Obamacare 2023 Rates for Dane County

Obamacare > Rates > Wisconsin > Dane 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 Dane County, WI.

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, 137 Plans and 2023 Rates for Dane County, Wisconsin

Below, you’ll find a summary of the 137 plans for Dane County, Wisconsin and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

Dane County Resources

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Quartz

Local: 1-608-644-3430 | Toll Free: 1-800-362-3310 | TTY: 1-800-877-8973
Toc - Plan #1 Quartz
Gold

(HMO) QUARTZ ONE GOLD I401 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$424.65
$481.98
$542.70
$758.42
$1,152.50 		$749.51
$806.84
$867.56
$1,083.28 		$1,074.37
$1,131.70
$1,192.42
$1,408.14 		$1,399.23
$1,456.56
$1,517.28
$1,733.00 		$324.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.30
$963.96
$1,085.40
$1,516.84
$2,305.00 		$1,174.16
$1,288.82
$1,410.26
$1,841.70 		$1,499.02
$1,613.68
$1,735.12
$2,166.56 		$1,823.88
$1,938.54
$2,059.98
$2,491.42 		$324.86
Toc - Plan #2 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 Maintenance with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$420.67
$477.46
$537.61
$751.31
$1,141.69 		$742.48
$799.27
$859.42
$1,073.12 		$1,064.29
$1,121.08
$1,181.23
$1,394.93 		$1,386.10
$1,442.89
$1,503.04
$1,716.74 		$321.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.34
$954.92
$1,075.22
$1,502.62
$2,283.38 		$1,163.15
$1,276.73
$1,397.03
$1,824.43 		$1,484.96
$1,598.54
$1,718.84
$2,146.24 		$1,806.77
$1,920.35
$2,040.65
$2,468.05 		$321.81
Toc - Plan #3 Quartz
Gold

(HMO) QUARTZ ONE GOLD I405 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$424.17
$481.43
$542.08
$757.56
$1,151.18 		$748.66
$805.92
$866.57
$1,082.05 		$1,073.15
$1,130.41
$1,191.06
$1,406.54 		$1,397.64
$1,454.90
$1,515.55
$1,731.03 		$324.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.34
$962.86
$1,084.16
$1,515.12
$2,302.36 		$1,172.83
$1,287.35
$1,408.65
$1,839.61 		$1,497.32
$1,611.84
$1,733.14
$2,164.10 		$1,821.81
$1,936.33
$2,057.63
$2,488.59 		$324.49
Toc - Plan #4 Quartz
Gold

(HMO) Quartz One Gold I410 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$435.03
$493.76
$555.96
$776.96
$1,180.66 		$767.83
$826.56
$888.76
$1,109.76 		$1,100.63
$1,159.36
$1,221.56
$1,442.56 		$1,433.43
$1,492.16
$1,554.36
$1,775.36 		$332.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.06
$987.52
$1,111.92
$1,553.92
$2,361.32 		$1,202.86
$1,320.32
$1,444.72
$1,886.72 		$1,535.66
$1,653.12
$1,777.52
$2,219.52 		$1,868.46
$1,985.92
$2,110.32
$2,552.32 		$332.80
Toc - Plan #5 Quartz
Silver

(HMO) QUARTZ ONE SILVER I301 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$437.10
$496.10
$558.61
$780.65
$1,186.28 		$771.48
$830.48
$892.99
$1,115.03 		$1,105.86
$1,164.86
$1,227.37
$1,449.41 		$1,440.24
$1,499.24
$1,561.75
$1,783.79 		$334.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.20
$992.20
$1,117.22
$1,561.30
$2,372.56 		$1,208.58
$1,326.58
$1,451.60
$1,895.68 		$1,542.96
$1,660.96
$1,785.98
$2,230.06 		$1,877.34
$1,995.34
$2,120.36
$2,564.44 		$334.38
Toc - Plan #6 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$433.40
$491.90
$553.88
$774.04
$1,176.24 		$764.95
$823.45
$885.43
$1,105.59 		$1,096.50
$1,155.00
$1,216.98
$1,437.14 		$1,428.05
$1,486.55
$1,548.53
$1,768.69 		$331.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.80
$983.80
$1,107.76
$1,548.08
$2,352.48 		$1,198.35
$1,315.35
$1,439.31
$1,879.63 		$1,529.90
$1,646.90
$1,770.86
$2,211.18 		$1,861.45
$1,978.45
$2,102.41
$2,542.73 		$331.55
Toc - Plan #7 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$454.72
$516.10
$581.12
$812.12
$1,234.09 		$802.57
$863.95
$928.97
$1,159.97 		$1,150.42
$1,211.80
$1,276.82
$1,507.82 		$1,498.27
$1,559.65
$1,624.67
$1,855.67 		$347.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.44
$1,032.20
$1,162.24
$1,624.24
$2,468.18 		$1,257.29
$1,380.05
$1,510.09
$1,972.09 		$1,605.14
$1,727.90
$1,857.94
$2,319.94 		$1,952.99
$2,075.75
$2,205.79
$2,667.79 		$347.85
Toc - Plan #8 Quartz
Silver

(HMO) Quartz One Silver I309 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$476.25
$540.53
$608.64
$850.57
$1,292.52 		$840.57
$904.85
$972.96
$1,214.89 		$1,204.89
$1,269.17
$1,337.28
$1,579.21 		$1,569.21
$1,633.49
$1,701.60
$1,943.53 		$364.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$952.50
$1,081.06
$1,217.28
$1,701.14
$2,585.04 		$1,316.82
$1,445.38
$1,581.60
$2,065.46 		$1,681.14
$1,809.70
$1,945.92
$2,429.78 		$2,045.46
$2,174.02
$2,310.24
$2,794.10 		$364.32
Toc - Plan #9 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$322.34
$365.85
$411.95
$575.70
$874.83 		$568.93
$612.44
$658.54
$822.29 		$815.52
$859.03
$905.13
$1,068.88 		$1,062.11
$1,105.62
$1,151.72
$1,315.47 		$246.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$644.68
$731.70
$823.90
$1,151.40
$1,749.66 		$891.27
$978.29
$1,070.49
$1,397.99 		$1,137.86
$1,224.88
$1,317.08
$1,644.58 		$1,384.45
$1,471.47
$1,563.67
$1,891.17 		$246.59
Toc - Plan #10 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I202 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.53
$369.47
$416.03
$581.39
$883.48 		$574.56
$618.50
$665.06
$830.42 		$823.59
$867.53
$914.09
$1,079.45 		$1,072.62
$1,116.56
$1,163.12
$1,328.48 		$249.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.06
$738.94
$832.06
$1,162.78
$1,766.96 		$900.09
$987.97
$1,081.09
$1,411.81 		$1,149.12
$1,237.00
$1,330.12
$1,660.84 		$1,398.15
$1,486.03
$1,579.15
$1,909.87 		$249.03
Toc - Plan #11 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$341.23
$387.29
$436.08
$609.42
$926.08 		$602.26
$648.32
$697.11
$870.45 		$863.29
$909.35
$958.14
$1,131.48 		$1,124.32
$1,170.38
$1,219.17
$1,392.51 		$261.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.46
$774.58
$872.16
$1,218.84
$1,852.16 		$943.49
$1,035.61
$1,133.19
$1,479.87 		$1,204.52
$1,296.64
$1,394.22
$1,740.90 		$1,465.55
$1,557.67
$1,655.25
$2,001.93 		$261.03
Toc - Plan #12 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$337.74
$383.33
$431.62
$603.19
$916.61 		$596.11
$641.70
$689.99
$861.56 		$854.48
$900.07
$948.36
$1,119.93 		$1,112.85
$1,158.44
$1,206.73
$1,378.30 		$258.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.48
$766.66
$863.24
$1,206.38
$1,833.22 		$933.85
$1,025.03
$1,121.61
$1,464.75 		$1,192.22
$1,283.40
$1,379.98
$1,723.12 		$1,450.59
$1,541.77
$1,638.35
$1,981.49 		$258.37
Toc - Plan #13 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I206 Standard with Dental & Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$351.64
$399.11
$449.39
$628.03
$954.35 		$620.64
$668.11
$718.39
$897.03 		$889.64
$937.11
$987.39
$1,166.03 		$1,158.64
$1,206.11
$1,256.39
$1,435.03 		$269.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.28
$798.22
$898.78
$1,256.06
$1,908.70 		$972.28
$1,067.22
$1,167.78
$1,525.06 		$1,241.28
$1,336.22
$1,436.78
$1,794.06 		$1,510.28
$1,605.22
$1,705.78
$2,063.06 		$269.00
Toc - Plan #14 Quartz
Gold

(HMO) QUARTZ ONE GOLD I401

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$405.83
$460.61
$518.64
$724.80
$1,101.40 		$716.28
$771.06
$829.09
$1,035.25 		$1,026.73
$1,081.51
$1,139.54
$1,345.70 		$1,337.18
$1,391.96
$1,449.99
$1,656.15 		$310.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$811.66
$921.22
$1,037.28
$1,449.60
$2,202.80 		$1,122.11
$1,231.67
$1,347.73
$1,760.05 		$1,432.56
$1,542.12
$1,658.18
$2,070.50 		$1,743.01
$1,852.57
$1,968.63
$2,380.95 		$310.45
Toc - Plan #15 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 Maintenance

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$402.02
$456.29
$513.78
$718.00
$1,091.07 		$709.56
$763.83
$821.32
$1,025.54 		$1,017.10
$1,071.37
$1,128.86
$1,333.08 		$1,324.64
$1,378.91
$1,436.40
$1,640.62 		$307.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.04
$912.58
$1,027.56
$1,436.00
$2,182.14 		$1,111.58
$1,220.12
$1,335.10
$1,743.54 		$1,419.12
$1,527.66
$1,642.64
$2,051.08 		$1,726.66
$1,835.20
$1,950.18
$2,358.62 		$307.54
Toc - Plan #16 Quartz
Gold

(HMO) QUARTZ ONE GOLD I405

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$405.36
$460.08
$518.05
$723.97
$1,100.14 		$715.46
$770.18
$828.15
$1,034.07 		$1,025.56
$1,080.28
$1,138.25
$1,344.17 		$1,335.66
$1,390.38
$1,448.35
$1,654.27 		$310.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.72
$920.16
$1,036.10
$1,447.94
$2,200.28 		$1,120.82
$1,230.26
$1,346.20
$1,758.04 		$1,430.92
$1,540.36
$1,656.30
$2,068.14 		$1,741.02
$1,850.46
$1,966.40
$2,378.24 		$310.10
Toc - Plan #17 Quartz
Gold

(HMO) Quartz One Gold I410 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$415.74
$471.86
$531.31
$742.51
$1,128.32 		$733.78
$789.90
$849.35
$1,060.55 		$1,051.82
$1,107.94
$1,167.39
$1,378.59 		$1,369.86
$1,425.98
$1,485.43
$1,696.63 		$318.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.48
$943.72
$1,062.62
$1,485.02
$2,256.64 		$1,149.52
$1,261.76
$1,380.66
$1,803.06 		$1,467.56
$1,579.80
$1,698.70
$2,121.10 		$1,785.60
$1,897.84
$2,016.74
$2,439.14 		$318.04
Toc - Plan #18 Quartz
Silver

