Obamacare 2023 Rates for Maricopa County

Obamacare > Rates > Arizona > Maricopa 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 Mesa, AZ.

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

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

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

Obamacare Providers, 138 Plans and 2023 Rates for Maricopa County, Arizona

Below, you’ll find a summary of the 138 plans for Maricopa County, Arizona 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 |

Maricopa County Resources

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Oscar Health Plan, Inc.

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755

Toc - Plan #1 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$262.47
$297.89
$335.43
$468.76
$712.32 		$463.25
$498.67
$536.21
$669.54 		$664.03
$699.45
$736.99
$870.32 		$864.81
$900.23
$937.77
$1,071.10 		$200.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$524.94
$595.78
$670.86
$937.52
$1,424.64 		$725.72
$796.56
$871.64
$1,138.30 		$926.50
$997.34
$1,072.42
$1,339.08 		$1,127.28
$1,198.12
$1,273.20
$1,539.86 		$200.78
Toc - Plan #2 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$257.24
$291.95
$328.73
$459.40
$698.11 		$454.02
$488.73
$525.51
$656.18 		$650.80
$685.51
$722.29
$852.96 		$847.58
$882.29
$919.07
$1,049.74 		$196.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$514.48
$583.90
$657.46
$918.80
$1,396.22 		$711.26
$780.68
$854.24
$1,115.58 		$908.04
$977.46
$1,051.02
$1,312.36 		$1,104.82
$1,174.24
$1,247.80
$1,509.14 		$196.78
Toc - Plan #3 Oscar Health Plan, Inc.
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.52
$346.75
$390.44
$545.64
$829.16 		$539.24
$580.47
$624.16
$779.36 		$772.96
$814.19
$857.88
$1,013.08 		$1,006.68
$1,047.91
$1,091.60
$1,246.80 		$233.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.04
$693.50
$780.88
$1,091.28
$1,658.32 		$844.76
$927.22
$1,014.60
$1,325.00 		$1,078.48
$1,160.94
$1,248.32
$1,558.72 		$1,312.20
$1,394.66
$1,482.04
$1,792.44 		$233.72
Toc - Plan #4 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $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 		$318.24
$361.19
$406.69
$568.35
$863.67 		$561.68
$604.63
$650.13
$811.79 		$805.12
$848.07
$893.57
$1,055.23 		$1,048.56
$1,091.51
$1,137.01
$1,298.67 		$243.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.48
$722.38
$813.38
$1,136.70
$1,727.34 		$879.92
$965.82
$1,056.82
$1,380.14 		$1,123.36
$1,209.26
$1,300.26
$1,623.58 		$1,366.80
$1,452.70
$1,543.70
$1,867.02 		$243.44
Toc - Plan #5 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.27
$355.55
$400.35
$559.49
$850.19 		$552.92
$595.20
$640.00
$799.14 		$792.57
$834.85
$879.65
$1,038.79 		$1,032.22
$1,074.50
$1,119.30
$1,278.44 		$239.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.54
$711.10
$800.70
$1,118.98
$1,700.38 		$866.19
$950.75
$1,040.35
$1,358.63 		$1,105.84
$1,190.40
$1,280.00
$1,598.28 		$1,345.49
$1,430.05
$1,519.65
$1,837.93 		$239.65
Toc - Plan #6 Oscar Health Plan, Inc.
Catastrophic

(HMO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$214.36
$243.29
$273.94
$382.83
$581.74 		$378.34
$407.27
$437.92
$546.81 		$542.32
$571.25
$601.90
$710.79 		$706.30
$735.23
$765.88
$874.77 		$163.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$428.72
$486.58
$547.88
$765.66
$1,163.48 		$592.70
$650.56
$711.86
$929.64 		$756.68
$814.54
$875.84
$1,093.62 		$920.66
$978.52
$1,039.82
$1,257.60 		$163.98
Toc - Plan #7 Oscar Health Plan, Inc.
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304.58
$345.69
$389.25
$543.97
$826.61 		$537.58
$578.69
$622.25
$776.97 		$770.58
$811.69
$855.25
$1,009.97 		$1,003.58
$1,044.69
$1,088.25
$1,242.97 		$233.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.16
$691.38
$778.50
$1,087.94
$1,653.22 		$842.16
$924.38
$1,011.50
$1,320.94 		$1,075.16
$1,157.38
$1,244.50
$1,553.94 		$1,308.16
$1,390.38
$1,477.50
$1,786.94 		$233.00
Toc - Plan #8 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$398.25
$452.00
$508.95
$711.26
$1,080.83 		$702.90
$756.65
$813.60
$1,015.91 		$1,007.55
$1,061.30
$1,118.25
$1,320.56 		$1,312.20
$1,365.95
$1,422.90
$1,625.21 		$304.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.50
$904.00
$1,017.90
$1,422.52
$2,161.66 		$1,101.15
$1,208.65
$1,322.55
$1,727.17 		$1,405.80
$1,513.30
$1,627.20
$2,031.82 		$1,710.45
$1,817.95
$1,931.85
$2,336.47 		$304.65
Toc - Plan #9 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$273.90
$310.87
$350.04
$489.18
$743.35 		$483.43
$520.40
$559.57
$698.71 		$692.96
$729.93
$769.10
$908.24 		$902.49
$939.46
$978.63
$1,117.77 		$209.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.80
$621.74
$700.08
$978.36
$1,486.70 		$757.33
$831.27
$909.61
$1,187.89 		$966.86
$1,040.80
$1,119.14
$1,397.42 		$1,176.39
$1,250.33
$1,328.67
$1,606.95 		$209.53
Toc - Plan #10 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic- $0 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.82
$386.82
$435.56
$608.69
$924.96 		$601.54
$647.54
$696.28
$869.41 		$862.26
$908.26
$957.00
$1,130.13 		$1,122.98
$1,168.98
$1,217.72
$1,390.85 		$260.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.64
$773.64
$871.12
$1,217.38
$1,849.92 		$942.36
$1,034.36
$1,131.84
$1,478.10 		$1,203.08
$1,295.08
$1,392.56
$1,738.82 		$1,463.80
$1,555.80
$1,653.28
$1,999.54 		$260.72
Toc - Plan #11 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- $4700 Ded

