$607.63
$653.36
$815.82 		$809.11
$852.28
$898.01
$1,060.47 		$1,053.76
$1,096.93
$1,142.66
$1,305.12 		$244.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.62
$725.96
$817.42
$1,142.34
$1,735.90 		$884.27
$970.61
$1,062.07
$1,386.99 		$1,128.92
$1,215.26
$1,306.72
$1,631.64 		$1,373.57
$1,459.91
$1,551.37
$1,876.29 		$244.65
Toc - Plan #3 Optima Health Plan
Expanded Bronze

(HMO) OptimaFit Bronze 7200 40% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$244.26
$277.24
$312.16
$436.25
$662.92 		$431.12
$464.10
$499.02
$623.11 		$617.98
$650.96
$685.88
$809.97 		$804.84
$837.82
$872.74
$996.83 		$186.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$488.52
$554.48
$624.32
$872.50
$1,325.84 		$675.38
$741.34
$811.18
$1,059.36 		$862.24
$928.20
$998.04
$1,246.22 		$1,049.10
$1,115.06
$1,184.90
$1,433.08 		$186.86
Toc - Plan #4 Optima Health Plan
Silver

(HMO) OptimaFit Silver 3800 25% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

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 		$322.27
$365.78
$411.86
$575.58
$874.65 		$568.81
$612.32
$658.40
$822.12 		$815.35
$858.86
$904.94
$1,068.66 		$1,061.89
$1,105.40
$1,151.48
$1,315.20 		$246.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.54
$731.56
$823.72
$1,151.16
$1,749.30 		$891.08
$978.10
$1,070.26
$1,397.70 		$1,137.62
$1,224.64
$1,316.80
$1,644.24 		$1,384.16
$1,471.18
$1,563.34
$1,890.78 		$246.54
Toc - Plan #5 Optima Health Plan
Silver

(HMO) OptimaFit Silver 6600 30% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$6,600 $13,200 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 		$315.71
$358.34
$403.48
$563.87
$856.85 		$557.23
$599.86
$645.00
$805.39 		$798.75
$841.38
$886.52
$1,046.91 		$1,040.27
$1,082.90
$1,128.04
$1,288.43 		$241.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$631.42
$716.68
$806.96
$1,127.74
$1,713.70 		$872.94
$958.20
$1,048.48
$1,369.26 		$1,114.46
$1,199.72
$1,290.00
$1,610.78 		$1,355.98
$1,441.24
$1,531.52
$1,852.30 		$241.52
Toc - Plan #6 Optima Health Plan
Gold

(HMO) OptimaFit Gold 2200 20% Direct M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$6,000 $12,000 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 		$324.05
$367.80
$414.14
$578.76
$879.48 		$571.95
$615.70
$662.04
$826.66 		$819.85
$863.60
$909.94
$1,074.56 		$1,067.75
$1,111.50
$1,157.84
$1,322.46 		$247.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.10
$735.60
$828.28
$1,157.52
$1,758.96 		$896.00
$983.50
$1,076.18
$1,405.42 		$1,143.90
$1,231.40
$1,324.08
$1,653.32 		$1,391.80
$1,479.30
$1,571.98
$1,901.22 		$247.90
Toc - Plan #7 Optima Health Plan
Gold

(HMO) OptimaFit Gold 2000 25% Standard M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

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 		$323.93
$367.66
$413.98
$578.54
$879.14 		$571.73
$615.46
$661.78
$826.34 		$819.53
$863.26
$909.58
$1,074.14 		$1,067.33
$1,111.06
$1,157.38
$1,321.94 		$247.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.86
$735.32
$827.96
$1,157.08
$1,758.28 		$895.66
$983.12
$1,075.76
$1,404.88 		$1,143.46
$1,230.92
$1,323.56
$1,652.68 		$1,391.26
$1,478.72
$1,571.36
$1,900.48 		$247.80
Toc - Plan #8 Optima Health Plan
Silver

(HMO) OptimaFit Silver 5800 40% Standard M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

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 		$316.53
$359.26
$404.52
$565.32
$859.05 		$558.67
$601.40
$646.66
$807.46 		$800.81
$843.54
$888.80
$1,049.60 		$1,042.95
$1,085.68
$1,130.94
$1,291.74 		$242.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$633.06
$718.52
$809.04
$1,130.64
$1,718.10 		$875.20
$960.66
$1,051.18
$1,372.78 		$1,117.34
$1,202.80
$1,293.32
$1,614.92 		$1,359.48
$1,444.94
$1,535.46
$1,857.06 		$242.14
Toc - Plan #9 Optima Health Plan
Bronze

(HMO) OptimaFit Bronze 9100 0% Standard M

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-946-6034

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 		$250.87
$284.74
$320.61
$448.05
$680.86 		$442.79
$476.66
$512.53
$639.97 		$634.71
$668.58
$704.45
$831.89 		$826.63
$860.50
$896.37
$1,023.81 		$191.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$501.74
$569.48
$641.22
$896.10
$1,361.72 		$693.66
$761.40
$833.14
$1,088.02 		$885.58
$953.32
$1,025.06
$1,279.94 		$1,077.50
$1,145.24
$1,216.98
$1,471.86 		$191.92

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UnitedHealthcare

Local: 1-877-265-9199 | Toll Free: 1-877-265-9199 | TTY: 1-877-265-9199
Toc - Plan #10 UnitedHealthcare
Silver