(HMO) QUARTZ ONE SILVER I301

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$417.72
$474.11
$533.84
$746.04
$1,133.68 		$737.27
$793.66
$853.39
$1,065.59 		$1,056.82
$1,113.21
$1,172.94
$1,385.14 		$1,376.37
$1,432.76
$1,492.49
$1,704.69 		$319.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$835.44
$948.22
$1,067.68
$1,492.08
$2,267.36 		$1,154.99
$1,267.77
$1,387.23
$1,811.63 		$1,474.54
$1,587.32
$1,706.78
$2,131.18 		$1,794.09
$1,906.87
$2,026.33
$2,450.73 		$319.55
Toc - Plan #19 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$414.19
$470.10
$529.32
$739.73
$1,124.09 		$731.04
$786.95
$846.17
$1,056.58 		$1,047.89
$1,103.80
$1,163.02
$1,373.43 		$1,364.74
$1,420.65
$1,479.87
$1,690.28 		$316.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.38
$940.20
$1,058.64
$1,479.46
$2,248.18 		$1,145.23
$1,257.05
$1,375.49
$1,796.31 		$1,462.08
$1,573.90
$1,692.34
$2,113.16 		$1,778.93
$1,890.75
$2,009.19
$2,430.01 		$316.85
Toc - Plan #20 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$434.56
$493.22
$555.36
$776.11
$1,179.37 		$766.99
$825.65
$887.79
$1,108.54 		$1,099.42
$1,158.08
$1,220.22
$1,440.97 		$1,431.85
$1,490.51
$1,552.65
$1,773.40 		$332.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.12
$986.44
$1,110.72
$1,552.22
$2,358.74 		$1,201.55
$1,318.87
$1,443.15
$1,884.65 		$1,533.98
$1,651.30
$1,775.58
$2,217.08 		$1,866.41
$1,983.73
$2,108.01
$2,549.51 		$332.43
Toc - Plan #21 Quartz
Silver

(HMO) Quartz One Silver I309 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$455.13
$516.57
$581.65
$812.86
$1,235.21 		$803.30
$864.74
$929.82
$1,161.03 		$1,151.47
$1,212.91
$1,277.99
$1,509.20 		$1,499.64
$1,561.08
$1,626.16
$1,857.37 		$348.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.26
$1,033.14
$1,163.30
$1,625.72
$2,470.42 		$1,258.43
$1,381.31
$1,511.47
$1,973.89 		$1,606.60
$1,729.48
$1,859.64
$2,322.06 		$1,954.77
$2,077.65
$2,207.81
$2,670.23 		$348.17
Toc - Plan #22 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$308.05
$349.63
$393.68
$550.17
$836.04 		$543.71
$585.29
$629.34
$785.83 		$779.37
$820.95
$865.00
$1,021.49 		$1,015.03
$1,056.61
$1,100.66
$1,257.15 		$235.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.10
$699.26
$787.36
$1,100.34
$1,672.08 		$851.76
$934.92
$1,023.02
$1,336.00 		$1,087.42
$1,170.58
$1,258.68
$1,571.66 		$1,323.08
$1,406.24
$1,494.34
$1,807.32 		$235.66
Toc - Plan #23 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I202

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$311.10
$353.09
$397.58
$555.62
$844.31 		$549.09
$591.08
$635.57
$793.61 		$787.08
$829.07
$873.56
$1,031.60 		$1,025.07
$1,067.06
$1,111.55
$1,269.59 		$237.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.20
$706.18
$795.16
$1,111.24
$1,688.62 		$860.19
$944.17
$1,033.15
$1,349.23 		$1,098.18
$1,182.16
$1,271.14
$1,587.22 		$1,336.17
$1,420.15
$1,509.13
$1,825.21 		$237.99
Toc - Plan #24 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$326.10
$370.12
$416.75
$582.40
$885.02 		$575.56
$619.58
$666.21
$831.86 		$825.02
$869.04
$915.67
$1,081.32 		$1,074.48
$1,118.50
$1,165.13
$1,330.78 		$249.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.20
$740.24
$833.50
$1,164.80
$1,770.04 		$901.66
$989.70
$1,082.96
$1,414.26 		$1,151.12
$1,239.16
$1,332.42
$1,663.72 		$1,400.58
$1,488.62
$1,581.88
$1,913.18 		$249.46
Toc - Plan #25 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$322.77
$366.33
$412.49
$576.45
$875.97 		$569.68
$613.24
$659.40
$823.36 		$816.59
$860.15
$906.31
$1,070.27 		$1,063.50
$1,107.06
$1,153.22
$1,317.18 		$246.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.54
$732.66
$824.98
$1,152.90
$1,751.94 		$892.45
$979.57
$1,071.89
$1,399.81 		$1,139.36
$1,226.48
$1,318.80
$1,646.72 		$1,386.27
$1,473.39
$1,565.71
$1,893.63 		$246.91
Toc - Plan #26 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I206 Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$336.05
$381.42
$429.47
$600.18
$912.04 		$593.13
$638.50
$686.55
$857.26 		$850.21
$895.58
$943.63
$1,114.34 		$1,107.29
$1,152.66
$1,200.71
$1,371.42 		$257.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.10
$762.84
$858.94
$1,200.36
$1,824.08 		$929.18
$1,019.92
$1,116.02
$1,457.44 		$1,186.26
$1,277.00
$1,373.10
$1,714.52 		$1,443.34
$1,534.08
$1,630.18
$1,971.60 		$257.08
Toc - Plan #27 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I203

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$323.73
$367.43
$413.72
$578.17
$878.59 		$571.38
$615.08
$661.37
$825.82 		$819.03
$862.73
$909.02
$1,073.47 		$1,066.68
$1,110.38
$1,156.67
$1,321.12 		$247.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.46
$734.86
$827.44
$1,156.34
$1,757.18 		$895.11
$982.51
$1,075.09
$1,403.99 		$1,142.76
$1,230.16
$1,322.74
$1,651.64 		$1,390.41
$1,477.81
$1,570.39
$1,899.29 		$247.65
Toc - Plan #28 Quartz
Catastrophic

(HMO) QUARTZ ONE CATASTROPHIC I101

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$238.65
$270.86
$304.99
$426.22
$647.68 		$421.21
$453.42
$487.55
$608.78 		$603.77
$635.98
$670.11
$791.34 		$786.33
$818.54
$852.67
$973.90 		$182.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$477.30
$541.72
$609.98
$852.44
$1,295.36 		$659.86
$724.28
$792.54
$1,035.00 		$842.42
$906.84
$975.10
$1,217.56 		$1,024.98
$1,089.40
$1,157.66
$1,400.12 		$182.56
Toc - Plan #29 Quartz
Silver

(HMO) QUARTZ ONE SILVER I304 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$457.59
$519.36
$584.80
$817.25
$1,241.90 		$807.65
$869.42
$934.86
$1,167.31 		$1,157.71
$1,219.48
$1,284.92
$1,517.37 		$1,507.77
$1,569.54
$1,634.98
$1,867.43 		$350.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$915.18
$1,038.72
$1,169.60
$1,634.50
$2,483.80 		$1,265.24
$1,388.78
$1,519.66
$1,984.56 		$1,615.30
$1,738.84
$1,869.72
$2,334.62 		$1,965.36
$2,088.90
$2,219.78
$2,684.68 		$350.06
Toc - Plan #30 Quartz
Gold

(HMO) QUARTZ ONE GOLD I403 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$3,500 $7,000 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 		$430.70
$488.84
$550.43
$769.22
$1,168.90 		$760.18
$818.32
$879.91
$1,098.70 		$1,089.66
$1,147.80
$1,209.39
$1,428.18 		$1,419.14
$1,477.28
$1,538.87
$1,757.66 		$329.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.40
$977.68
$1,100.86
$1,538.44
$2,337.80 		$1,190.88
$1,307.16
$1,430.34
$1,867.92 		$1,520.36
$1,636.64
$1,759.82
$2,197.40 		$1,849.84
$1,966.12
$2,089.30
$2,526.88 		$329.48
Toc - Plan #31 Quartz
Silver

(HMO) QUARTZ ONE SILVER I307

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$459.59
$521.63
$587.35
$820.82
$1,247.31 		$811.17
$873.21
$938.93
$1,172.40 		$1,162.75
$1,224.79
$1,290.51
$1,523.98 		$1,514.33
$1,576.37
$1,642.09
$1,875.56 		$351.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919.18
$1,043.26
$1,174.70
$1,641.64
$2,494.62 		$1,270.76
$1,394.84
$1,526.28
$1,993.22 		$1,622.34
$1,746.42
$1,877.86
$2,344.80 		$1,973.92
$2,098.00
$2,229.44
$2,696.38 		$351.58
Toc - Plan #32 Quartz
Gold

(HMO) QUARTZ ONE GOLD I401 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$410.54
$465.96
$524.67
$733.22
$1,114.20 		$724.60
$780.02
$838.73
$1,047.28 		$1,038.66
$1,094.08
$1,152.79
$1,361.34 		$1,352.72
$1,408.14
$1,466.85
$1,675.40 		$314.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.08
$931.92
$1,049.34
$1,466.44
$2,228.40 		$1,135.14
$1,245.98
$1,363.40
$1,780.50 		$1,449.20
$1,560.04
$1,677.46
$2,094.56 		$1,763.26
$1,874.10
$1,991.52
$2,408.62 		$314.06
Toc - Plan #33 Quartz
Gold

(HMO) QUARTZ ONE GOLD I402 Maintenance with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$406.69
$461.59
$519.74
$726.34
$1,103.75 		$717.80
$772.70
$830.85
$1,037.45 		$1,028.91
$1,083.81
$1,141.96
$1,348.56 		$1,340.02
$1,394.92
$1,453.07
$1,659.67 		$311.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.38
$923.18
$1,039.48
$1,452.68
$2,207.50 		$1,124.49
$1,234.29
$1,350.59
$1,763.79 		$1,435.60
$1,545.40
$1,661.70
$2,074.90 		$1,746.71
$1,856.51
$1,972.81
$2,386.01 		$311.11
Toc - Plan #34 Quartz
Gold

(HMO) QUARTZ ONE GOLD I405 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$410.07
$465.43
$524.07
$732.38
$1,112.92 		$723.77
$779.13
$837.77
$1,046.08 		$1,037.47
$1,092.83
$1,151.47
$1,359.78 		$1,351.17
$1,406.53
$1,465.17
$1,673.48 		$313.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.14
$930.86
$1,048.14
$1,464.76
$2,225.84 		$1,133.84
$1,244.56
$1,361.84
$1,778.46 		$1,447.54
$1,558.26
$1,675.54
$2,092.16 		$1,761.24
$1,871.96
$1,989.24
$2,405.86 		$313.70
Toc - Plan #35 Quartz
Gold