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$275.82
$313.05
$352.49
$492.60
$748.55 		$486.82
$524.05
$563.49
$703.60 		$697.82
$735.05
$774.49
$914.60 		$908.82
$946.05
$985.49
$1,125.60 		$211.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$551.64
$626.10
$704.98
$985.20
$1,497.10 		$762.64
$837.10
$915.98
$1,196.20 		$973.64
$1,048.10
$1,126.98
$1,407.20 		$1,184.64
$1,259.10
$1,337.98
$1,618.20 		$211.00
Toc - Plan #12 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$304.59
$345.70
$389.26
$543.99
$826.64 		$537.60
$578.71
$622.27
$777.00 		$770.61
$811.72
$855.28
$1,010.01 		$1,003.62
$1,044.73
$1,088.29
$1,243.02 		$233.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.18
$691.40
$778.52
$1,087.98
$1,653.28 		$842.19
$924.41
$1,011.53
$1,320.99 		$1,075.20
$1,157.42
$1,244.54
$1,554.00 		$1,308.21
$1,390.43
$1,477.55
$1,787.01 		$233.01
Toc - Plan #13 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- $0 PCP

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$327.75
$371.98
$418.85
$585.34
$889.48 		$578.47
$622.70
$669.57
$836.06 		$829.19
$873.42
$920.29
$1,086.78 		$1,079.91
$1,124.14
$1,171.01
$1,337.50 		$250.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.50
$743.96
$837.70
$1,170.68
$1,778.96 		$906.22
$994.68
$1,088.42
$1,421.40 		$1,156.94
$1,245.40
$1,339.14
$1,672.12 		$1,407.66
$1,496.12
$1,589.86
$1,922.84 		$250.72
Toc - Plan #14 Oscar Health Plan, Inc.
Silver

(HMO) Silver Elite- $0 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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 		$325.17
$369.05
$415.55
$580.73
$882.47 		$573.91
$617.79
$664.29
$829.47 		$822.65
$866.53
$913.03
$1,078.21 		$1,071.39
$1,115.27
$1,161.77
$1,326.95 		$248.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.34
$738.10
$831.10
$1,161.46
$1,764.94 		$899.08
$986.84
$1,079.84
$1,410.20 		$1,147.82
$1,235.58
$1,328.58
$1,658.94 		$1,396.56
$1,484.32
$1,577.32
$1,907.68 		$248.74
Toc - Plan #15 Oscar Health Plan, Inc.
Gold

(HMO) Gold Elite- $0 Ded

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$439.92
$499.30
$562.21
$785.68
$1,193.92 		$776.45
$835.83
$898.74
$1,122.21 		$1,112.98
$1,172.36
$1,235.27
$1,458.74 		$1,449.51
$1,508.89
$1,571.80
$1,795.27 		$336.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$879.84
$998.60
$1,124.42
$1,571.36
$2,387.84 		$1,216.37
$1,335.13
$1,460.95
$1,907.89 		$1,552.90
$1,671.66
$1,797.48
$2,244.42 		$1,889.43
$2,008.19
$2,134.01
$2,580.95 		$336.53
Toc - Plan #16 Oscar Health Plan, Inc.
Gold

(HMO) Gold Elite

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.34
$469.13
$528.23
$738.20
$1,121.77 		$729.54
$785.33
$844.43
$1,054.40 		$1,045.74
$1,101.53
$1,160.63
$1,370.60 		$1,361.94
$1,417.73
$1,476.83
$1,686.80 		$316.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$826.68
$938.26
$1,056.46
$1,476.40
$2,243.54 		$1,142.88
$1,254.46
$1,372.66
$1,792.60 		$1,459.08
$1,570.66
$1,688.86
$2,108.80 		$1,775.28
$1,886.86
$2,005.06
$2,425.00 		$316.20
Toc - Plan #17 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 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 		$315.23
$357.78
$402.86
$562.99
$855.52 		$556.38
$598.93
$644.01
$804.14 		$797.53
$840.08
$885.16
$1,045.29 		$1,038.68
$1,081.23
$1,126.31
$1,286.44 		$241.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$630.46
$715.56
$805.72
$1,125.98
$1,711.04 		$871.61
$956.71
$1,046.87
$1,367.13 		$1,112.76
$1,197.86
$1,288.02
$1,608.28 		$1,353.91
$1,439.01
$1,529.17
$1,849.43 		$241.15
Toc - Plan #18 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$270.26
$306.74
$345.39
$482.68
$733.47 		$477.00
$513.48
$552.13
$689.42 		$683.74
$720.22
$758.87
$896.16 		$890.48
$926.96
$965.61
$1,102.90 		$206.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.52
$613.48
$690.78
$965.36
$1,466.94 		$747.26
$820.22
$897.52
$1,172.10 		$954.00
$1,026.96
$1,104.26
$1,378.84 		$1,160.74
$1,233.70
$1,311.00
$1,585.58 		$206.74
Toc - Plan #19 Oscar Health Plan, Inc.
Bronze