(HMO) UHC Silver Value $2,950 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$2,950 $5,900 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 		$318.96
$362.02
$407.63
$569.66
$865.66 		$562.96
$606.02
$651.63
$813.66 		$806.96
$850.02
$895.63
$1,057.66 		$1,050.96
$1,094.02
$1,139.63
$1,301.66 		$244.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$637.92
$724.04
$815.26
$1,139.32
$1,731.32 		$881.92
$968.04
$1,059.26
$1,383.32 		$1,125.92
$1,212.04
$1,303.26
$1,627.32 		$1,369.92
$1,456.04
$1,547.26
$1,871.32 		$244.00
Toc - Plan #11 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $6,500 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$248.05
$281.53
$317.00
$443.01
$673.19 		$437.80
$471.28
$506.75
$632.76 		$627.55
$661.03
$696.50
$822.51 		$817.30
$850.78
$886.25
$1,012.26 		$189.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$496.10
$563.06
$634.00
$886.02
$1,346.38 		$685.85
$752.81
$823.75
$1,075.77 		$875.60
$942.56
$1,013.50
$1,265.52 		$1,065.35
$1,132.31
$1,203.25
$1,455.27 		$189.75
Toc - Plan #12 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,600 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 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 		$307.68
$349.21
$393.21
$549.51
$835.03 		$543.05
$584.58
$628.58
$784.88 		$778.42
$819.95
$863.95
$1,020.25 		$1,013.79
$1,055.32
$1,099.32
$1,255.62 		$235.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.36
$698.42
$786.42
$1,099.02
$1,670.06 		$850.73
$933.79
$1,021.79
$1,334.39 		$1,086.10
$1,169.16
$1,257.16
$1,569.76 		$1,321.47
$1,404.53
$1,492.53
$1,805.13 		$235.37
Toc - Plan #13 UnitedHealthcare
Gold

(HMO) UHC Gold Value $1,800 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.00
$340.50
$383.40
$535.80
$814.20 		$529.50
$570.00
$612.90
$765.30 		$759.00
$799.50
$842.40
$994.80 		$988.50
$1,029.00
$1,071.90
$1,224.30 		$229.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.00
$681.00
$766.80
$1,071.60
$1,628.40 		$829.50
$910.50
$996.30
$1,301.10 		$1,059.00
$1,140.00
$1,225.80
$1,530.60 		$1,288.50
$1,369.50
$1,455.30
$1,760.10 		$229.50
Toc - Plan #14 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $2 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$328.63
$372.99
$419.98
$586.93
$891.89 		$580.03
$624.39
$671.38
$838.33 		$831.43
$875.79
$922.78
$1,089.73 		$1,082.83
$1,127.19
$1,174.18
$1,341.13 		$251.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.26
$745.98
$839.96
$1,173.86
$1,783.78 		$908.66
$997.38
$1,091.36
$1,425.26 		$1,160.06
$1,248.78
$1,342.76
$1,676.66 		$1,411.46
$1,500.18
$1,594.16
$1,928.06 		$251.40
Toc - Plan #15 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$304.46
$345.57
$389.10
$543.77
$826.31 		$537.37
$578.48
$622.01
$776.68 		$770.28
$811.39
$854.92
$1,009.59 		$1,003.19
$1,044.30
$1,087.83
$1,242.50 		$232.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.92
$691.14
$778.20
$1,087.54
$1,652.62 		$841.83
$924.05
$1,011.11
$1,320.45 		$1,074.74
$1,156.96
$1,244.02
$1,553.36 		$1,307.65
$1,389.87
$1,476.93
$1,786.27 		$232.91
Toc - Plan #16 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$308.70
$350.38
$394.52
$551.34
$837.82 		$544.86
$586.54
$630.68
$787.50 		$781.02
$822.70
$866.84
$1,023.66 		$1,017.18
$1,058.86
$1,103.00
$1,259.82 		$236.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.40
$700.76
$789.04
$1,102.68
$1,675.64 		$853.56
$936.92
$1,025.20
$1,338.84 		$1,089.72
$1,173.08
$1,261.36
$1,575.00 		$1,325.88
$1,409.24
$1,497.52
$1,811.16 		$236.16
Toc - Plan #17 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$243.10
$275.92
$310.69
$434.18
$659.78 		$429.07
$461.89
$496.66
$620.15 		$615.04
$647.86
$682.63
$806.12 		$801.01
$833.83
$868.60
$992.09 		$185.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.20
$551.84
$621.38
$868.36
$1,319.56 		$672.17
$737.81
$807.35
$1,054.33 		$858.14
$923.78
$993.32
$1,240.30 		$1,044.11
$1,109.75
$1,179.29
$1,426.27 		$185.97
Toc - Plan #18 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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 		$231.72
$263.00
$296.13
$413.84
$628.87 		$408.98
$440.26
$473.39
$591.10 		$586.24
$617.52
$650.65
$768.36 		$763.50
$794.78
$827.91
$945.62 		$177.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$463.44
$526.00
$592.26
$827.68
$1,257.74 		$640.70
$703.26
$769.52
$1,004.94 		$817.96
$880.52
$946.78
$1,182.20 		$995.22
$1,057.78
$1,124.04
$1,359.46 		$177.26
Toc - Plan #19 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$234.29
$265.92
$299.43
$418.45
$635.87 		$413.52
$445.15
$478.66
$597.68 		$592.75
$624.38
$657.89
$776.91 		$771.98
$803.61
$837.12
$956.14 		$179.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$468.58
$531.84
$598.86
$836.90
$1,271.74 		$647.81
$711.07
$778.09
$1,016.13 		$827.04
$890.30
$957.32
$1,195.36 		$1,006.27
$1,069.53
$1,136.55
$1,374.59 		$179.23
Toc - Plan #20 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$241.64
$274.27
$308.82
$431.58
$655.82 		$426.50
$459.13
$493.68
$616.44 		$611.36
$643.99
$678.54
$801.30 		$796.22
$828.85
$863.40
$986.16 		$184.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$483.28
$548.54
$617.64
$863.16
$1,311.64 		$668.14
$733.40
$802.50
$1,048.02 		$853.00
$918.26
$987.36
$1,232.88 		$1,037.86
$1,103.12
$1,172.22
$1,417.74 		$184.86
Toc - Plan #21 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