(HMO) Quartz One Gold I410 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$420.57
$477.35
$537.49
$751.14
$1,141.42 		$742.30
$799.08
$859.22
$1,072.87 		$1,064.03
$1,120.81
$1,180.95
$1,394.60 		$1,385.76
$1,442.54
$1,502.68
$1,716.33 		$321.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.14
$954.70
$1,074.98
$1,502.28
$2,282.84 		$1,162.87
$1,276.43
$1,396.71
$1,824.01 		$1,484.60
$1,598.16
$1,718.44
$2,145.74 		$1,806.33
$1,919.89
$2,040.17
$2,467.47 		$321.73
Toc - Plan #36 Quartz
Silver

(HMO) QUARTZ ONE SILVER I301 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$422.57
$479.61
$540.04
$754.71
$1,146.85 		$745.83
$802.87
$863.30
$1,077.97 		$1,069.09
$1,126.13
$1,186.56
$1,401.23 		$1,392.35
$1,449.39
$1,509.82
$1,724.49 		$323.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$845.14
$959.22
$1,080.08
$1,509.42
$2,293.70 		$1,168.40
$1,282.48
$1,403.34
$1,832.68 		$1,491.66
$1,605.74
$1,726.60
$2,155.94 		$1,814.92
$1,929.00
$2,049.86
$2,479.20 		$323.26
Toc - Plan #37 Quartz
Silver

(HMO) QUARTZ ONE SILVER I303 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$419.00
$475.56
$535.47
$748.32
$1,137.14 		$739.53
$796.09
$856.00
$1,068.85 		$1,060.06
$1,116.62
$1,176.53
$1,389.38 		$1,380.59
$1,437.15
$1,497.06
$1,709.91 		$320.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$838.00
$951.12
$1,070.94
$1,496.64
$2,274.28 		$1,158.53
$1,271.65
$1,391.47
$1,817.17 		$1,479.06
$1,592.18
$1,712.00
$2,137.70 		$1,799.59
$1,912.71
$2,032.53
$2,458.23 		$320.53
Toc - Plan #38 Quartz
Silver

(HMO) QUARTZ ONE SILVER I308 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$439.61
$498.95
$561.81
$785.13
$1,193.07 		$775.90
$835.24
$898.10
$1,121.42 		$1,112.19
$1,171.53
$1,234.39
$1,457.71 		$1,448.48
$1,507.82
$1,570.68
$1,794.00 		$336.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.22
$997.90
$1,123.62
$1,570.26
$2,386.14 		$1,215.51
$1,334.19
$1,459.91
$1,906.55 		$1,551.80
$1,670.48
$1,796.20
$2,242.84 		$1,888.09
$2,006.77
$2,132.49
$2,579.13 		$336.29
Toc - Plan #39 Quartz
Silver

(HMO) Quartz One Silver I309 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$460.42
$522.57
$588.41
$822.30
$1,249.56 		$812.64
$874.79
$940.63
$1,174.52 		$1,164.86
$1,227.01
$1,292.85
$1,526.74 		$1,517.08
$1,579.23
$1,645.07
$1,878.96 		$352.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$920.84
$1,045.14
$1,176.82
$1,644.60
$2,499.12 		$1,273.06
$1,397.36
$1,529.04
$1,996.82 		$1,625.28
$1,749.58
$1,881.26
$2,349.04 		$1,977.50
$2,101.80
$2,233.48
$2,701.26 		$352.22
Toc - Plan #40 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I201 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$311.63
$353.70
$398.26
$556.56
$845.75 		$550.02
$592.09
$636.65
$794.95 		$788.41
$830.48
$875.04
$1,033.34 		$1,026.80
$1,068.87
$1,113.43
$1,271.73 		$238.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.26
$707.40
$796.52
$1,113.12
$1,691.50 		$861.65
$945.79
$1,034.91
$1,351.51 		$1,100.04
$1,184.18
$1,273.30
$1,589.90 		$1,338.43
$1,422.57
$1,511.69
$1,828.29 		$238.39
Toc - Plan #41 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I202 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$314.71
$357.20
$402.20
$562.07
$854.12 		$555.46
$597.95
$642.95
$802.82 		$796.21
$838.70
$883.70
$1,043.57 		$1,036.96
$1,079.45
$1,124.45
$1,284.32 		$240.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.42
$714.40
$804.40
$1,124.14
$1,708.24 		$870.17
$955.15
$1,045.15
$1,364.89 		$1,110.92
$1,195.90
$1,285.90
$1,605.64 		$1,351.67
$1,436.65
$1,526.65
$1,846.39 		$240.75
Toc - Plan #42 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I204 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$329.89
$374.42
$421.59
$589.17
$895.30 		$582.25
$626.78
$673.95
$841.53 		$834.61
$879.14
$926.31
$1,093.89 		$1,086.97
$1,131.50
$1,178.67
$1,346.25 		$252.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.78
$748.84
$843.18
$1,178.34
$1,790.60 		$912.14
$1,001.20
$1,095.54
$1,430.70 		$1,164.50
$1,253.56
$1,347.90
$1,683.06 		$1,416.86
$1,505.92
$1,600.26
$1,935.42 		$252.36
Toc - Plan #43 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I205 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$326.52
$370.59
$417.28
$583.15
$886.15 		$576.30
$620.37
$667.06
$832.93 		$826.08
$870.15
$916.84
$1,082.71 		$1,075.86
$1,119.93
$1,166.62
$1,332.49 		$249.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.04
$741.18
$834.56
$1,166.30
$1,772.30 		$902.82
$990.96
$1,084.34
$1,416.08 		$1,152.60
$1,240.74
$1,334.12
$1,665.86 		$1,402.38
$1,490.52
$1,583.90
$1,915.64 		$249.78
Toc - Plan #44 Quartz
Expanded Bronze

(HMO) Quartz One Bronze I206 Standard with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

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 		$339.96
$385.85
$434.46
$607.15
$922.63 		$600.02
$645.91
$694.52
$867.21 		$860.08
$905.97
$954.58
$1,127.27 		$1,120.14
$1,166.03
$1,214.64
$1,387.33 		$260.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.92
$771.70
$868.92
$1,214.30
$1,845.26 		$939.98
$1,031.76
$1,128.98
$1,474.36 		$1,200.04
$1,291.82
$1,389.04
$1,734.42 		$1,460.10
$1,551.88
$1,649.10
$1,994.48 		$260.06
Toc - Plan #45 Quartz
Gold

(HMO) QUARTZ ONE GOLD I403 HSA with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$3,500 $7,000 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 		$435.70
$494.52
$556.82
$778.15
$1,182.48 		$769.01
$827.83
$890.13
$1,111.46 		$1,102.32
$1,161.14
$1,223.44
$1,444.77 		$1,435.63
$1,494.45
$1,556.75
$1,778.08 		$333.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.40
$989.04
$1,113.64
$1,556.30
$2,364.96 		$1,204.71
$1,322.35
$1,446.95
$1,889.61 		$1,538.02
$1,655.66
$1,780.26
$2,222.92 		$1,871.33
$1,988.97
$2,113.57
$2,556.23 		$333.31
Toc - Plan #46 Quartz
Silver

(HMO) QUARTZ ONE SILVER I304 HSA with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$462.91
$525.40
$591.59
$826.75
$1,256.32 		$817.03
$879.52
$945.71
$1,180.87 		$1,171.15
$1,233.64
$1,299.83
$1,534.99 		$1,525.27
$1,587.76
$1,653.95
$1,889.11 		$354.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.82
$1,050.80
$1,183.18
$1,653.50
$2,512.64 		$1,279.94
$1,404.92
$1,537.30
$2,007.62 		$1,634.06
$1,759.04
$1,891.42
$2,361.74 		$1,988.18
$2,113.16
$2,245.54
$2,715.86 		$354.12
Toc - Plan #47 Quartz
Silver

(HMO) QUARTZ ONE SILVER I307 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$464.93
$527.69
$594.17
$830.35
$1,261.80 		$820.60
$883.36
$949.84
$1,186.02 		$1,176.27
$1,239.03
$1,305.51
$1,541.69 		$1,531.94
$1,594.70
$1,661.18
$1,897.36 		$355.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.86
$1,055.38
$1,188.34
$1,660.70
$2,523.60 		$1,285.53
$1,411.05
$1,544.01
$2,016.37 		$1,641.20
$1,766.72
$1,899.68
$2,372.04 		$1,996.87
$2,122.39
$2,255.35
$2,727.71 		$355.67
Toc - Plan #48 Quartz
Expanded Bronze

(HMO) QUARTZ ONE BRONZE I203 with Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-362-3310

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 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 		$327.49
$371.70
$418.53
$584.89
$888.80 		$578.02
$622.23
$669.06
$835.42 		$828.55
$872.76
$919.59
$1,085.95 		$1,079.08
$1,123.29
$1,170.12
$1,336.48 		$250.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.98
$743.40
$837.06
$1,169.78
$1,777.60 		$905.51
$993.93
$1,087.59
$1,420.31 		$1,156.04
$1,244.46
$1,338.12
$1,670.84 		$1,406.57
$1,494.99
$1,588.65
$1,921.37 		$250.53

ADVERTISEMENT

Dean Health Plan

Local: 1-800-279-1302 | Toll Free: 1-800-279-1302 | TTY: 1-800-279-1302
Toc - Plan #49 Dean Health Plan
Catastrophic

(HMO) Dean Catastrophic Safety Net (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$183.23
$207.96
$234.17
$327.25
$497.28 		$323.40
$348.13
$374.34
$467.42 		$463.57
$488.30
$514.51
$607.59 		$603.74
$628.47
$654.68
$747.76 		$140.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$366.46
$415.92
$468.34
$654.50
$994.56 		$506.63
$556.09
$608.51
$794.67 		$646.80
$696.26
$748.68
$934.84 		$786.97
$836.43
$888.85
$1,075.01 		$140.17
Toc - Plan #50 Dean Health Plan
Silver

(HMO) Dean Silver Copay Plus 4800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$361.71
$410.54
$462.26
$646.01
$981.67 		$638.42
$687.25
$738.97
$922.72 		$915.13
$963.96
$1,015.68
$1,199.43 		$1,191.84
$1,240.67
$1,292.39
$1,476.14 		$276.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.42
$821.08
$924.52
$1,292.02
$1,963.34 		$1,000.13
$1,097.79
$1,201.23
$1,568.73 		$1,276.84
$1,374.50
$1,477.94
$1,845.44 		$1,553.55
$1,651.21
$1,754.65
$2,122.15 		$276.71
Toc - Plan #51 Dean Health Plan
Silver