(HMO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$245.29
$278.39
$313.46
$438.06
$665.68 		$432.93
$466.03
$501.10
$625.70 		$620.57
$653.67
$688.74
$813.34 		$808.21
$841.31
$876.38
$1,000.98 		$187.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$490.58
$556.78
$626.92
$876.12
$1,331.36 		$678.22
$744.42
$814.56
$1,063.76 		$865.86
$932.06
$1,002.20
$1,251.40 		$1,053.50
$1,119.70
$1,189.84
$1,439.04 		$187.64
Toc - Plan #20 Oscar Health Plan, Inc.
Silver

(HMO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$307.31
$348.79
$392.73
$548.84
$834.02 		$542.40
$583.88
$627.82
$783.93 		$777.49
$818.97
$862.91
$1,019.02 		$1,012.58
$1,054.06
$1,098.00
$1,254.11 		$235.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.62
$697.58
$785.46
$1,097.68
$1,668.04 		$849.71
$932.67
$1,020.55
$1,332.77 		$1,084.80
$1,167.76
$1,255.64
$1,567.86 		$1,319.89
$1,402.85
$1,490.73
$1,802.95 		$235.09
Toc - Plan #21 Oscar Health Plan, Inc.
Gold

(HMO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.50
$429.59
$483.71
$675.99
$1,027.23 		$668.05
$719.14
$773.26
$965.54 		$957.60
$1,008.69
$1,062.81
$1,255.09 		$1,247.15
$1,298.24
$1,352.36
$1,544.64 		$289.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.00
$859.18
$967.42
$1,351.98
$2,054.46 		$1,046.55
$1,148.73
$1,256.97
$1,641.53 		$1,336.10
$1,438.28
$1,546.52
$1,931.08 		$1,625.65
$1,727.83
$1,836.07
$2,220.63 		$289.55

ADVERTISEMENT

BannerAetna

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915 | TTY: 1-855-586-6960
Toc - Plan #22 BannerAetna
Expanded Bronze

(HMO) BannerAetna Bronze (Low Premium + Unlimited $5 98point6 Telehealth + Low-Cost MinuteClinic)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$231.26
$262.48
$295.55
$413.03
$627.64 		$408.17
$439.39
$472.46
$589.94 		$585.08
$616.30
$649.37
$766.85 		$761.99
$793.21
$826.28
$943.76 		$176.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$462.52
$524.96
$591.10
$826.06
$1,255.28 		$639.43
$701.87
$768.01
$1,002.97 		$816.34
$878.78
$944.92
$1,179.88 		$993.25
$1,055.69
$1,121.83
$1,356.79 		$176.91
Toc - Plan #23 BannerAetna
Expanded Bronze

(HMO) BannerAetna Bronze (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$8,800 $17,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$228.32
$259.15
$291.80
$407.79
$619.67 		$402.99
$433.82
$466.47
$582.46 		$577.66
$608.49
$641.14
$757.13 		$752.33
$783.16
$815.81
$931.80 		$174.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$456.64
$518.30
$583.60
$815.58
$1,239.34 		$631.31
$692.97
$758.27
$990.25 		$805.98
$867.64
$932.94
$1,164.92 		$980.65
$1,042.31
$1,107.61
$1,339.59 		$174.67
Toc - Plan #24 BannerAetna
Gold

(HMO) BannerAetna Gold (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.17
$437.17
$492.25
$687.91
$1,045.35 		$679.83
$731.83
$786.91
$982.57 		$974.49
$1,026.49
$1,081.57
$1,277.23 		$1,269.15
$1,321.15
$1,376.23
$1,571.89 		$294.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$770.34
$874.34
$984.50
$1,375.82
$2,090.70 		$1,065.00
$1,169.00
$1,279.16
$1,670.48 		$1,359.66
$1,463.66
$1,573.82
$1,965.14 		$1,654.32
$1,758.32
$1,868.48
$2,259.80 		$294.66
Toc - Plan #25 BannerAetna
Silver

(HMO) BannerAetna Silver 2 (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$287.67
$326.51
$367.64
$513.78
$780.74 		$507.74
$546.58
$587.71
$733.85 		$727.81
$766.65
$807.78
$953.92 		$947.88
$986.72
$1,027.85
$1,173.99 		$220.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$575.34
$653.02
$735.28
$1,027.56
$1,561.48 		$795.41
$873.09
$955.35
$1,247.63 		$1,015.48
$1,093.16
$1,175.42
$1,467.70 		$1,235.55
$1,313.23
$1,395.49
$1,687.77 		$220.07
Toc - Plan #26 BannerAetna
Expanded Bronze

(HMO) BannerAetna Bronze S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$236.43
$268.35
$302.16
$422.27
$641.68 		$417.30
$449.22
$483.03
$603.14 		$598.17
$630.09
$663.90
$784.01 		$779.04
$810.96
$844.77
$964.88 		$180.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$472.86
$536.70
$604.32
$844.54
$1,283.36 		$653.73
$717.57
$785.19
$1,025.41 		$834.60
$898.44
$966.06
$1,206.28 		$1,015.47
$1,079.31
$1,146.93
$1,387.15 		$180.87
Toc - Plan #27 BannerAetna
Gold