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 		$228.23
$259.04
$291.68
$407.62
$619.42 		$402.83
$433.64
$466.28
$582.22 		$577.43
$608.24
$640.88
$756.82 		$752.03
$782.84
$815.48
$931.42 		$174.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.46
$518.08
$583.36
$815.24
$1,238.84 		$631.06
$692.68
$757.96
$989.84 		$805.66
$867.28
$932.56
$1,164.44 		$980.26
$1,041.88
$1,107.16
$1,339.04 		$174.60
Toc - Plan #22 UnitedHealthcare
Gold

(HMO) UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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 		$308.07
$349.66
$393.72
$550.22
$836.11 		$543.75
$585.34
$629.40
$785.90 		$779.43
$821.02
$865.08
$1,021.58 		$1,015.11
$1,056.70
$1,100.76
$1,257.26 		$235.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.14
$699.32
$787.44
$1,100.44
$1,672.22 		$851.82
$935.00
$1,023.12
$1,336.12 		$1,087.50
$1,170.68
$1,258.80
$1,571.80 		$1,323.18
$1,406.36
$1,494.48
$1,807.48 		$235.68
Toc - Plan #23 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-265-9199

Annual Out of Pocket Expenses:

Individual Family
$3,600 $7,200 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 		$302.16
$342.95
$386.16
$539.66
$820.06 		$533.31
$574.10
$617.31
$770.81 		$764.46
$805.25
$848.46
$1,001.96 		$995.61
$1,036.40
$1,079.61
$1,233.11 		$231.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.32
$685.90
$772.32
$1,079.32
$1,640.12 		$835.47
$917.05
$1,003.47
$1,310.47 		$1,066.62
$1,148.20
$1,234.62
$1,541.62 		$1,297.77
$1,379.35
$1,465.77
$1,772.77 		$231.15

ADVERTISEMENT

Cigna Health and Life Insurance Company

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #24 Cigna Health and Life Insurance Company
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 		$224.28
$254.55
$286.62
$400.56
$608.68 		$395.85
$426.12
$458.19
$572.13 		$567.42
$597.69
$629.76
$743.70 		$738.99
$769.26
$801.33
$915.27 		$171.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$448.56
$509.10
$573.24
$801.12
$1,217.36 		$620.13
$680.67
$744.81
$972.69 		$791.70
$852.24
$916.38
$1,144.26 		$963.27
$1,023.81
$1,087.95
$1,315.83 		$171.57
Toc - Plan #25 Cigna Health and Life Insurance Company
Expanded Bronze

(EPO) Cigna Connect 6750

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

Annual Out of Pocket Expenses:

Individual Family
$6,750 $13,500 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 		$235.60
$267.41
$301.10
$420.79
$639.43 		$415.84
$447.65
$481.34
$601.03 		$596.08
$627.89
$661.58
$781.27 		$776.32
$808.13
$841.82
$961.51 		$180.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$471.20
$534.82
$602.20
$841.58
$1,278.86 		$651.44
$715.06
$782.44
$1,021.82 		$831.68
$895.30
$962.68
$1,202.06 		$1,011.92
$1,075.54
$1,142.92
$1,382.30 		$180.24
Toc - Plan #26 Cigna Health and Life Insurance Company
Silver

(EPO) Cigna Connect 5000 + Acupuncture

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$303.17
$344.10
$387.45
$541.46
$822.80 		$535.09
$576.02
$619.37
$773.38 		$767.01
$807.94
$851.29
$1,005.30 		$998.93
$1,039.86
$1,083.21
$1,237.22 		$231.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.34
$688.20
$774.90
$1,082.92
$1,645.60 		$838.26
$920.12
$1,006.82
$1,314.84 		$1,070.18
$1,152.04
$1,238.74
$1,546.76 		$1,302.10
$1,383.96
$1,470.66
$1,778.68 		$231.92
Toc - Plan #27 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 1600

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

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 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 		$290.29
$329.48
$371.00
$518.46
$787.86 		$512.36
$551.55
$593.07
$740.53 		$734.43
$773.62
$815.14
$962.60 		$956.50
$995.69
$1,037.21
$1,184.67 		$222.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$580.58
$658.96
$742.00
$1,036.92
$1,575.72 		$802.65
$881.03
$964.07
$1,258.99 		$1,024.72
$1,103.10
$1,186.14
$1,481.06 		$1,246.79
$1,325.17
$1,408.21
$1,703.13 		$222.07
Toc - Plan #28 Cigna Health and Life Insurance Company
Silver

(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 		$299.60
$340.05
$382.90
$535.09
$813.13 		$528.80
$569.25
$612.10
$764.29 		$758.00
$798.45
$841.30
$993.49 		$987.20
$1,027.65
$1,070.50
$1,222.69 		$229.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.20
$680.10
$765.80
$1,070.18
$1,626.26 		$828.40
$909.30
$995.00
$1,299.38 		$1,057.60
$1,138.50
$1,224.20
$1,528.58 		$1,286.80
$1,367.70
$1,453.40
$1,757.78 		$229.20
Toc - Plan #29 Cigna Health and Life Insurance Company
Expanded Bronze

(EPO) Cigna Connect 3400

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

Annual Out of Pocket Expenses:

Individual Family
$3,400 $6,800 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 		$234.59
$266.27
$299.81
$418.99
$636.69 		$414.05
$445.73
$479.27
$598.45 		$593.51
$625.19
$658.73
$777.91 		$772.97
$804.65
$838.19
$957.37 		$179.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$469.18
$532.54
$599.62
$837.98
$1,273.38 		$648.64
$712.00
$779.08
$1,017.44 		$828.10
$891.46
$958.54
$1,196.90 		$1,007.56
$1,070.92
$1,138.00
$1,376.36 		$179.46
Toc - Plan #30 Cigna Health and Life Insurance Company
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 		$300.51
$341.08
$384.06
$536.72
$815.59 		$530.40
$570.97
$613.95
$766.61 		$760.29
$800.86
$843.84
$996.50 		$990.18
$1,030.75
$1,073.73
$1,226.39 		$229.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$601.02
$682.16
$768.12
$1,073.44
$1,631.18 		$830.91
$912.05
$998.01
$1,303.33 		$1,060.80
$1,141.94
$1,227.90
$1,533.22 		$1,290.69
$1,371.83
$1,457.79
$1,763.11 		$229.89
Toc - Plan #31 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 1950