(HMO) Dean Silver Value Copay 4100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$358.91
$407.36
$458.69
$641.01
$974.08 		$633.48
$681.93
$733.26
$915.58 		$908.05
$956.50
$1,007.83
$1,190.15 		$1,182.62
$1,231.07
$1,282.40
$1,464.72 		$274.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.82
$814.72
$917.38
$1,282.02
$1,948.16 		$992.39
$1,089.29
$1,191.95
$1,556.59 		$1,266.96
$1,363.86
$1,466.52
$1,831.16 		$1,541.53
$1,638.43
$1,741.09
$2,105.73 		$274.57
Toc - Plan #52 Dean Health Plan
Gold

(HMO) Dean Gold Value Copay 4000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$4,000 $8,000 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 		$344.63
$391.15
$440.44
$615.51
$935.32 		$608.27
$654.79
$704.08
$879.15 		$871.91
$918.43
$967.72
$1,142.79 		$1,135.55
$1,182.07
$1,231.36
$1,406.43 		$263.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$689.26
$782.30
$880.88
$1,231.02
$1,870.64 		$952.90
$1,045.94
$1,144.52
$1,494.66 		$1,216.54
$1,309.58
$1,408.16
$1,758.30 		$1,480.18
$1,573.22
$1,671.80
$2,021.94 		$263.64
Toc - Plan #53 Dean Health Plan
Bronze

(HMO) Dean Bronze Value Copay 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$228.15
$258.95
$291.57
$407.47
$619.20 		$402.68
$433.48
$466.10
$582.00 		$577.21
$608.01
$640.63
$756.53 		$751.74
$782.54
$815.16
$931.06 		$174.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.30
$517.90
$583.14
$814.94
$1,238.40 		$630.83
$692.43
$757.67
$989.47 		$805.36
$866.96
$932.20
$1,164.00 		$979.89
$1,041.49
$1,106.73
$1,338.53 		$174.53
Toc - Plan #54 Dean Health Plan
Silver

(HMO) Dean Silver HSA-E HDHP 3550X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 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 		$344.21
$390.68
$439.90
$614.76
$934.18 		$607.53
$654.00
$703.22
$878.08 		$870.85
$917.32
$966.54
$1,141.40 		$1,134.17
$1,180.64
$1,229.86
$1,404.72 		$263.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.42
$781.36
$879.80
$1,229.52
$1,868.36 		$951.74
$1,044.68
$1,143.12
$1,492.84 		$1,215.06
$1,308.00
$1,406.44
$1,756.16 		$1,478.38
$1,571.32
$1,669.76
$2,019.48 		$263.32
Toc - Plan #55 Dean Health Plan
Gold

(HMO) Dean Gold Copay Plus 1500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 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 		$362.70
$411.66
$463.53
$647.78
$984.37 		$640.16
$689.12
$740.99
$925.24 		$917.62
$966.58
$1,018.45
$1,202.70 		$1,195.08
$1,244.04
$1,295.91
$1,480.16 		$277.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.40
$823.32
$927.06
$1,295.56
$1,968.74 		$1,002.86
$1,100.78
$1,204.52
$1,573.02 		$1,280.32
$1,378.24
$1,481.98
$1,850.48 		$1,557.78
$1,655.70
$1,759.44
$2,127.94 		$277.46
Toc - Plan #56 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze HSA-E HDHP 7000X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$245.62
$278.78
$313.90
$438.67
$666.61 		$433.52
$466.68
$501.80
$626.57 		$621.42
$654.58
$689.70
$814.47 		$809.32
$842.48
$877.60
$1,002.37 		$187.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$491.24
$557.56
$627.80
$877.34
$1,333.22 		$679.14
$745.46
$815.70
$1,065.24 		$867.04
$933.36
$1,003.60
$1,253.14 		$1,054.94
$1,121.26
$1,191.50
$1,441.04 		$187.90
Toc - Plan #57 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay Plus 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$238.88
$271.13
$305.29
$426.65
$648.33 		$421.63
$453.88
$488.04
$609.40 		$604.38
$636.63
$670.79
$792.15 		$787.13
$819.38
$853.54
$974.90 		$182.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$477.76
$542.26
$610.58
$853.30
$1,296.66 		$660.51
$725.01
$793.33
$1,036.05 		$843.26
$907.76
$976.08
$1,218.80 		$1,026.01
$1,090.51
$1,158.83
$1,401.55 		$182.75
Toc - Plan #58 Dean Health Plan
Gold

(HMO) Dean Gold HSA HDHP 2000X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 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 		$323.43
$367.09
$413.35
$577.65
$877.79 		$570.86
$614.52
$660.78
$825.08 		$818.29
$861.95
$908.21
$1,072.51 		$1,065.72
$1,109.38
$1,155.64
$1,319.94 		$247.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.86
$734.18
$826.70
$1,155.30
$1,755.58 		$894.29
$981.61
$1,074.13
$1,402.73 		$1,141.72
$1,229.04
$1,321.56
$1,650.16 		$1,389.15
$1,476.47
$1,568.99
$1,897.59 		$247.43
Toc - Plan #59 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Copay PCP 8000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$228.99
$259.90
$292.65
$408.98
$621.48 		$404.17
$435.08
$467.83
$584.16 		$579.35
$610.26
$643.01
$759.34 		$754.53
$785.44
$818.19
$934.52 		$175.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$457.98
$519.80
$585.30
$817.96
$1,242.96 		$633.16
$694.98
$760.48
$993.14 		$808.34
$870.16
$935.66
$1,168.32 		$983.52
$1,045.34
$1,110.84
$1,343.50 		$175.18
Toc - Plan #60 Dean Health Plan
Silver

(HMO) Dean Silver Copay PCP 4500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335.94
$381.29
$429.33
$599.99
$911.74 		$592.93
$638.28
$686.32
$856.98 		$849.92
$895.27
$943.31
$1,113.97 		$1,106.91
$1,152.26
$1,200.30
$1,370.96 		$256.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$671.88
$762.58
$858.66
$1,199.98
$1,823.48 		$928.87
$1,019.57
$1,115.65
$1,456.97 		$1,185.86
$1,276.56
$1,372.64
$1,713.96 		$1,442.85
$1,533.55
$1,629.63
$1,970.95 		$256.99
Toc - Plan #61 Dean Health Plan
Gold

(HMO) Dean Gold Copay PCP 2000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$333.41
$378.42
$426.10
$595.48
$904.89 		$588.47
$633.48
$681.16
$850.54 		$843.53
$888.54
$936.22
$1,105.60 		$1,098.59
$1,143.60
$1,191.28
$1,360.66 		$255.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$666.82
$756.84
$852.20
$1,190.96
$1,809.78 		$921.88
$1,011.90
$1,107.26
$1,446.02 		$1,176.94
$1,266.96
$1,362.32
$1,701.08 		$1,432.00
$1,522.02
$1,617.38
$1,956.14 		$255.06
Toc - Plan #62 Dean Health Plan
Gold

(HMO) Dean Gold Standard 2000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$347.49
$394.40
$444.09
$620.61
$943.08 		$613.32
$660.23
$709.92
$886.44 		$879.15
$926.06
$975.75
$1,152.27 		$1,144.98
$1,191.89
$1,241.58
$1,418.10 		$265.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.98
$788.80
$888.18
$1,241.22
$1,886.16 		$960.81
$1,054.63
$1,154.01
$1,507.05 		$1,226.64
$1,320.46
$1,419.84
$1,772.88 		$1,492.47
$1,586.29
$1,685.67
$2,038.71 		$265.83
Toc - Plan #63 Dean Health Plan
Silver

(HMO) Dean Silver Standard 5800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$345.26
$391.87
$441.24
$616.63
$937.04 		$609.38
$655.99
$705.36
$880.75 		$873.50
$920.11
$969.48
$1,144.87 		$1,137.62
$1,184.23
$1,233.60
$1,408.99 		$264.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.52
$783.74
$882.48
$1,233.26
$1,874.08 		$954.64
$1,047.86
$1,146.60
$1,497.38 		$1,218.76
$1,311.98
$1,410.72
$1,761.50 		$1,482.88
$1,576.10
$1,674.84
$2,025.62 		$264.12
Toc - Plan #64 Dean Health Plan
Expanded Bronze

(HMO) Dean Bronze Standard 7500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$235.79
$267.62
$301.33
$421.11
$639.92 		$416.17
$448.00
$481.71
$601.49 		$596.55
$628.38
$662.09
$781.87 		$776.93
$808.76
$842.47
$962.25 		$180.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$471.58
$535.24
$602.66
$842.22
$1,279.84 		$651.96
$715.62
$783.04
$1,022.60 		$832.34
$896.00
$963.42
$1,202.98 		$1,012.72
$1,076.38
$1,143.80
$1,383.36 		$180.38
Toc - Plan #65 Dean Health Plan
Bronze

(HMO) Dean Bronze Standard 9100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$210.83
$239.29
$269.44
$376.54
$572.19 		$372.12
$400.58
$430.73
$537.83 		$533.41
$561.87
$592.02
$699.12 		$694.70
$723.16
$753.31
$860.41 		$161.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$421.66
$478.58
$538.88
$753.08
$1,144.38 		$582.95
$639.87
$700.17
$914.37 		$744.24
$801.16
$861.46
$1,075.66 		$905.53
$962.45
$1,022.75
$1,236.95 		$161.29
Toc - Plan #66 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Copay Plus 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$215.67
$244.79
$275.63
$385.19
$585.33 		$380.66
$409.78
$440.62
$550.18 		$545.65
$574.77
$605.61
$715.17 		$710.64
$739.76
$770.60
$880.16 		$164.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$431.34
$489.58
$551.26
$770.38
$1,170.66 		$596.33
$654.57
$716.25
$935.37 		$761.32
$819.56
$881.24
$1,100.36 		$926.31
$984.55
$1,046.23
$1,265.35 		$164.99
Toc - Plan #67 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Value Copay 4000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$4,000 $8,000 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 		$311.10
$353.10
$397.59
$555.63
$844.34 		$549.09
$591.09
$635.58
$793.62 		$787.08
$829.08
$873.57
$1,031.61 		$1,025.07
$1,067.07
$1,111.56
$1,269.60 		$237.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.20
$706.20
$795.18
$1,111.26
$1,688.68 		$860.19
$944.19
$1,033.17
$1,349.25 		$1,098.18
$1,182.18
$1,271.16
$1,587.24 		$1,336.17
$1,420.17
$1,509.15
$1,825.23 		$237.99
Toc - Plan #68 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Value Copay 4100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$323.97
$367.71
$414.04
$578.62
$879.26 		$571.81
$615.55
$661.88
$826.46 		$819.65
$863.39
$909.72
$1,074.30 		$1,067.49
$1,111.23
$1,157.56
$1,322.14 		$247.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.94
$735.42
$828.08
$1,157.24
$1,758.52 		$895.78
$983.26
$1,075.92
$1,405.08 		$1,143.62
$1,231.10
$1,323.76
$1,652.92 		$1,391.46
$1,478.94
$1,571.60
$1,900.76 		$247.84
Toc - Plan #69 Dean Health Plan
Bronze