(HMO) BannerAetna Gold S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$377.72
$428.71
$482.72
$674.60
$1,025.12 		$666.67
$717.66
$771.67
$963.55 		$955.62
$1,006.61
$1,060.62
$1,252.50 		$1,244.57
$1,295.56
$1,349.57
$1,541.45 		$288.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.44
$857.42
$965.44
$1,349.20
$2,050.24 		$1,044.39
$1,146.37
$1,254.39
$1,638.15 		$1,333.34
$1,435.32
$1,543.34
$1,927.10 		$1,622.29
$1,724.27
$1,832.29
$2,216.05 		$288.95
Toc - Plan #28 BannerAetna
Silver

(HMO) BannerAetna Silver 3 (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.82
$331.22
$372.95
$521.20
$792.01 		$515.07
$554.47
$596.20
$744.45 		$738.32
$777.72
$819.45
$967.70 		$961.57
$1,000.97
$1,042.70
$1,190.95 		$223.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.64
$662.44
$745.90
$1,042.40
$1,584.02 		$806.89
$885.69
$969.15
$1,265.65 		$1,030.14
$1,108.94
$1,192.40
$1,488.90 		$1,253.39
$1,332.19
$1,415.65
$1,712.15 		$223.25
Toc - Plan #29 BannerAetna
Silver

(HMO) BannerAetna Silver 4 $0 Ded (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,950 $17,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$307.39
$348.88
$392.84
$548.99
$834.25 		$542.54
$584.03
$627.99
$784.14 		$777.69
$819.18
$863.14
$1,019.29 		$1,012.84
$1,054.33
$1,098.29
$1,254.44 		$235.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.78
$697.76
$785.68
$1,097.98
$1,668.50 		$849.93
$932.91
$1,020.83
$1,333.13 		$1,085.08
$1,168.06
$1,255.98
$1,568.28 		$1,320.23
$1,403.21
$1,491.13
$1,803.43 		$235.15
Toc - Plan #30 BannerAetna
Silver

(HMO) BannerAetna Silver S (Unlimited Free 98point6 Telehealth & MinuteClinic Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$280.94
$318.86
$359.04
$501.76
$762.47 		$495.86
$533.78
$573.96
$716.68 		$710.78
$748.70
$788.88
$931.60 		$925.70
$963.62
$1,003.80
$1,146.52 		$214.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$561.88
$637.72
$718.08
$1,003.52
$1,524.94 		$776.80
$852.64
$933.00
$1,218.44 		$991.72
$1,067.56
$1,147.92
$1,433.36 		$1,206.64
$1,282.48
$1,362.84
$1,648.28 		$214.92

ADVERTISEMENT

Medica

Local: 1-877-347-0267 | Toll Free: 1-877-347-0267 | TTY: 1-800-676-3777
Toc - Plan #31 Medica
Gold

(HMO) Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$1,300 $2,600 Annual Deductible
$8,450 $16,900 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 		$462.57
$525.01
$591.16
$826.14
$1,255.40 		$816.43
$878.87
$945.02
$1,180.00 		$1,170.29
$1,232.73
$1,298.88
$1,533.86 		$1,524.15
$1,586.59
$1,652.74
$1,887.72 		$353.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.14
$1,050.02
$1,182.32
$1,652.28
$2,510.80 		$1,279.00
$1,403.88
$1,536.18
$2,006.14 		$1,632.86
$1,757.74
$1,890.04
$2,360.00 		$1,986.72
$2,111.60
$2,243.90
$2,713.86 		$353.86
Toc - Plan #32 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Copay ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$261.04
$296.28
$333.60
$466.21
$708.45 		$460.73
$495.97
$533.29
$665.90 		$660.42
$695.66
$732.98
$865.59 		$860.11
$895.35
$932.67
$1,065.28 		$199.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522.08
$592.56
$667.20
$932.42
$1,416.90 		$721.77
$792.25
$866.89
$1,132.11 		$921.46
$991.94
$1,066.58
$1,331.80 		$1,121.15
$1,191.63
$1,266.27
$1,531.49 		$199.69
Toc - Plan #33 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze H S A ($0 Non-Urgent Virtual Care after deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$349.54
$396.72
$446.71
$624.27
$948.64 		$616.94
$664.12
$714.11
$891.67 		$884.34
$931.52
$981.51
$1,159.07 		$1,151.74
$1,198.92
$1,248.91
$1,426.47 		$267.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.08
$793.44
$893.42
$1,248.54
$1,897.28 		$966.48
$1,060.84
$1,160.82
$1,515.94 		$1,233.88
$1,328.24
$1,428.22
$1,783.34 		$1,501.28
$1,595.64
$1,695.62
$2,050.74 		$267.40
Toc - Plan #34 Medica
Gold