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

Annual Out of Pocket Expenses:

Individual Family
$1,950 $3,900 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 		$286.60
$325.29
$366.27
$511.86
$777.82 		$505.85
$544.54
$585.52
$731.11 		$725.10
$763.79
$804.77
$950.36 		$944.35
$983.04
$1,024.02
$1,169.61 		$219.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.20
$650.58
$732.54
$1,023.72
$1,555.64 		$792.45
$869.83
$951.79
$1,242.97 		$1,011.70
$1,089.08
$1,171.04
$1,462.22 		$1,230.95
$1,308.33
$1,390.29
$1,681.47 		$219.25
Toc - Plan #32 Cigna Health and Life Insurance Company
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 		$234.76
$266.46
$300.03
$419.29
$637.15 		$414.35
$446.05
$479.62
$598.88 		$593.94
$625.64
$659.21
$778.47 		$773.53
$805.23
$838.80
$958.06 		$179.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$469.52
$532.92
$600.06
$838.58
$1,274.30 		$649.11
$712.51
$779.65
$1,018.17 		$828.70
$892.10
$959.24
$1,197.76 		$1,008.29
$1,071.69
$1,138.83
$1,377.35 		$179.59
Toc - Plan #33 Cigna Health and Life Insurance Company
Expanded Bronze

(EPO) Cigna Connect HSA 7050

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$235.80
$267.64
$301.36
$421.15
$639.97 		$416.19
$448.03
$481.75
$601.54 		$596.58
$628.42
$662.14
$781.93 		$776.97
$808.81
$842.53
$962.32 		$180.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$471.60
$535.28
$602.72
$842.30
$1,279.94 		$651.99
$715.67
$783.11
$1,022.69 		$832.38
$896.06
$963.50
$1,203.08 		$1,012.77
$1,076.45
$1,143.89
$1,383.47 		$180.39
Toc - Plan #34 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 1900 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.24
$327.16
$368.37
$514.80
$782.29 		$508.75
$547.67
$588.88
$735.31 		$729.26
$768.18
$809.39
$955.82 		$949.77
$988.69
$1,029.90
$1,176.33 		$220.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.48
$654.32
$736.74
$1,029.60
$1,564.58 		$796.99
$874.83
$957.25
$1,250.11 		$1,017.50
$1,095.34
$1,177.76
$1,470.62 		$1,238.01
$1,315.85
$1,398.27
$1,691.13 		$220.51
Toc - Plan #35 Cigna Health and Life Insurance Company
Silver

(EPO) Cigna Connect 3250

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

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 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 		$294.02
$333.72
$375.76
$525.13
$797.98 		$518.95
$558.65
$600.69
$750.06 		$743.88
$783.58
$825.62
$974.99 		$968.81
$1,008.51
$1,050.55
$1,199.92 		$224.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$588.04
$667.44
$751.52
$1,050.26
$1,595.96 		$812.97
$892.37
$976.45
$1,275.19 		$1,037.90
$1,117.30
$1,201.38
$1,500.12 		$1,262.83
$1,342.23
$1,426.31
$1,725.05 		$224.93
Toc - Plan #36 Cigna Health and Life Insurance Company
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 		$301.62
$342.34
$385.47
$538.70
$818.60 		$532.36
$573.08
$616.21
$769.44 		$763.10
$803.82
$846.95
$1,000.18 		$993.84
$1,034.56
$1,077.69
$1,230.92 		$230.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.24
$684.68
$770.94
$1,077.40
$1,637.20 		$833.98
$915.42
$1,001.68
$1,308.14 		$1,064.72
$1,146.16
$1,232.42
$1,538.88 		$1,295.46
$1,376.90
$1,463.16
$1,769.62 		$230.74
Toc - Plan #37 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 2300

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

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287.10
$325.86
$366.91
$512.76
$779.19 		$506.73
$545.49
$586.54
$732.39 		$726.36
$765.12
$806.17
$952.02 		$945.99
$984.75
$1,025.80
$1,171.65 		$219.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.20
$651.72
$733.82
$1,025.52
$1,558.38 		$793.83
$871.35
$953.45
$1,245.15 		$1,013.46
$1,090.98
$1,173.08
$1,464.78 		$1,233.09
$1,310.61
$1,392.71
$1,684.41 		$219.63
Toc - Plan #38 Cigna Health and Life Insurance Company
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 		$286.16
$324.79
$365.71
$511.08
$776.64 		$505.07
$543.70
$584.62
$729.99 		$723.98
$762.61
$803.53
$948.90 		$942.89
$981.52
$1,022.44
$1,167.81 		$218.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.32
$649.58
$731.42
$1,022.16
$1,553.28 		$791.23
$868.49
$950.33
$1,241.07 		$1,010.14
$1,087.40
$1,169.24
$1,459.98 		$1,229.05
$1,306.31
$1,388.15
$1,678.89 		$218.91
Toc - Plan #39 Cigna Health and Life Insurance Company
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 		$299.64
$340.09
$382.94
$535.15
$813.22 		$528.86
$569.31
$612.16
$764.37 		$758.08
$798.53
$841.38
$993.59 		$987.30
$1,027.75
$1,070.60
$1,222.81 		$229.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.28
$680.18
$765.88
$1,070.30
$1,626.44 		$828.50
$909.40
$995.10
$1,299.52 		$1,057.72
$1,138.62
$1,224.32
$1,528.74 		$1,286.94
$1,367.84
$1,453.54
$1,757.96 		$229.22
Toc - Plan #40 Cigna Health and Life Insurance Company
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 		$223.77
$253.98
$285.98
$399.65
$607.31 		$394.95
$425.16
$457.16
$570.83 		$566.13
$596.34
$628.34
$742.01 		$737.31
$767.52
$799.52
$913.19 		$171.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447.54
$507.96
$571.96
$799.30
$1,214.62 		$618.72
$679.14
$743.14
$970.48 		$789.90
$850.32
$914.32
$1,141.66 		$961.08
$1,021.50
$1,085.50
$1,312.84 		$171.18
Toc - Plan #41 Cigna Health and Life Insurance Company
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 		$232.61
$264.01
$297.28
$415.44
$631.31 		$410.56
$441.96
$475.23
$593.39 		$588.51
$619.91
$653.18
$771.34 		$766.46
$797.86
$831.13
$949.29 		$177.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$465.22
$528.02
$594.56
$830.88
$1,262.62 		$643.17
$705.97
$772.51
$1,008.83 		$821.12
$883.92
$950.46
$1,186.78 		$999.07
$1,061.87
$1,128.41
$1,364.73 		$177.95
Toc - Plan #42 Cigna Health and Life Insurance Company
Expanded Bronze