(EPO) Dean Focus Network Bronze Value Copay 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$206.23
$234.07
$263.56
$368.33
$559.71 		$364.00
$391.84
$421.33
$526.10 		$521.77
$549.61
$579.10
$683.87 		$679.54
$707.38
$736.87
$841.64 		$157.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$412.46
$468.14
$527.12
$736.66
$1,119.42 		$570.23
$625.91
$684.89
$894.43 		$728.00
$783.68
$842.66
$1,052.20 		$885.77
$941.45
$1,000.43
$1,209.97 		$157.77
Toc - Plan #70 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver HSA-E HDHP 3550X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 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 		$310.71
$352.66
$397.09
$554.93
$843.28 		$548.41
$590.36
$634.79
$792.63 		$786.11
$828.06
$872.49
$1,030.33 		$1,023.81
$1,065.76
$1,110.19
$1,268.03 		$237.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.42
$705.32
$794.18
$1,109.86
$1,686.56 		$859.12
$943.02
$1,031.88
$1,347.56 		$1,096.82
$1,180.72
$1,269.58
$1,585.26 		$1,334.52
$1,418.42
$1,507.28
$1,822.96 		$237.70
Toc - Plan #71 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze HSA-E HDHP 7000X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$221.96
$251.92
$283.66
$396.41
$602.39 		$391.76
$421.72
$453.46
$566.21 		$561.56
$591.52
$623.26
$736.01 		$731.36
$761.32
$793.06
$905.81 		$169.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$443.92
$503.84
$567.32
$792.82
$1,204.78 		$613.72
$673.64
$737.12
$962.62 		$783.52
$843.44
$906.92
$1,132.42 		$953.32
$1,013.24
$1,076.72
$1,302.22 		$169.80
Toc - Plan #72 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Copay Plus 1500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 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 		$327.01
$371.16
$417.92
$584.04
$887.50 		$577.17
$621.32
$668.08
$834.20 		$827.33
$871.48
$918.24
$1,084.36 		$1,077.49
$1,121.64
$1,168.40
$1,334.52 		$250.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$654.02
$742.32
$835.84
$1,168.08
$1,775.00 		$904.18
$992.48
$1,086.00
$1,418.24 		$1,154.34
$1,242.64
$1,336.16
$1,668.40 		$1,404.50
$1,492.80
$1,586.32
$1,918.56 		$250.16
Toc - Plan #73 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Copay Plus 4800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$326.11
$370.13
$416.77
$582.43
$885.06 		$575.58
$619.60
$666.24
$831.90 		$825.05
$869.07
$915.71
$1,081.37 		$1,074.52
$1,118.54
$1,165.18
$1,330.84 		$249.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.22
$740.26
$833.54
$1,164.86
$1,770.12 		$901.69
$989.73
$1,083.01
$1,414.33 		$1,151.16
$1,239.20
$1,332.48
$1,663.80 		$1,400.63
$1,488.67
$1,581.95
$1,913.27 		$249.47
Toc - Plan #74 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold HSA HDHP 2000X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$4,500 $9,000 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 		$292.01
$331.43
$373.19
$521.53
$792.52 		$515.40
$554.82
$596.58
$744.92 		$738.79
$778.21
$819.97
$968.31 		$962.18
$1,001.60
$1,043.36
$1,191.70 		$223.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.02
$662.86
$746.38
$1,043.06
$1,585.04 		$807.41
$886.25
$969.77
$1,266.45 		$1,030.80
$1,109.64
$1,193.16
$1,489.84 		$1,254.19
$1,333.03
$1,416.55
$1,713.23 		$223.39
Toc - Plan #75 Dean Health Plan
Catastrophic

(EPO) Dean Focus Network Catastrophic Safety Net (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$165.79
$188.17
$211.88
$296.10
$449.95 		$292.62
$315.00
$338.71
$422.93 		$419.45
$441.83
$465.54
$549.76 		$546.28
$568.66
$592.37
$676.59 		$126.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$331.58
$376.34
$423.76
$592.20
$899.90 		$458.41
$503.17
$550.59
$719.03 		$585.24
$630.00
$677.42
$845.86 		$712.07
$756.83
$804.25
$972.69 		$126.83
Toc - Plan #76 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Copay PCP 8000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$206.98
$234.92
$264.52
$369.67
$561.75 		$365.32
$393.26
$422.86
$528.01 		$523.66
$551.60
$581.20
$686.35 		$682.00
$709.94
$739.54
$844.69 		$158.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$413.96
$469.84
$529.04
$739.34
$1,123.50 		$572.30
$628.18
$687.38
$897.68 		$730.64
$786.52
$845.72
$1,056.02 		$888.98
$944.86
$1,004.06
$1,214.36 		$158.34
Toc - Plan #77 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Copay PCP 4500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.29
$344.23
$387.60
$541.67
$823.12 		$535.30
$576.24
$619.61
$773.68 		$767.31
$808.25
$851.62
$1,005.69 		$999.32
$1,040.26
$1,083.63
$1,237.70 		$232.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$606.58
$688.46
$775.20
$1,083.34
$1,646.24 		$838.59
$920.47
$1,007.21
$1,315.35 		$1,070.60
$1,152.48
$1,239.22
$1,547.36 		$1,302.61
$1,384.49
$1,471.23
$1,779.37 		$232.01
Toc - Plan #78 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Copay PCP 2000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$301.00
$341.64
$384.68
$537.59
$816.92 		$531.27
$571.91
$614.95
$767.86 		$761.54
$802.18
$845.22
$998.13 		$991.81
$1,032.45
$1,075.49
$1,228.40 		$230.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.00
$683.28
$769.36
$1,075.18
$1,633.84 		$832.27
$913.55
$999.63
$1,305.45 		$1,062.54
$1,143.82
$1,229.90
$1,535.72 		$1,292.81
$1,374.09
$1,460.17
$1,765.99 		$230.27
Toc - Plan #79 Dean Health Plan
Gold

(EPO) Dean Focus Network Gold Standard 2000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$313.66
$356.00
$400.86
$560.20
$851.27 		$553.61
$595.95
$640.81
$800.15 		$793.56
$835.90
$880.76
$1,040.10 		$1,033.51
$1,075.85
$1,120.71
$1,280.05 		$239.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.32
$712.00
$801.72
$1,120.40
$1,702.54 		$867.27
$951.95
$1,041.67
$1,360.35 		$1,107.22
$1,191.90
$1,281.62
$1,600.30 		$1,347.17
$1,431.85
$1,521.57
$1,840.25 		$239.95
Toc - Plan #80 Dean Health Plan
Silver

(EPO) Dean Focus Network Silver Standard 5800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$311.68
$353.75
$398.32
$556.65
$845.89 		$550.11
$592.18
$636.75
$795.08 		$788.54
$830.61
$875.18
$1,033.51 		$1,026.97
$1,069.04
$1,113.61
$1,271.94 		$238.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.36
$707.50
$796.64
$1,113.30
$1,691.78 		$861.79
$945.93
$1,035.07
$1,351.73 		$1,100.22
$1,184.36
$1,273.50
$1,590.16 		$1,338.65
$1,422.79
$1,511.93
$1,828.59 		$238.43
Toc - Plan #81 Dean Health Plan
Expanded Bronze

(EPO) Dean Focus Network Bronze Standard 7500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$213.12
$241.89
$272.36
$380.62
$578.40 		$376.15
$404.92
$435.39
$543.65 		$539.18
$567.95
$598.42
$706.68 		$702.21
$730.98
$761.45
$869.71 		$163.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$426.24
$483.78
$544.72
$761.24
$1,156.80 		$589.27
$646.81
$707.75
$924.27 		$752.30
$809.84
$870.78
$1,087.30 		$915.33
$972.87
$1,033.81
$1,250.33 		$163.03
Toc - Plan #82 Dean Health Plan
Bronze

(EPO) Dean Focus Network Bronze Standard 9100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-279-1302

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 		$190.63
$216.36
$243.62
$340.46
$517.36 		$336.46
$362.19
$389.45
$486.29 		$482.29
$508.02
$535.28
$632.12 		$628.12
$653.85
$681.11
$777.95 		$145.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$381.26
$432.72
$487.24
$680.92
$1,034.72 		$527.09
$578.55
$633.07
$826.75 		$672.92
$724.38
$778.90
$972.58 		$818.75
$870.21
$924.73
$1,118.41 		$145.83

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-748-1813 | Toll Free: 1-855-748-1813

Toc - Plan #83 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$291.65
$331.02
$372.73
$520.89
$791.54 		$514.76
$554.13
$595.84
$744.00 		$737.87
$777.24
$818.95
$967.11 		$960.98
$1,000.35
$1,042.06
$1,190.22 		$223.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.30
$662.04
$745.46
$1,041.78
$1,583.08 		$806.41
$885.15
$968.57
$1,264.89 		$1,029.52
$1,108.26
$1,191.68
$1,488.00 		$1,252.63
$1,331.37
$1,414.79
$1,711.11 		$223.11
Toc - Plan #84 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$282.78
$320.96
$361.39
$505.05
$767.46 		$499.11
$537.29
$577.72
$721.38 		$715.44
$753.62
$794.05
$937.71 		$931.77
$969.95
$1,010.38
$1,154.04 		$216.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.56
$641.92
$722.78
$1,010.10
$1,534.92 		$781.89
$858.25
$939.11
$1,226.43 		$998.22
$1,074.58
$1,155.44
$1,442.76 		$1,214.55
$1,290.91
$1,371.77
$1,659.09 		$216.33
Toc - Plan #85 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 6550 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$6,550 $13,100 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 		$277.72
$315.21
$354.93
$496.01
$753.73 		$490.18
$527.67
$567.39
$708.47 		$702.64
$740.13
$779.85
$920.93 		$915.10
$952.59
$992.31
$1,133.39 		$212.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.44
$630.42
$709.86
$992.02
$1,507.46 		$767.90
$842.88
$922.32
$1,204.48 		$980.36
$1,055.34
$1,134.78
$1,416.94 		$1,192.82
$1,267.80
$1,347.24
$1,629.40 		$212.46
Toc - Plan #86 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$263.24
$298.78
$336.42
$470.15
$714.43 		$464.62
$500.16
$537.80
$671.53 		$666.00
$701.54
$739.18
$872.91 		$867.38
$902.92
$940.56
$1,074.29 		$201.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.48
$597.56
$672.84
$940.30
$1,428.86 		$727.86
$798.94
$874.22
$1,141.68 		$929.24
$1,000.32
$1,075.60
$1,343.06 		$1,130.62
$1,201.70
$1,276.98
$1,544.44 		$201.38
Toc - Plan #87 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 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 		$277.14
$314.55
$354.18
$494.97
$752.16 		$489.15
$526.56
$566.19
$706.98 		$701.16
$738.57
$778.20
$918.99 		$913.17
$950.58
$990.21
$1,131.00 		$212.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.28
$629.10
$708.36
$989.94
$1,504.32 		$766.29
$841.11
$920.37
$1,201.95 		$978.30
$1,053.12
$1,132.38
$1,413.96 		$1,190.31
$1,265.13
$1,344.39
$1,625.97 		$212.01
Toc - Plan #88 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Preferred/Broad 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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 		$359.50
$408.03
$459.44
$642.07
$975.68 		$634.52
$683.05
$734.46
$917.09 		$909.54
$958.07
$1,009.48
$1,192.11 		$1,184.56
$1,233.09
$1,284.50
$1,467.13 		$275.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.00
$816.06
$918.88
$1,284.14
$1,951.36 		$994.02
$1,091.08
$1,193.90
$1,559.16 		$1,269.04
$1,366.10
$1,468.92
$1,834.18 		$1,544.06
$1,641.12
$1,743.94
$2,109.20 		$275.02
Toc - Plan #89 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$347.09
$393.95
$443.58
$619.90
$942.00 		$612.61
$659.47
$709.10
$885.42 		$878.13
$924.99
$974.62
$1,150.94 		$1,143.65
$1,190.51
$1,240.14
$1,416.46 		$265.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.18
$787.90
$887.16
$1,239.80
$1,884.00 		$959.70
$1,053.42
$1,152.68
$1,505.32 		$1,225.22
$1,318.94
$1,418.20
$1,770.84 		$1,490.74
$1,584.46
$1,683.72
$2,036.36 		$265.52
Toc - Plan #90 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$351.27
$398.69
$448.92
$627.37
$953.35 		$619.99
$667.41
$717.64
$896.09 		$888.71
$936.13
$986.36
$1,164.81 		$1,157.43
$1,204.85
$1,255.08
$1,433.53 		$268.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.54
$797.38
$897.84
$1,254.74
$1,906.70 		$971.26
$1,066.10
$1,166.56
$1,523.46 		$1,239.98
$1,334.82
$1,435.28
$1,792.18 		$1,508.70
$1,603.54
$1,704.00
$2,060.90 		$268.72
Toc - Plan #91 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 5300 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