(HMO) Medica Pinnacle Gold Share ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$8,450 $16,900 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 		$469.02
$532.34
$599.41
$837.67
$1,272.92 		$827.82
$891.14
$958.21
$1,196.47 		$1,186.62
$1,249.94
$1,317.01
$1,555.27 		$1,545.42
$1,608.74
$1,675.81
$1,914.07 		$358.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$938.04
$1,064.68
$1,198.82
$1,675.34
$2,545.84 		$1,296.84
$1,423.48
$1,557.62
$2,034.14 		$1,655.64
$1,782.28
$1,916.42
$2,392.94 		$2,014.44
$2,141.08
$2,275.22
$2,751.74 		$358.80
Toc - Plan #35 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Share Plus ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$278.37
$315.94
$355.75
$497.16
$755.48 		$491.32
$528.89
$568.70
$710.11 		$704.27
$741.84
$781.65
$923.06 		$917.22
$954.79
$994.60
$1,136.01 		$212.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.74
$631.88
$711.50
$994.32
$1,510.96 		$769.69
$844.83
$924.45
$1,207.27 		$982.64
$1,057.78
$1,137.40
$1,420.22 		$1,195.59
$1,270.73
$1,350.35
$1,633.17 		$212.95
Toc - Plan #36 Medica
Expanded Bronze

(HMO) Medica Pinnacle Bronze Copay $0 PCP ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271.26
$307.87
$346.66
$484.46
$736.19 		$478.77
$515.38
$554.17
$691.97 		$686.28
$722.89
$761.68
$899.48 		$893.79
$930.40
$969.19
$1,106.99 		$207.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$542.52
$615.74
$693.32
$968.92
$1,472.38 		$750.03
$823.25
$900.83
$1,176.43 		$957.54
$1,030.76
$1,108.34
$1,383.94 		$1,165.05
$1,238.27
$1,315.85
$1,591.45 		$207.51
Toc - Plan #37 Medica
Silver

(HMO) Medica Pinnacle Silver Copay $0 PCP ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

Annual Out of Pocket Expenses:

Individual Family
$4,600 $9,200 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 		$382.07
$433.64
$488.28
$682.37
$1,036.93 		$674.35
$725.92
$780.56
$974.65 		$966.63
$1,018.20
$1,072.84
$1,266.93 		$1,258.91
$1,310.48
$1,365.12
$1,559.21 		$292.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.14
$867.28
$976.56
$1,364.74
$2,073.86 		$1,056.42
$1,159.56
$1,268.84
$1,657.02 		$1,348.70
$1,451.84
$1,561.12
$1,949.30 		$1,640.98
$1,744.12
$1,853.40
$2,241.58 		$292.28
Toc - Plan #38 Medica
Gold

(HMO) Medica Pinnacle Gold Standard ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

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 		$448.26
$508.77
$572.87
$800.59
$1,216.57 		$791.18
$851.69
$915.79
$1,143.51 		$1,134.10
$1,194.61
$1,258.71
$1,486.43 		$1,477.02
$1,537.53
$1,601.63
$1,829.35 		$342.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.52
$1,017.54
$1,145.74
$1,601.18
$2,433.14 		$1,239.44
$1,360.46
$1,488.66
$1,944.10 		$1,582.36
$1,703.38
$1,831.58
$2,287.02 		$1,925.28
$2,046.30
$2,174.50
$2,629.94 		$342.92
Toc - Plan #39 Medica
Silver

(HMO) Medica Pinnacle Silver Standard ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

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 		$368.55
$418.30
$471.00
$658.22
$1,000.23 		$650.49
$700.24
$752.94
$940.16 		$932.43
$982.18
$1,034.88
$1,222.10 		$1,214.37
$1,264.12
$1,316.82
$1,504.04 		$281.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.10
$836.60
$942.00
$1,316.44
$2,000.46 		$1,019.04
$1,118.54
$1,223.94
$1,598.38 		$1,300.98
$1,400.48
$1,505.88
$1,880.32 		$1,582.92
$1,682.42
$1,787.82
$2,162.26 		$281.94
Toc - Plan #40 Medica
Bronze

(HMO) Medica Pinnacle Bronze Standard ($0 Non-Urgent Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-347-0267

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 		$251.88
$285.88
$321.90
$449.86
$683.60 		$444.57
$478.57
$514.59
$642.55 		$637.26
$671.26
$707.28
$835.24 		$829.95
$863.95
$899.97
$1,027.93 		$192.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$503.76
$571.76
$643.80
$899.72
$1,367.20 		$696.45
$764.45
$836.49
$1,092.41 		$889.14
$957.14
$1,029.18
$1,285.10 		$1,081.83
$1,149.83
$1,221.87
$1,477.79 		$192.69