(EPO) Cigna Connect 0

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 		$252.14
$286.18
$322.24
$450.32
$684.31 		$445.03
$479.07
$515.13
$643.21 		$637.92
$671.96
$708.02
$836.10 		$830.81
$864.85
$900.91
$1,028.99 		$192.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.28
$572.36
$644.48
$900.64
$1,368.62 		$697.17
$765.25
$837.37
$1,093.53 		$890.06
$958.14
$1,030.26
$1,286.42 		$1,082.95
$1,151.03
$1,223.15
$1,479.31 		$192.89
Toc - Plan #43 Cigna Health and Life Insurance Company
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 		$234.36
$266.00
$299.51
$418.57
$636.05 		$413.64
$445.28
$478.79
$597.85 		$592.92
$624.56
$658.07
$777.13 		$772.20
$803.84
$837.35
$956.41 		$179.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$468.72
$532.00
$599.02
$837.14
$1,272.10 		$648.00
$711.28
$778.30
$1,016.42 		$827.28
$890.56
$957.58
$1,195.70 		$1,006.56
$1,069.84
$1,136.86
$1,374.98 		$179.28
Toc - Plan #44 Cigna Health and Life Insurance Company
Gold

(EPO) Cigna Connect 2100 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286.26
$324.91
$365.84
$511.26
$776.91 		$505.25
$543.90
$584.83
$730.25 		$724.24
$762.89
$803.82
$949.24 		$943.23
$981.88
$1,022.81
$1,168.23 		$218.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.52
$649.82
$731.68
$1,022.52
$1,553.82 		$791.51
$868.81
$950.67
$1,241.51 		$1,010.50
$1,087.80
$1,169.66
$1,460.50 		$1,229.49
$1,306.79
$1,388.65
$1,679.49 		$218.99

ADVERTISEMENT

HealthKeepers, Inc.

Local: 1-855-748-1810 | Toll Free: 1-855-748-1810

Toc - Plan #45 HealthKeepers, Inc.
Catastrophic

(HMO) Anthem HealthKeepers Catastrophic X 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$184.55
$209.46
$235.85
$329.61
$500.87 		$325.73
$350.64
$377.03
$470.79 		$466.91
$491.82
$518.21
$611.97 		$608.09
$633.00
$659.39
$753.15 		$141.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$369.10
$418.92
$471.70
$659.22
$1,001.74 		$510.28
$560.10
$612.88
$800.40 		$651.46
$701.28
$754.06
$941.58 		$792.64
$842.46
$895.24
$1,082.76 		$141.18
Toc - Plan #46 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$244.98
$278.05
$313.08
$437.53
$664.88 		$432.39
$465.46
$500.49
$624.94 		$619.80
$652.87
$687.90
$812.35 		$807.21
$840.28
$875.31
$999.76 		$187.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$489.96
$556.10
$626.16
$875.06
$1,329.76 		$677.37
$743.51
$813.57
$1,062.47 		$864.78
$930.92
$1,000.98
$1,249.88 		$1,052.19
$1,118.33
$1,188.39
$1,437.29 		$187.41
Toc - Plan #47 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 5900 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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 		$247.85
$281.31
$316.75
$442.66
$672.66 		$437.46
$470.92
$506.36
$632.27 		$627.07
$660.53
$695.97
$821.88 		$816.68
$850.14
$885.58
$1,011.49 		$189.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$495.70
$562.62
$633.50
$885.32
$1,345.32 		$685.31
$752.23
$823.11
$1,074.93 		$874.92
$941.84
$1,012.72
$1,264.54 		$1,064.53
$1,131.45
$1,202.33
$1,454.15 		$189.61
Toc - Plan #48 HealthKeepers, Inc.
Bronze

(HMO) Anthem HealthKeepers Bronze X 8200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 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 		$234.36
$266.00
$299.51
$418.57
$636.05 		$413.65
$445.29
$478.80
$597.86 		$592.94
$624.58
$658.09
$777.15 		$772.23
$803.87
$837.38
$956.44 		$179.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$468.72
$532.00
$599.02
$837.14
$1,272.10 		$648.01
$711.29
$778.31
$1,016.43 		$827.30
$890.58
$957.60
$1,195.72 		$1,006.59
$1,069.87
$1,136.89
$1,375.01 		$179.29
Toc - Plan #49 HealthKeepers, Inc.
Gold

(HMO) Anthem HealthKeepers Gold X 1800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$1,800 $5,400 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 		$310.60
$352.53
$396.95
$554.73
$842.97 		$548.21
$590.14
$634.56
$792.34 		$785.82
$827.75
$872.17
$1,029.95 		$1,023.43
$1,065.36
$1,109.78
$1,267.56 		$237.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.20
$705.06
$793.90
$1,109.46
$1,685.94 		$858.81
$942.67
$1,031.51
$1,347.07 		$1,096.42
$1,180.28
$1,269.12
$1,584.68 		$1,334.03
$1,417.89
$1,506.73
$1,822.29 		$237.61
Toc - Plan #50 HealthKeepers, Inc.
Silver