Individual Family
$5,300 $10,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.05
$391.63
$440.97
$616.26
$936.47 		$609.01
$655.59
$704.93
$880.22 		$872.97
$919.55
$968.89
$1,144.18 		$1,136.93
$1,183.51
$1,232.85
$1,408.14 		$263.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.10
$783.26
$881.94
$1,232.52
$1,872.94 		$954.06
$1,047.22
$1,145.90
$1,496.48 		$1,218.02
$1,311.18
$1,409.86
$1,760.44 		$1,481.98
$1,575.14
$1,673.82
$2,024.40 		$263.96
Toc - Plan #92 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$263.61
$299.20
$336.89
$470.81
$715.44 		$465.27
$500.86
$538.55
$672.47 		$666.93
$702.52
$740.21
$874.13 		$868.59
$904.18
$941.87
$1,075.79 		$201.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$527.22
$598.40
$673.78
$941.62
$1,430.88 		$728.88
$800.06
$875.44
$1,143.28 		$930.54
$1,001.72
$1,077.10
$1,344.94 		$1,132.20
$1,203.38
$1,278.76
$1,546.60 		$201.66
Toc - Plan #93 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Blue Preferred/Broad 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$286.53
$325.21
$366.19
$511.74
$777.64 		$505.73
$544.41
$585.39
$730.94 		$724.93
$763.61
$804.59
$950.14 		$944.13
$982.81
$1,023.79
$1,169.34 		$219.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$573.06
$650.42
$732.38
$1,023.48
$1,555.28 		$792.26
$869.62
$951.58
$1,242.68 		$1,011.46
$1,088.82
$1,170.78
$1,461.88 		$1,230.66
$1,308.02
$1,389.98
$1,681.08 		$219.20
Toc - Plan #94 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Preferred/Broad 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$342.11
$388.29
$437.22
$611.01
$928.49 		$603.82
$650.00
$698.93
$872.72 		$865.53
$911.71
$960.64
$1,134.43 		$1,127.24
$1,173.42
$1,222.35
$1,396.14 		$261.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.22
$776.58
$874.44
$1,222.02
$1,856.98 		$945.93
$1,038.29
$1,136.15
$1,483.73 		$1,207.64
$1,300.00
$1,397.86
$1,745.44 		$1,469.35
$1,561.71
$1,659.57
$2,007.15 		$261.71
Toc - Plan #95 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Preferred/Broad 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1813

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 		$359.76
$408.33
$459.77
$642.53
$976.39 		$634.98
$683.55
$734.99
$917.75 		$910.20
$958.77
$1,010.21
$1,192.97 		$1,185.42
$1,233.99
$1,285.43
$1,468.19 		$275.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.52
$816.66
$919.54
$1,285.06
$1,952.78 		$994.74
$1,091.88
$1,194.76
$1,560.28 		$1,269.96
$1,367.10
$1,469.98
$1,835.50 		$1,545.18
$1,642.32
$1,745.20
$2,110.72 		$275.22

ADVERTISEMENT

Group Health Cooperative-SCW

Local: 1-608-828-4831 | Toll Free: 1-855-344-2729 | TTY: 1-608-828-4815
Toc - Plan #96 Group Health Cooperative-SCW
Platinum

(HMO) Platinum 500 Ded/1500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$1,500 $3,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.29
$478.16
$538.40
$752.42
$1,143.37 		$743.58
$800.45
$860.69
$1,074.71 		$1,065.87
$1,122.74
$1,182.98
$1,397.00 		$1,388.16
$1,445.03
$1,505.27
$1,719.29 		$322.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.58
$956.32
$1,076.80
$1,504.84
$2,286.74 		$1,164.87
$1,278.61
$1,399.09
$1,827.13 		$1,487.16
$1,600.90
$1,721.38
$2,149.42 		$1,809.45
$1,923.19
$2,043.67
$2,471.71 		$322.29
Toc - Plan #97 Group Health Cooperative-SCW
Gold

(HMO) Gold 2600 Ded/2600 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,600 $5,200 Annual Deductible
$2,600 $5,200 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 		$351.26
$398.68
$448.91
$627.35
$953.31 		$619.98
$667.40
$717.63
$896.07 		$888.70
$936.12
$986.35
$1,164.79 		$1,157.42
$1,204.84
$1,255.07
$1,433.51 		$268.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.52
$797.36
$897.82
$1,254.70
$1,906.62 		$971.24
$1,066.08
$1,166.54
$1,523.42 		$1,239.96
$1,334.80
$1,435.26
$1,792.14 		$1,508.68
$1,603.52
$1,703.98
$2,060.86 		$268.72
Toc - Plan #98 Group Health Cooperative-SCW
Silver

(HMO) Silver 5400 Ded/5400 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$411.27
$466.79
$525.60
$734.52
$1,116.18 		$725.89
$781.41
$840.22
$1,049.14 		$1,040.51
$1,096.03
$1,154.84
$1,363.76 		$1,355.13
$1,410.65
$1,469.46
$1,678.38 		$314.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.54
$933.58
$1,051.20
$1,469.04
$2,232.36 		$1,137.16
$1,248.20
$1,365.82
$1,783.66 		$1,451.78
$1,562.82
$1,680.44
$2,098.28 		$1,766.40
$1,877.44
$1,995.06
$2,412.90 		$314.62
Toc - Plan #99 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 4000 Ded/8500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$286.49
$325.16
$366.13
$511.66
$777.52 		$505.65
$544.32
$585.29
$730.82 		$724.81
$763.48
$804.45
$949.98 		$943.97
$982.64
$1,023.61
$1,169.14 		$219.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$572.98
$650.32
$732.26
$1,023.32
$1,555.04 		$792.14
$869.48
$951.42
$1,242.48 		$1,011.30
$1,088.64
$1,170.58
$1,461.64 		$1,230.46
$1,307.80
$1,389.74
$1,680.80 		$219.16
Toc - Plan #100 Group Health Cooperative-SCW
Platinum

(HMO) Select Platinum 500 Ded/1500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$1,500 $3,000 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 		$401.32
$455.50
$512.89
$716.76
$1,089.18 		$708.33
$762.51
$819.90
$1,023.77 		$1,015.34
$1,069.52
$1,126.91
$1,330.78 		$1,322.35
$1,376.53
$1,433.92
$1,637.79 		$307.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.64
$911.00
$1,025.78
$1,433.52
$2,178.36 		$1,109.65
$1,218.01
$1,332.79
$1,740.53 		$1,416.66
$1,525.02
$1,639.80
$2,047.54 		$1,723.67
$1,832.03
$1,946.81
$2,354.55 		$307.01
Toc - Plan #101 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 2600 Ded/2600 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,600 $5,200 Annual Deductible
$2,600 $5,200 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 		$334.63
$379.81
$427.66
$597.65
$908.18 		$590.63
$635.81
$683.66
$853.65 		$846.63
$891.81
$939.66
$1,109.65 		$1,102.63
$1,147.81
$1,195.66
$1,365.65 		$256.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.26
$759.62
$855.32
$1,195.30
$1,816.36 		$925.26
$1,015.62
$1,111.32
$1,451.30 		$1,181.26
$1,271.62
$1,367.32
$1,707.30 		$1,437.26
$1,527.62
$1,623.32
$1,963.30 		$256.00
Toc - Plan #102 Group Health Cooperative-SCW
Silver

(HMO) Select Silver 5400 Ded/5400 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$382.06
$433.64
$488.27
$682.36
$1,036.91 		$674.34
$725.92
$780.55
$974.64 		$966.62
$1,018.20
$1,072.83
$1,266.92 		$1,258.90
$1,310.48
$1,365.11
$1,559.20 		$292.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.12
$867.28
$976.54
$1,364.72
$2,073.82 		$1,056.40
$1,159.56
$1,268.82
$1,657.00 		$1,348.68
$1,451.84
$1,561.10
$1,949.28 		$1,640.96
$1,744.12
$1,853.38
$2,241.56 		$292.28
Toc - Plan #103 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Select Bronze 4000 Ded/8500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$272.94
$309.79
$348.82
$487.47
$740.76 		$481.74
$518.59
$557.62
$696.27 		$690.54
$727.39
$766.42
$905.07 		$899.34
$936.19
$975.22
$1,113.87 		$208.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$545.88
$619.58
$697.64
$974.94
$1,481.52 		$754.68
$828.38
$906.44
$1,183.74 		$963.48
$1,037.18
$1,115.24
$1,392.54 		$1,172.28
$1,245.98
$1,324.04
$1,601.34 		$208.80
Toc - Plan #104 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 7500 Ded/7500 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$278.60
$316.21
$356.04
$497.57
$756.10 		$491.73
$529.34
$569.17
$710.70 		$704.86
$742.47
$782.30
$923.83 		$917.99
$955.60
$995.43
$1,136.96 		$213.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.20
$632.42
$712.08
$995.14
$1,512.20 		$770.33
$845.55
$925.21
$1,208.27 		$983.46
$1,058.68
$1,138.34
$1,421.40 		$1,196.59
$1,271.81
$1,351.47
$1,634.53 		$213.13
Toc - Plan #105 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Select Bronze 7500 Ded/7500 MOOP HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$265.43
$301.26
$339.22
$474.05
$720.36 		$468.48
$504.31
$542.27
$677.10 		$671.53
$707.36
$745.32
$880.15 		$874.58
$910.41
$948.37
$1,083.20 		$203.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$530.86
$602.52
$678.44
$948.10
$1,440.72 		$733.91
$805.57
$881.49
$1,151.15 		$936.96
$1,008.62
$1,084.54
$1,354.20 		$1,140.01
$1,211.67
$1,287.59
$1,557.25 		$203.05
Toc - Plan #106 Group Health Cooperative-SCW
Gold