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-482-9045 | Toll Free: 1-877-482-9045 | TTY: 1-877-482-9045
Toc - Plan #41 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$2,150 $4,300 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 		$401.28
$455.45
$512.83
$716.68
$1,089.07 		$708.26
$762.43
$819.81
$1,023.66 		$1,015.24
$1,069.41
$1,126.79
$1,330.64 		$1,322.22
$1,376.39
$1,433.77
$1,637.62 		$306.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.56
$910.90
$1,025.66
$1,433.36
$2,178.14 		$1,109.54
$1,217.88
$1,332.64
$1,740.34 		$1,416.52
$1,524.86
$1,639.62
$2,047.32 		$1,723.50
$1,831.84
$1,946.60
$2,354.30 		$306.98
Toc - Plan #42 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$304.96
$346.13
$389.74
$544.67
$827.67 		$538.26
$579.43
$623.04
$777.97 		$771.56
$812.73
$856.34
$1,011.27 		$1,004.86
$1,046.03
$1,089.64
$1,244.57 		$233.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$609.92
$692.26
$779.48
$1,089.34
$1,655.34 		$843.22
$925.56
$1,012.78
$1,322.64 		$1,076.52
$1,158.86
$1,246.08
$1,555.94 		$1,309.82
$1,392.16
$1,479.38
$1,789.24 		$233.30
Toc - Plan #43 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$245.06
$278.14
$313.18
$437.67
$665.08 		$432.53
$465.61
$500.65
$625.14 		$620.00
$653.08
$688.12
$812.61 		$807.47
$840.55
$875.59
$1,000.08 		$187.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$490.12
$556.28
$626.36
$875.34
$1,330.16 		$677.59
$743.75
$813.83
$1,062.81 		$865.06
$931.22
$1,001.30
$1,250.28 		$1,052.53
$1,118.69
$1,188.77
$1,437.75 		$187.47
Toc - Plan #44 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Deductible 2 (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.02
$275.82
$310.57
$434.02
$659.54 		$428.93
$461.73
$496.48
$619.93 		$614.84
$647.64
$682.39
$805.84 		$800.75
$833.55
$868.30
$991.75 		$185.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.04
$551.64
$621.14
$868.04
$1,319.08 		$671.95
$737.55
$807.05
$1,053.95 		$857.86
$923.46
$992.96
$1,239.86 		$1,043.77
$1,109.37
$1,178.87
$1,425.77 		$185.91
Toc - Plan #45 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.33
$346.55
$390.21
$545.32
$828.67 		$538.91
$580.13
$623.79
$778.90 		$772.49
$813.71
$857.37
$1,012.48 		$1,006.07
$1,047.29
$1,090.95
$1,246.06 		$233.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.66
$693.10
$780.42
$1,090.64
$1,657.34 		$844.24
$926.68
$1,014.00
$1,324.22 		$1,077.82
$1,160.26
$1,247.58
$1,557.80 		$1,311.40
$1,393.84
$1,481.16
$1,791.38 		$233.58
Toc - Plan #46 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$243.02
$275.83
$310.59
$434.04
$659.57 		$428.93
$461.74
$496.50
$619.95 		$614.84
$647.65
$682.41
$805.86 		$800.75
$833.56
$868.32
$991.77 		$185.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$486.04
$551.66
$621.18
$868.08
$1,319.14 		$671.95
$737.57
$807.09
$1,053.99 		$857.86
$923.48
$993.00
$1,239.90 		$1,043.77
$1,109.39
$1,178.91
$1,425.81 		$185.91
Toc - Plan #47 UnitedHealthcare
Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$226.68
$257.29
$289.70
$404.86
$615.22 		$400.09
$430.70
$463.11
$578.27 		$573.50
$604.11
$636.52
$751.68 		$746.91
$777.52
$809.93
$925.09 		$173.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$453.36
$514.58
$579.40
$809.72
$1,230.44 		$626.77
$687.99
$752.81
$983.13 		$800.18
$861.40
$926.22
$1,156.54 		$973.59
$1,034.81
$1,099.63
$1,329.95 		$173.41
Toc - Plan #48 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$406.07
$460.89
$518.95
$725.24
$1,102.07 		$716.71
$771.53
$829.59
$1,035.88 		$1,027.35
$1,082.17
$1,140.23
$1,346.52 		$1,337.99
$1,392.81
$1,450.87
$1,657.16 		$310.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$812.14
$921.78
$1,037.90
$1,450.48
$2,204.14 		$1,122.78
$1,232.42
$1,348.54
$1,761.12 		$1,433.42
$1,543.06
$1,659.18
$2,071.76 		$1,744.06
$1,853.70
$1,969.82
$2,382.40 		$310.64
Toc - Plan #49 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$412.65
$468.36
$527.37
$736.99
$1,119.93 		$728.33
$784.04
$843.05
$1,052.67 		$1,044.01
$1,099.72
$1,158.73
$1,368.35 		$1,359.69
$1,415.40
$1,474.41
$1,684.03 		$315.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$825.30
$936.72
$1,054.74
$1,473.98
$2,239.86 		$1,140.98
$1,252.40
$1,370.42
$1,789.66 		$1,456.66
$1,568.08
$1,686.10
$2,105.34 		$1,772.34
$1,883.76
$2,001.78
$2,421.02 		$315.68
Toc - Plan #50 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.10
$341.75
$384.81
$537.76
$817.19 		$531.44
$572.09
$615.15
$768.10 		$761.78
$802.43
$845.49
$998.44 		$992.12
$1,032.77
$1,075.83
$1,228.78 		$230.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.20
$683.50
$769.62
$1,075.52
$1,634.38 		$832.54
$913.84
$999.96
$1,305.86 		$1,062.88
$1,144.18
$1,230.30
$1,536.20 		$1,293.22
$1,374.52
$1,460.64
$1,766.54 		$230.34
Toc - Plan #51 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$308.74
$350.42
$394.57
$551.41
$837.91 		$544.92
$586.60
$630.75
$787.59 		$781.10
$822.78
$866.93
$1,023.77 		$1,017.28
$1,058.96
$1,103.11
$1,259.95 		$236.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.48
$700.84
$789.14
$1,102.82
$1,675.82 		$853.66
$937.02
$1,025.32
$1,339.00 		$1,089.84
$1,173.20
$1,261.50
$1,575.18 		$1,326.02
$1,409.38
$1,497.68
$1,811.36 		$236.18
Toc - Plan #52 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$245.80
$278.99
$314.14
$439.00
$667.11 		$433.84
$467.03
$502.18
$627.04 		$621.88
$655.07
$690.22
$815.08 		$809.92
$843.11
$878.26
$1,003.12 		$188.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$491.60
$557.98
$628.28
$878.00
$1,334.22 		$679.64
$746.02
$816.32
$1,066.04 		$867.68
$934.06
$1,004.36
$1,254.08 		$1,055.72
$1,122.10
$1,192.40
$1,442.12 		$188.04
Toc - Plan #53 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$226.68
$257.29
$289.70
$404.86
$615.22 		$400.09
$430.70
$463.11
$578.27 		$573.50
$604.11
$636.52
$751.68 		$746.91
$777.52
$809.93
$925.09 		$173.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$453.36
$514.58
$579.40
$809.72
$1,230.44 		$626.77
$687.99
$752.81
$983.13 		$800.18
$861.40
$926.22
$1,156.54 		$973.59
$1,034.81
$1,099.63
$1,329.95 		$173.41
Toc - Plan #54 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $1 T1 Pref Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$420.93
$477.76
$537.95
$751.79
$1,142.42 		$742.94
$799.77
$859.96
$1,073.80 		$1,064.95
$1,121.78
$1,181.97
$1,395.81 		$1,386.96
$1,443.79
$1,503.98
$1,717.82 		$322.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.86
$955.52
$1,075.90
$1,503.58
$2,284.84 		$1,163.87
$1,277.53
$1,397.91
$1,825.59 		$1,485.88
$1,599.54
$1,719.92
$2,147.60 		$1,807.89
$1,921.55
$2,041.93
$2,469.61 		$322.01
Toc - Plan #55 UnitedHealthcare
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$425.64
$483.11
$543.97
$760.20
$1,155.20 		$751.26
$808.73
$869.59
$1,085.82 		$1,076.88
$1,134.35
$1,195.21
$1,411.44 		$1,402.50
$1,459.97
$1,520.83
$1,737.06 		$325.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.28
$966.22
$1,087.94
$1,520.40
$2,310.40 		$1,176.90
$1,291.84
$1,413.56
$1,846.02 		$1,502.52
$1,617.46
$1,739.18
$2,171.64 		$1,828.14
$1,943.08
$2,064.80
$2,497.26 		$325.62
Toc - Plan #56 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Deductible 1 (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.63
$346.89
$390.60
$545.86
$829.48 		$539.44
$580.70
$624.41
$779.67 		$773.25
$814.51
$858.22
$1,013.48 		$1,007.06
$1,048.32
$1,092.03
$1,247.29 		$233.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$611.26
$693.78
$781.20
$1,091.72
$1,658.96 		$845.07
$927.59
$1,015.01
$1,325.53 		$1,078.88
$1,161.40
$1,248.82
$1,559.34 		$1,312.69
$1,395.21
$1,482.63
$1,793.15 		$233.81
Toc - Plan #57 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$3,300 $6,600 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 		$305.15
$346.35
$389.99
$545.00
$828.19 		$538.59
$579.79
$623.43
$778.44 		$772.03
$813.23
$856.87
$1,011.88 		$1,005.47
$1,046.67
$1,090.31
$1,245.32 		$233.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.30
$692.70
$779.98
$1,090.00
$1,656.38 		$843.74
$926.14
$1,013.42
$1,323.44 		$1,077.18
$1,159.58
$1,246.86
$1,556.88 		$1,310.62
$1,393.02
$1,480.30
$1,790.32 		$233.44
Toc - Plan #58 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 T1 Pref Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