(HMO) Anthem HealthKeepers Silver X 2400

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$2,400 $4,800 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 		$314.69
$357.17
$402.17
$562.04
$854.07 		$555.43
$597.91
$642.91
$802.78 		$796.17
$838.65
$883.65
$1,043.52 		$1,036.91
$1,079.39
$1,124.39
$1,284.26 		$240.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.38
$714.34
$804.34
$1,124.08
$1,708.14 		$870.12
$955.08
$1,045.08
$1,364.82 		$1,110.86
$1,195.82
$1,285.82
$1,605.56 		$1,351.60
$1,436.56
$1,526.56
$1,846.30 		$240.74
Toc - Plan #51 HealthKeepers, Inc.
Silver

(HMO) Anthem HealthKeepers Silver X 5000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$304.24
$345.31
$388.82
$543.37
$825.71 		$536.98
$578.05
$621.56
$776.11 		$769.72
$810.79
$854.30
$1,008.85 		$1,002.46
$1,043.53
$1,087.04
$1,241.59 		$232.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$608.48
$690.62
$777.64
$1,086.74
$1,651.42 		$841.22
$923.36
$1,010.38
$1,319.48 		$1,073.96
$1,156.10
$1,243.12
$1,552.22 		$1,306.70
$1,388.84
$1,475.86
$1,784.96 		$232.74
Toc - Plan #52 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 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 		$252.08
$286.11
$322.16
$450.21
$684.15 		$444.92
$478.95
$515.00
$643.05 		$637.76
$671.79
$707.84
$835.89 		$830.60
$864.63
$900.68
$1,028.73 		$192.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.16
$572.22
$644.32
$900.42
$1,368.30 		$697.00
$765.06
$837.16
$1,093.26 		$889.84
$957.90
$1,030.00
$1,286.10 		$1,082.68
$1,150.74
$1,222.84
$1,478.94 		$192.84
Toc - Plan #53 HealthKeepers, Inc.
Silver

(HMO) Anthem HealthKeepers Silver X 4200

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$305.86
$347.15
$390.89
$546.27
$830.10 		$539.84
$581.13
$624.87
$780.25 		$773.82
$815.11
$858.85
$1,014.23 		$1,007.80
$1,049.09
$1,092.83
$1,248.21 		$233.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.72
$694.30
$781.78
$1,092.54
$1,660.20 		$845.70
$928.28
$1,015.76
$1,326.52 		$1,079.68
$1,162.26
$1,249.74
$1,560.50 		$1,313.66
$1,396.24
$1,483.72
$1,794.48 		$233.98
Toc - Plan #54 HealthKeepers, Inc.
Gold

(HMO) Anthem HealthKeepers Gold X 1500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

Annual Out of Pocket Expenses:

Individual Family
$1,500 $4,500 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 		$309.67
$351.48
$395.76
$553.07
$840.44 		$546.57
$588.38
$632.66
$789.97 		$783.47
$825.28
$869.56
$1,026.87 		$1,020.37
$1,062.18
$1,106.46
$1,263.77 		$236.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.34
$702.96
$791.52
$1,106.14
$1,680.88 		$856.24
$939.86
$1,028.42
$1,343.04 		$1,093.14
$1,176.76
$1,265.32
$1,579.94 		$1,330.04
$1,413.66
$1,502.22
$1,816.84 		$236.90
Toc - Plan #55 HealthKeepers, Inc.
Expanded Bronze

(HMO) Anthem HealthKeepers Bronze X 7500 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$257.28
$292.01
$328.80
$459.50
$698.26 		$454.10
$488.83
$525.62
$656.32 		$650.92
$685.65
$722.44
$853.14 		$847.74
$882.47
$919.26
$1,049.96 		$196.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514.56
$584.02
$657.60
$919.00
$1,396.52 		$711.38
$780.84
$854.42
$1,115.82 		$908.20
$977.66
$1,051.24
$1,312.64 		$1,105.02
$1,174.48
$1,248.06
$1,509.46 		$196.82
Toc - Plan #56 HealthKeepers, Inc.
Bronze

(HMO) Anthem HealthKeepers Bronze X 9100 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$235.98
$267.84
$301.58
$421.46
$640.45 		$416.50
$448.36
$482.10
$601.98 		$597.02
$628.88
$662.62
$782.50 		$777.54
$809.40
$843.14
$963.02 		$180.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$471.96
$535.68
$603.16
$842.92
$1,280.90 		$652.48
$716.20
$783.68
$1,023.44 		$833.00
$896.72
$964.20
$1,203.96 		$1,013.52
$1,077.24
$1,144.72
$1,384.48 		$180.52
Toc - Plan #57 HealthKeepers, Inc.
Silver

(HMO) Anthem HealthKeepers Silver X 5800 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$306.54
$347.92
$391.76
$547.48
$831.95 		$541.04
$582.42
$626.26
$781.98 		$775.54
$816.92
$860.76
$1,016.48 		$1,010.04
$1,051.42
$1,095.26
$1,250.98 		$234.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$613.08
$695.84
$783.52
$1,094.96
$1,663.90 		$847.58
$930.34
$1,018.02
$1,329.46 		$1,082.08
$1,164.84
$1,252.52
$1,563.96 		$1,316.58
$1,399.34
$1,487.02
$1,798.46 		$234.50
Toc - Plan #58 HealthKeepers, Inc.
Gold

(HMO) Anthem HealthKeepers Gold X 2000 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1810