(HMO) Gold 2500 Ded/6500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$351.45
$398.90
$449.16
$627.69
$953.84 		$620.31
$667.76
$718.02
$896.55 		$889.17
$936.62
$986.88
$1,165.41 		$1,158.03
$1,205.48
$1,255.74
$1,434.27 		$268.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$702.90
$797.80
$898.32
$1,255.38
$1,907.68 		$971.76
$1,066.66
$1,167.18
$1,524.24 		$1,240.62
$1,335.52
$1,436.04
$1,793.10 		$1,509.48
$1,604.38
$1,704.90
$2,061.96 		$268.86
Toc - Plan #107 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 2500 Ded/6500 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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 		$334.81
$380.01
$427.89
$597.98
$908.68 		$590.94
$636.14
$684.02
$854.11 		$847.07
$892.27
$940.15
$1,110.24 		$1,103.20
$1,148.40
$1,196.28
$1,366.37 		$256.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.62
$760.02
$855.78
$1,195.96
$1,817.36 		$925.75
$1,016.15
$1,111.91
$1,452.09 		$1,181.88
$1,272.28
$1,368.04
$1,708.22 		$1,438.01
$1,528.41
$1,624.17
$1,964.35 		$256.13
Toc - Plan #108 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 1800 Ded/5600 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$5,600 $11,200 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 		$340.33
$386.27
$434.94
$607.82
$923.64 		$600.68
$646.62
$695.29
$868.17 		$861.03
$906.97
$955.64
$1,128.52 		$1,121.38
$1,167.32
$1,215.99
$1,388.87 		$260.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.66
$772.54
$869.88
$1,215.64
$1,847.28 		$941.01
$1,032.89
$1,130.23
$1,475.99 		$1,201.36
$1,293.24
$1,390.58
$1,736.34 		$1,461.71
$1,553.59
$1,650.93
$1,996.69 		$260.35
Toc - Plan #109 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Select Bronze 6850 Ded/8200 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$8,200 $16,400 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 		$280.69
$318.58
$358.72
$501.30
$761.78 		$495.42
$533.31
$573.45
$716.03 		$710.15
$748.04
$788.18
$930.76 		$924.88
$962.77
$1,002.91
$1,145.49 		$214.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.38
$637.16
$717.44
$1,002.60
$1,523.56 		$776.11
$851.89
$932.17
$1,217.33 		$990.84
$1,066.62
$1,146.90
$1,432.06 		$1,205.57
$1,281.35
$1,361.63
$1,646.79 		$214.73
Toc - Plan #110 Group Health Cooperative-SCW
Catastrophic

(HMO) Select Catastrophic 9100 Ded/9100 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$213.07
$241.83
$272.30
$380.54
$578.26 		$376.07
$404.83
$435.30
$543.54 		$539.07
$567.83
$598.30
$706.54 		$702.07
$730.83
$761.30
$869.54 		$163.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$426.14
$483.66
$544.60
$761.08
$1,156.52 		$589.14
$646.66
$707.60
$924.08 		$752.14
$809.66
$870.60
$1,087.08 		$915.14
$972.66
$1,033.60
$1,250.08 		$163.00
Toc - Plan #111 Group Health Cooperative-SCW
Gold

(HMO) Gold 1800 Ded/5600 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$5,600 $11,200 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 		$357.24
$405.47
$456.55
$638.03
$969.55 		$630.53
$678.76
$729.84
$911.32 		$903.82
$952.05
$1,003.13
$1,184.61 		$1,177.11
$1,225.34
$1,276.42
$1,457.90 		$273.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.48
$810.94
$913.10
$1,276.06
$1,939.10 		$987.77
$1,084.23
$1,186.39
$1,549.35 		$1,261.06
$1,357.52
$1,459.68
$1,822.64 		$1,534.35
$1,630.81
$1,732.97
$2,095.93 		$273.29
Toc - Plan #112 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 6850 Ded/8200 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$8,200 $16,400 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 		$294.62
$334.39
$376.52
$526.19
$799.59 		$520.00
$559.77
$601.90
$751.57 		$745.38
$785.15
$827.28
$976.95 		$970.76
$1,010.53
$1,052.66
$1,202.33 		$225.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$589.24
$668.78
$753.04
$1,052.38
$1,599.18 		$814.62
$894.16
$978.42
$1,277.76 		$1,040.00
$1,119.54
$1,203.80
$1,503.14 		$1,265.38
$1,344.92
$1,429.18
$1,728.52 		$225.38
Toc - Plan #113 Group Health Cooperative-SCW
Platinum

(HMO) Platinum No Ded/2200 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,200 $4,400 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 		$420.91
$477.73
$537.92
$751.74
$1,142.34 		$742.91
$799.73
$859.92
$1,073.74 		$1,064.91
$1,121.73
$1,181.92
$1,395.74 		$1,386.91
$1,443.73
$1,503.92
$1,717.74 		$322.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.82
$955.46
$1,075.84
$1,503.48
$2,284.68 		$1,163.82
$1,277.46
$1,397.84
$1,825.48 		$1,485.82
$1,599.46
$1,719.84
$2,147.48 		$1,807.82
$1,921.46
$2,041.84
$2,469.48 		$322.00
Toc - Plan #114 Group Health Cooperative-SCW
Platinum

(HMO) Select Platinum No Ded/2200 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$2,200 $4,400 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 		$400.97
$455.10
$512.44
$716.13
$1,088.22 		$707.71
$761.84
$819.18
$1,022.87 		$1,014.45
$1,068.58
$1,125.92
$1,329.61 		$1,321.19
$1,375.32
$1,432.66
$1,636.35 		$306.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.94
$910.20
$1,024.88
$1,432.26
$2,176.44 		$1,108.68
$1,216.94
$1,331.62
$1,739.00 		$1,415.42
$1,523.68
$1,638.36
$2,045.74 		$1,722.16
$1,830.42
$1,945.10
$2,352.48 		$306.74
Toc - Plan #115 Group Health Cooperative-SCW
Bronze

(HMO) Bronze 9050 Ded/9050 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$273.13
$310.00
$349.06
$487.81
$741.27 		$482.08
$518.95
$558.01
$696.76 		$691.03
$727.90
$766.96
$905.71 		$899.98
$936.85
$975.91
$1,114.66 		$208.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$546.26
$620.00
$698.12
$975.62
$1,482.54 		$755.21
$828.95
$907.07
$1,184.57 		$964.16
$1,037.90
$1,116.02
$1,393.52 		$1,173.11
$1,246.85
$1,324.97
$1,602.47 		$208.95
Toc - Plan #116 Group Health Cooperative-SCW
Bronze

(HMO) Select Bronze 9050 Ded/9050 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$260.22
$295.35
$332.56
$464.75
$706.24 		$459.29
$494.42
$531.63
$663.82 		$658.36
$693.49
$730.70
$862.89 		$857.43
$892.56
$929.77
$1,061.96 		$199.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$520.44
$590.70
$665.12
$929.50
$1,412.48 		$719.51
$789.77
$864.19
$1,128.57 		$918.58
$988.84
$1,063.26
$1,327.64 		$1,117.65
$1,187.91
$1,262.33
$1,526.71 		$199.07
Toc - Plan #117 Group Health Cooperative-SCW
Silver

(HMO) Silver 4900 Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 Annual Deductible
$7,900 $15,800 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 		$414.10
$470.00
$529.22
$739.58
$1,123.86 		$730.89
$786.79
$846.01
$1,056.37 		$1,047.68
$1,103.58
$1,162.80
$1,373.16 		$1,364.47
$1,420.37
$1,479.59
$1,689.95 		$316.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.20
$940.00
$1,058.44
$1,479.16
$2,247.72 		$1,144.99
$1,256.79
$1,375.23
$1,795.95 		$1,461.78
$1,573.58
$1,692.02
$2,112.74 		$1,778.57
$1,890.37
$2,008.81
$2,429.53 		$316.79
Toc - Plan #118 Group Health Cooperative-SCW
Silver

(HMO) Select Silver 4900 Ded/7900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 Annual Deductible
$7,900 $15,800 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 		$390.18
$442.86
$498.65
$696.86
$1,058.94 		$688.67
$741.35
$797.14
$995.35 		$987.16
$1,039.84
$1,095.63
$1,293.84 		$1,285.65
$1,338.33
$1,394.12
$1,592.33 		$298.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.36
$885.72
$997.30
$1,393.72
$2,117.88 		$1,078.85
$1,184.21
$1,295.79
$1,692.21 		$1,377.34
$1,482.70
$1,594.28
$1,990.70 		$1,675.83
$1,781.19
$1,892.77
$2,289.19 		$298.49
Toc - Plan #119 Group Health Cooperative-SCW
Gold

(HMO) Gold 1500 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$341.38
$387.47
$436.29
$609.71
$926.51 		$602.54
$648.63
$697.45
$870.87 		$863.70
$909.79
$958.61
$1,132.03 		$1,124.86
$1,170.95
$1,219.77
$1,393.19 		$261.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.76
$774.94
$872.58
$1,219.42
$1,853.02 		$943.92
$1,036.10
$1,133.74
$1,480.58 		$1,205.08
$1,297.26
$1,394.90
$1,741.74 		$1,466.24
$1,558.42
$1,656.06
$2,002.90 		$261.16
Toc - Plan #120 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 1500 Ded/8550 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$325.23
$369.13
$415.64
$580.85
$882.65 		$574.03
$617.93
$664.44
$829.65 		$822.83
$866.73
$913.24
$1,078.45 		$1,071.63
$1,115.53
$1,162.04
$1,327.25 		$248.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.46
$738.26
$831.28
$1,161.70
$1,765.30 		$899.26
$987.06
$1,080.08
$1,410.50 		$1,148.06
$1,235.86
$1,328.88
$1,659.30 		$1,396.86
$1,484.66
$1,577.68
$1,908.10 		$248.80
Toc - Plan #121 Group Health Cooperative-SCW
Catastrophic

(HMO) Catastrophic 9100 Ded/9100 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$223.62
$253.81
$285.79
$399.39
$606.90 		$394.69
$424.88
$456.86
$570.46 		$565.76
$595.95
$627.93
$741.53 		$736.83
$767.02
$799.00
$912.60 		$171.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$447.24
$507.62
$571.58
$798.78
$1,213.80 		$618.31
$678.69
$742.65
$969.85 		$789.38
$849.76
$913.72
$1,140.92 		$960.45
$1,020.83
$1,084.79
$1,311.99 		$171.07
Toc - Plan #122 Group Health Cooperative-SCW
Platinum