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 		$312.56
$354.76
$399.45
$558.24
$848.29 		$551.67
$593.87
$638.56
$797.35 		$790.78
$832.98
$877.67
$1,036.46 		$1,029.89
$1,072.09
$1,116.78
$1,275.57 		$239.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.12
$709.52
$798.90
$1,116.48
$1,696.58 		$864.23
$948.63
$1,038.01
$1,355.59 		$1,103.34
$1,187.74
$1,277.12
$1,594.70 		$1,342.45
$1,426.85
$1,516.23
$1,833.81 		$239.11
Toc - Plan #59 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.69
$363.98
$409.84
$572.75
$870.35 		$566.02
$609.31
$655.17
$818.08 		$811.35
$854.64
$900.50
$1,063.41 		$1,056.68
$1,099.97
$1,145.83
$1,308.74 		$245.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.38
$727.96
$819.68
$1,145.50
$1,740.70 		$886.71
$973.29
$1,065.01
$1,390.83 		$1,132.04
$1,218.62
$1,310.34
$1,636.16 		$1,377.37
$1,463.95
$1,555.67
$1,881.49 		$245.33
Toc - Plan #60 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-482-9045

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$245.06
$278.14
$313.18
$437.67
$665.08 		$432.53
$465.61
$500.65
$625.14 		$620.00
$653.08
$688.12
$812.61 		$807.47
$840.55
$875.59
$1,000.08 		$187.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$490.12
$556.28
$626.36
$875.34
$1,330.16 		$677.59
$743.75
$813.83
$1,062.81 		$865.06
$931.22
$1,001.30
$1,250.28 		$1,052.53
$1,118.69
$1,188.77
$1,437.75 		$187.47