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 		$319.09
$362.17
$407.80
$569.89
$866.01 		$563.19
$606.27
$651.90
$813.99 		$807.29
$850.37
$896.00
$1,058.09 		$1,051.39
$1,094.47
$1,140.10
$1,302.19 		$244.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.18
$724.34
$815.60
$1,139.78
$1,732.02 		$882.28
$968.44
$1,059.70
$1,383.88 		$1,126.38
$1,212.54
$1,303.80
$1,627.98 		$1,370.48
$1,456.64
$1,547.90
$1,872.08 		$244.10

ADVERTISEMENT

Kaiser Permanente

Local: 1-800-807-1140 | Toll Free: 1-800-807-1140 | TTY: 1-703-359-7616
Toc - Plan #59 Kaiser Permanente
Gold

(HMO) KP VA Gold 0/20/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.49
$372.84
$419.81
$586.68
$891.52 		$579.78
$624.13
$671.10
$837.97 		$831.07
$875.42
$922.39
$1,089.26 		$1,082.36
$1,126.71
$1,173.68
$1,340.55 		$251.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.98
$745.68
$839.62
$1,173.36
$1,783.04 		$908.27
$996.97
$1,090.91
$1,424.65 		$1,159.56
$1,248.26
$1,342.20
$1,675.94 		$1,410.85
$1,499.55
$1,593.49
$1,927.23 		$251.29
Toc - Plan #60 Kaiser Permanente
Silver

(HMO) KP VA Silver 2500/35/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$330.24
$374.82
$422.05
$589.81
$896.27 		$582.87
$627.45
$674.68
$842.44 		$835.50
$880.08
$927.31
$1,095.07 		$1,088.13
$1,132.71
$1,179.94
$1,347.70 		$252.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.48
$749.64
$844.10
$1,179.62
$1,792.54 		$913.11
$1,002.27
$1,096.73
$1,432.25 		$1,165.74
$1,254.90
$1,349.36
$1,684.88 		$1,418.37
$1,507.53
$1,601.99
$1,937.51 		$252.63
Toc - Plan #61 Kaiser Permanente
Expanded Bronze

(HMO) KP VA Bronze 6000/55/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$238.82
$271.06
$305.21
$426.53
$648.16 		$421.52
$453.76
$487.91
$609.23 		$604.22
$636.46
$670.61
$791.93 		$786.92
$819.16
$853.31
$974.63 		$182.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$477.64
$542.12
$610.42
$853.06
$1,296.32 		$660.34
$724.82
$793.12
$1,035.76 		$843.04
$907.52
$975.82
$1,218.46 		$1,025.74
$1,090.22
$1,158.52
$1,401.16 		$182.70
Toc - Plan #62 Kaiser Permanente
Catastrophic

(HMO) KP VA Catastrophic 9100/0/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$150.51
$170.83
$192.35
$268.81
$408.48 		$265.65
$285.97
$307.49
$383.95 		$380.79
$401.11
$422.63
$499.09 		$495.93
$516.25
$537.77
$614.23 		$115.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$301.02
$341.66
$384.70
$537.62
$816.96 		$416.16
$456.80
$499.84
$652.76 		$531.30
$571.94
$614.98
$767.90 		$646.44
$687.08
$730.12
$883.04 		$115.14
Toc - Plan #63 Kaiser Permanente
Platinum

(HMO) KP VA Platinum 0/15/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,900 $7,800 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 		$368.51
$418.26
$470.96
$658.16
$1,000.14 		$650.42
$700.17
$752.87
$940.07 		$932.33
$982.08
$1,034.78
$1,221.98 		$1,214.24
$1,263.99
$1,316.69
$1,503.89 		$281.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.02
$836.52
$941.92
$1,316.32
$2,000.28 		$1,018.93
$1,118.43
$1,223.83
$1,598.23 		$1,300.84
$1,400.34
$1,505.74
$1,880.14 		$1,582.75
$1,682.25
$1,787.65
$2,162.05 		$281.91
Toc - Plan #64 Kaiser Permanente
Silver

(HMO) KP VA Silver 5000/40/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.49
$362.62
$408.31
$570.61
$867.10 		$563.90
$607.03
$652.72
$815.02 		$808.31
$851.44
$897.13
$1,059.43 		$1,052.72
$1,095.85
$1,141.54
$1,303.84 		$244.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$638.98
$725.24
$816.62
$1,141.22
$1,734.20 		$883.39
$969.65
$1,061.03
$1,385.63 		$1,127.80
$1,214.06
$1,305.44
$1,630.04 		$1,372.21
$1,458.47
$1,549.85
$1,874.45 		$244.41
Toc - Plan #65 Kaiser Permanente
Gold

(HMO) KP VA Gold 1250/20/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 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 		$301.93
$342.69
$385.87
$539.25
$819.44 		$532.91
$573.67
$616.85
$770.23 		$763.89
$804.65
$847.83
$1,001.21 		$994.87
$1,035.63
$1,078.81
$1,232.19 		$230.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.86
$685.38
$771.74
$1,078.50
$1,638.88 		$834.84
$916.36
$1,002.72
$1,309.48 		$1,065.82
$1,147.34
$1,233.70
$1,540.46 		$1,296.80
$1,378.32
$1,464.68
$1,771.44 		$230.98
Toc - Plan #66 Kaiser Permanente
Gold

(HMO) KP VA Gold 1700/25/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$1,700 $3,400 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287.77
$326.62
$367.77
$513.96
$781.01 		$507.91
$546.76
$587.91
$734.10 		$728.05
$766.90
$808.05
$954.24 		$948.19
$987.04
$1,028.19
$1,174.38 		$220.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.54
$653.24
$735.54
$1,027.92
$1,562.02 		$795.68
$873.38
$955.68
$1,248.06 		$1,015.82
$1,093.52
$1,175.82
$1,468.20 		$1,235.96
$1,313.66
$1,395.96
$1,688.34 		$220.14
Toc - Plan #67 Kaiser Permanente
Silver