(HMO) Platinum 1000 Ded/4000 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 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 		$396.89
$450.47
$507.23
$708.84
$1,077.15 		$700.51
$754.09
$810.85
$1,012.46 		$1,004.13
$1,057.71
$1,114.47
$1,316.08 		$1,307.75
$1,361.33
$1,418.09
$1,619.70 		$303.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$793.78
$900.94
$1,014.46
$1,417.68
$2,154.30 		$1,097.40
$1,204.56
$1,318.08
$1,721.30 		$1,401.02
$1,508.18
$1,621.70
$2,024.92 		$1,704.64
$1,811.80
$1,925.32
$2,328.54 		$303.62
Toc - Plan #123 Group Health Cooperative-SCW
Gold

(HMO) Gold 4450 Ded/7450 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,450 $8,900 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 		$337.55
$383.11
$431.38
$602.85
$916.09 		$595.77
$641.33
$689.60
$861.07 		$853.99
$899.55
$947.82
$1,119.29 		$1,112.21
$1,157.77
$1,206.04
$1,377.51 		$258.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.10
$766.22
$862.76
$1,205.70
$1,832.18 		$933.32
$1,024.44
$1,120.98
$1,463.92 		$1,191.54
$1,282.66
$1,379.20
$1,722.14 		$1,449.76
$1,540.88
$1,637.42
$1,980.36 		$258.22
Toc - Plan #124 Group Health Cooperative-SCW
Silver

(HMO) Silver 9050 Ded/9050 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$404.81
$459.46
$517.35
$722.99
$1,098.65 		$714.49
$769.14
$827.03
$1,032.67 		$1,024.17
$1,078.82
$1,136.71
$1,342.35 		$1,333.85
$1,388.50
$1,446.39
$1,652.03 		$309.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$809.62
$918.92
$1,034.70
$1,445.98
$2,197.30 		$1,119.30
$1,228.60
$1,344.38
$1,755.66 		$1,428.98
$1,538.28
$1,654.06
$2,065.34 		$1,738.66
$1,847.96
$1,963.74
$2,375.02 		$309.68
Toc - Plan #125 Group Health Cooperative-SCW
Platinum

(HMO) Select Platinum 1000 Ded/4000 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$4,000 $8,000 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 		$378.09
$429.13
$483.20
$675.26
$1,026.13 		$667.33
$718.37
$772.44
$964.50 		$956.57
$1,007.61
$1,061.68
$1,253.74 		$1,245.81
$1,296.85
$1,350.92
$1,542.98 		$289.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.18
$858.26
$966.40
$1,350.52
$2,052.26 		$1,045.42
$1,147.50
$1,255.64
$1,639.76 		$1,334.66
$1,436.74
$1,544.88
$1,929.00 		$1,623.90
$1,725.98
$1,834.12
$2,218.24 		$289.24
Toc - Plan #126 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 4450 Ded/7450 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$4,450 $8,900 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 		$321.57
$364.98
$410.97
$574.32
$872.73 		$567.57
$610.98
$656.97
$820.32 		$813.57
$856.98
$902.97
$1,066.32 		$1,059.57
$1,102.98
$1,148.97
$1,312.32 		$246.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.14
$729.96
$821.94
$1,148.64
$1,745.46 		$889.14
$975.96
$1,067.94
$1,394.64 		$1,135.14
$1,221.96
$1,313.94
$1,640.64 		$1,381.14
$1,467.96
$1,559.94
$1,886.64 		$246.00
Toc - Plan #127 Group Health Cooperative-SCW
Silver

(HMO) Select Silver 9050 Ded/9050 MOOP Primary Care Preferred

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$392.91
$445.96
$502.14
$701.74
$1,066.36 		$693.49
$746.54
$802.72
$1,002.32 		$994.07
$1,047.12
$1,103.30
$1,302.90 		$1,294.65
$1,347.70
$1,403.88
$1,603.48 		$300.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.82
$891.92
$1,004.28
$1,403.48
$2,132.72 		$1,086.40
$1,192.50
$1,304.86
$1,704.06 		$1,386.98
$1,493.08
$1,605.44
$2,004.64 		$1,687.56
$1,793.66
$1,906.02
$2,305.22 		$300.58
Toc - Plan #128 Group Health Cooperative-SCW
Platinum

(HMO) Platinum No Ded/3000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$436.42
$495.34
$557.75
$779.45
$1,184.44 		$770.28
$829.20
$891.61
$1,113.31 		$1,104.14
$1,163.06
$1,225.47
$1,447.17 		$1,438.00
$1,496.92
$1,559.33
$1,781.03 		$333.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.84
$990.68
$1,115.50
$1,558.90
$2,368.88 		$1,206.70
$1,324.54
$1,449.36
$1,892.76 		$1,540.56
$1,658.40
$1,783.22
$2,226.62 		$1,874.42
$1,992.26
$2,117.08
$2,560.48 		$333.86
Toc - Plan #129 Group Health Cooperative-SCW
Gold

(HMO) Gold 2000 Ded/8700 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$341.58
$387.69
$436.53
$610.05
$927.03 		$602.89
$649.00
$697.84
$871.36 		$864.20
$910.31
$959.15
$1,132.67 		$1,125.51
$1,171.62
$1,220.46
$1,393.98 		$261.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.16
$775.38
$873.06
$1,220.10
$1,854.06 		$944.47
$1,036.69
$1,134.37
$1,481.41 		$1,205.78
$1,298.00
$1,395.68
$1,742.72 		$1,467.09
$1,559.31
$1,656.99
$2,004.03 		$261.31
Toc - Plan #130 Group Health Cooperative-SCW
Silver

(HMO) Silver 5800 Ded/8900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$398.39
$452.17
$509.14
$711.52
$1,081.22 		$703.16
$756.94
$813.91
$1,016.29 		$1,007.93
$1,061.71
$1,118.68
$1,321.06 		$1,312.70
$1,366.48
$1,423.45
$1,625.83 		$304.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.78
$904.34
$1,018.28
$1,423.04
$2,162.44 		$1,101.55
$1,209.11
$1,323.05
$1,727.81 		$1,406.32
$1,513.88
$1,627.82
$2,032.58 		$1,711.09
$1,818.65
$1,932.59
$2,337.35 		$304.77
Toc - Plan #131 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Bronze 7500 Ded/9000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$291.66
$331.03
$372.74
$520.90
$791.55 		$514.78
$554.15
$595.86
$744.02 		$737.90
$777.27
$818.98
$967.14 		$961.02
$1,000.39
$1,042.10
$1,190.26 		$223.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.32
$662.06
$745.48
$1,041.80
$1,583.10 		$806.44
$885.18
$968.60
$1,264.92 		$1,029.56
$1,108.30
$1,191.72
$1,488.04 		$1,252.68
$1,331.42
$1,414.84
$1,711.16 		$223.12
Toc - Plan #132 Group Health Cooperative-SCW
Bronze

(HMO) Bronze 9100 Ded/9100 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$259.64
$294.69
$331.82
$463.71
$704.66 		$458.27
$493.32
$530.45
$662.34 		$656.90
$691.95
$729.08
$860.97 		$855.53
$890.58
$927.71
$1,059.60 		$198.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$519.28
$589.38
$663.64
$927.42
$1,409.32 		$717.91
$788.01
$862.27
$1,126.05 		$916.54
$986.64
$1,060.90
$1,324.68 		$1,115.17
$1,185.27
$1,259.53
$1,523.31 		$198.63
Toc - Plan #133 Group Health Cooperative-SCW
Platinum

(HMO) Select Platinum No Ded/3000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$415.73
$471.86
$531.31
$742.50
$1,128.30 		$733.77
$789.90
$849.35
$1,060.54 		$1,051.81
$1,107.94
$1,167.39
$1,378.58 		$1,369.85
$1,425.98
$1,485.43
$1,696.62 		$318.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.46
$943.72
$1,062.62
$1,485.00
$2,256.60 		$1,149.50
$1,261.76
$1,380.66
$1,803.04 		$1,467.54
$1,579.80
$1,698.70
$2,121.08 		$1,785.58
$1,897.84
$2,016.74
$2,439.12 		$318.04
Toc - Plan #134 Group Health Cooperative-SCW
Gold

(HMO) Select Gold 2000 Ded/8700 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$325.41
$369.34
$415.87
$581.17
$883.15 		$574.35
$618.28
$664.81
$830.11 		$823.29
$867.22
$913.75
$1,079.05 		$1,072.23
$1,116.16
$1,162.69
$1,327.99 		$248.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.82
$738.68
$831.74
$1,162.34
$1,766.30 		$899.76
$987.62
$1,080.68
$1,411.28 		$1,148.70
$1,236.56
$1,329.62
$1,660.22 		$1,397.64
$1,485.50
$1,578.56
$1,909.16 		$248.94
Toc - Plan #135 Group Health Cooperative-SCW
Silver

(HMO) Select Silver 5800 Ded/8900 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$380.67
$432.06
$486.50
$679.88
$1,033.14 		$671.89
$723.28
$777.72
$971.10 		$963.11
$1,014.50
$1,068.94
$1,262.32 		$1,254.33
$1,305.72
$1,360.16
$1,553.54 		$291.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$761.34
$864.12
$973.00
$1,359.76
$2,066.28 		$1,052.56
$1,155.34
$1,264.22
$1,650.98 		$1,343.78
$1,446.56
$1,555.44
$1,942.20 		$1,635.00
$1,737.78
$1,846.66
$2,233.42 		$291.22
Toc - Plan #136 Group Health Cooperative-SCW
Expanded Bronze

(HMO) Select Bronze 7500 Ded/9000 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$277.87
$315.38
$355.11
$496.27
$754.12 		$490.44
$527.95
$567.68
$708.84 		$703.01
$740.52
$780.25
$921.41 		$915.58
$953.09
$992.82
$1,133.98 		$212.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.74
$630.76
$710.22
$992.54
$1,508.24 		$768.31
$843.33
$922.79
$1,205.11 		$980.88
$1,055.90
$1,135.36
$1,417.68 		$1,193.45
$1,268.47
$1,347.93
$1,630.25 		$212.57
Toc - Plan #137 Group Health Cooperative-SCW
Bronze

(HMO) Select Bronze 9100 Ded/9100 MOOP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-344-2729

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 		$247.37
$280.77
$316.14
$441.80
$671.36 		$436.61
$470.01
$505.38
$631.04 		$625.85
$659.25
$694.62
$820.28 		$815.09
$848.49
$883.86
$1,009.52 		$189.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.74
$561.54
$632.28
$883.60
$1,342.72 		$683.98
$750.78
$821.52
$1,072.84 		$873.22
$940.02
$1,010.76
$1,262.08 		$1,062.46
$1,129.26
$1,200.00
$1,451.32 		$189.24

‡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 Dane County here.

Dane County is in “Rating Area 2” of Wisconsin.

Currently, there are 137 plans offered in Rating Area 2.

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