(HMO) KP VA Silver 6000/40/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.06
$343.97
$387.31
$541.27
$822.50 		$534.90
$575.81
$619.15
$773.11 		$766.74
$807.65
$850.99
$1,004.95 		$998.58
$1,039.49
$1,082.83
$1,236.79 		$231.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.12
$687.94
$774.62
$1,082.54
$1,645.00 		$837.96
$919.78
$1,006.46
$1,314.38 		$1,069.80
$1,151.62
$1,238.30
$1,546.22 		$1,301.64
$1,383.46
$1,470.14
$1,778.06 		$231.84
Toc - Plan #68 Kaiser Permanente
Bronze

(HMO) KP VA Bronze 7500/40%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$221.04
$250.88
$282.49
$394.78
$599.90 		$390.14
$419.98
$451.59
$563.88 		$559.24
$589.08
$620.69
$732.98 		$728.34
$758.18
$789.79
$902.08 		$169.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$442.08
$501.76
$564.98
$789.56
$1,199.80 		$611.18
$670.86
$734.08
$958.66 		$780.28
$839.96
$903.18
$1,127.76 		$949.38
$1,009.06
$1,072.28
$1,296.86 		$169.10
Toc - Plan #69 Kaiser Permanente
Expanded Bronze

(HMO) KP VA Bronze 6900/0%/HSA/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$228.10
$258.89
$291.51
$407.39
$619.06 		$402.60
$433.39
$466.01
$581.89 		$577.10
$607.89
$640.51
$756.39 		$751.60
$782.39
$815.01
$930.89 		$174.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.20
$517.78
$583.02
$814.78
$1,238.12 		$630.70
$692.28
$757.52
$989.28 		$805.20
$866.78
$932.02
$1,163.78 		$979.70
$1,041.28
$1,106.52
$1,338.28 		$174.50
Toc - Plan #70 Kaiser Permanente
Gold

(HMO) KP VA Gold Virtual Forward 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$293.38
$332.99
$374.94
$523.98
$796.23 		$517.82
$557.43
$599.38
$748.42 		$742.26
$781.87
$823.82
$972.86 		$966.70
$1,006.31
$1,048.26
$1,197.30 		$224.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.76
$665.98
$749.88
$1,047.96
$1,592.46 		$811.20
$890.42
$974.32
$1,272.40 		$1,035.64
$1,114.86
$1,198.76
$1,496.84 		$1,260.08
$1,339.30
$1,423.20
$1,721.28 		$224.44
Toc - Plan #71 Kaiser Permanente
Silver

(HMO) KP VA Silver Virtual Forward 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$286.83
$325.55
$366.57
$512.28
$778.46 		$506.25
$544.97
$585.99
$731.70 		$725.67
$764.39
$805.41
$951.12 		$945.09
$983.81
$1,024.83
$1,170.54 		$219.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.66
$651.10
$733.14
$1,024.56
$1,556.92 		$793.08
$870.52
$952.56
$1,243.98 		$1,012.50
$1,089.94
$1,171.98
$1,463.40 		$1,231.92
$1,309.36
$1,391.40
$1,682.82 		$219.42
Toc - Plan #72 Kaiser Permanente
Platinum

(HMO) KP VA Standard Platinum 0/10/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 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 		$378.56
$429.67
$483.80
$676.11
$1,027.41 		$668.16
$719.27
$773.40
$965.71 		$957.76
$1,008.87
$1,063.00
$1,255.31 		$1,247.36
$1,298.47
$1,352.60
$1,544.91 		$289.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.12
$859.34
$967.60
$1,352.22
$2,054.82 		$1,046.72
$1,148.94
$1,257.20
$1,641.82 		$1,336.32
$1,438.54
$1,546.80
$1,931.42 		$1,625.92
$1,728.14
$1,836.40
$2,221.02 		$289.60
Toc - Plan #73 Kaiser Permanente
Gold

(HMO) KP VA Standard Gold 2000/30/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$292.69
$332.20
$374.06
$522.74
$794.36 		$516.60
$556.11
$597.97
$746.65 		$740.51
$780.02
$821.88
$970.56 		$964.42
$1,003.93
$1,045.79
$1,194.47 		$223.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.38
$664.40
$748.12
$1,045.48
$1,588.72 		$809.29
$888.31
$972.03
$1,269.39 		$1,033.20
$1,112.22
$1,195.94
$1,493.30 		$1,257.11
$1,336.13
$1,419.85
$1,717.21 		$223.91
Toc - Plan #74 Kaiser Permanente
Silver

(HMO) KP VA Standard Silver 5800/40/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$305.06
$346.24
$389.87
$544.84
$827.93 		$538.43
$579.61
$623.24
$778.21 		$771.80
$812.98
$856.61
$1,011.58 		$1,005.17
$1,046.35
$1,089.98
$1,244.95 		$233.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.12
$692.48
$779.74
$1,089.68
$1,655.86 		$843.49
$925.85
$1,013.11
$1,323.05 		$1,076.86
$1,159.22
$1,246.48
$1,556.42 		$1,310.23
$1,392.59
$1,479.85
$1,789.79 		$233.37
Toc - Plan #75 Kaiser Permanente
Expanded Bronze

(HMO) KP VA Standard Expanded Bronze 7500/50/Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-807-1140

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 		$249.76
$283.48
$319.19
$446.07
$677.85 		$440.83
$474.55
$510.26
$637.14 		$631.90
$665.62
$701.33
$828.21 		$822.97
$856.69
$892.40
$1,019.28 		$191.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$499.52
$566.96
$638.38
$892.14
$1,355.70 		$690.59
$758.03
$829.45
$1,083.21 		$881.66
$949.10
$1,020.52
$1,274.28 		$1,072.73
$1,140.17
$1,211.59
$1,465.35 		$191.07

‡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 Louisa County here.

Louisa County is in “Rating Area 2” of Virginia.

Currently, there are 75 plans offered in Rating Area 2.

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2023 Obamacare Plans for Louisa County, VA

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