ADVERTISEMENT

Blue Cross Blue Shield of Arizona

Local: 1-844-341-5837 | Toll Free: 1-844-341-5837 | TTY: 1-602-864-4823
Toc - Plan #61 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue EverydayHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$450.05
$510.81
$575.17
$803.79
$1,221.43 		$794.34
$855.10
$919.46
$1,148.08 		$1,138.63
$1,199.39
$1,263.75
$1,492.37 		$1,482.92
$1,543.68
$1,608.04
$1,836.66 		$344.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$900.10
$1,021.62
$1,150.34
$1,607.58
$2,442.86 		$1,244.39
$1,365.91
$1,494.63
$1,951.87 		$1,588.68
$1,710.20
$1,838.92
$2,296.16 		$1,932.97
$2,054.49
$2,183.21
$2,640.45 		$344.29
Toc - Plan #62 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue EverydayHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$4,750 $9,500 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 		$339.21
$385.01
$433.51
$605.83
$920.62 		$598.71
$644.51
$693.01
$865.33 		$858.21
$904.01
$952.51
$1,124.83 		$1,117.71
$1,163.51
$1,212.01
$1,384.33 		$259.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$678.42
$770.02
$867.02
$1,211.66
$1,841.24 		$937.92
$1,029.52
$1,126.52
$1,471.16 		$1,197.42
$1,289.02
$1,386.02
$1,730.66 		$1,456.92
$1,548.52
$1,645.52
$1,990.16 		$259.50
Toc - Plan #63 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue EverydayHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.22
$340.75
$383.68
$536.19
$814.78 		$529.89
$570.42
$613.35
$765.86 		$759.56
$800.09
$843.02
$995.53 		$989.23
$1,029.76
$1,072.69
$1,225.20 		$229.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.44
$681.50
$767.36
$1,072.38
$1,629.56 		$830.11
$911.17
$997.03
$1,302.05 		$1,059.78
$1,140.84
$1,226.70
$1,531.72 		$1,289.45
$1,370.51
$1,456.37
$1,761.39 		$229.67
Toc - Plan #64 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue TrueHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$6,750 $13,500 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 		$347.11
$393.97
$443.61
$619.94
$942.06 		$612.65
$659.51
$709.15
$885.48 		$878.19
$925.05
$974.69
$1,151.02 		$1,143.73
$1,190.59
$1,240.23
$1,416.56 		$265.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.22
$787.94
$887.22
$1,239.88
$1,884.12 		$959.76
$1,053.48
$1,152.76
$1,505.42 		$1,225.30
$1,319.02
$1,418.30
$1,770.96 		$1,490.84
$1,584.56
$1,683.84
$2,036.50 		$265.54
Toc - Plan #65 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue AdvanceHealth Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.90
$373.31
$420.34
$587.42
$892.64 		$580.51
$624.92
$671.95
$839.03 		$832.12
$876.53
$923.56
$1,090.64 		$1,083.73
$1,128.14
$1,175.17
$1,342.25 		$251.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.80
$746.62
$840.68
$1,174.84
$1,785.28 		$909.41
$998.23
$1,092.29
$1,426.45 		$1,161.02
$1,249.84
$1,343.90
$1,678.06 		$1,412.63
$1,501.45
$1,595.51
$1,929.67 		$251.61
Toc - Plan #66 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue Portfolio HSA Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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 		$322.79
$366.37
$412.53
$576.50
$876.05 		$569.73
$613.31
$659.47
$823.44 		$816.67
$860.25
$906.41
$1,070.38 		$1,063.61
$1,107.19
$1,153.35
$1,317.32 		$246.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$645.58
$732.74
$825.06
$1,153.00
$1,752.10 		$892.52
$979.68
$1,072.00
$1,399.94 		$1,139.46
$1,226.62
$1,318.94
$1,646.88 		$1,386.40
$1,473.56
$1,565.88
$1,893.82 		$246.94
Toc - Plan #67 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue AdvanceHealth Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.76
$319.79
$360.09
$503.22
$764.68 		$497.31
$535.34
$575.64
$718.77 		$712.86
$750.89
$791.19
$934.32 		$928.41
$966.44
$1,006.74
$1,149.87 		$215.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.52
$639.58
$720.18
$1,006.44
$1,529.36 		$779.07
$855.13
$935.73
$1,221.99 		$994.62
$1,070.68
$1,151.28
$1,437.54 		$1,210.17
$1,286.23
$1,366.83
$1,653.09 		$215.55
Toc - Plan #68 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue AdvanceHealth Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$4,375 $8,750 Annual Deductible
$4,375 $8,750 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.42
$501.02
$564.14
$788.38
$1,198.02 		$779.11
$838.71
$901.83
$1,126.07 		$1,116.80
$1,176.40
$1,239.52
$1,463.76 		$1,454.49
$1,514.09
$1,577.21
$1,801.45 		$337.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.84
$1,002.04
$1,128.28
$1,576.76
$2,396.04 		$1,220.53
$1,339.73
$1,465.97
$1,914.45 		$1,558.22
$1,677.42
$1,803.66
$2,252.14 		$1,895.91
$2,015.11
$2,141.35
$2,589.83 		$337.69
Toc - Plan #69 Blue Cross Blue Shield of Arizona
Gold

(HMO) Blue Standardized Gold - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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 		$448.10
$508.60
$572.67
$800.31
$1,216.14 		$790.90
$851.40
$915.47
$1,143.11 		$1,133.70
$1,194.20
$1,258.27
$1,485.91 		$1,476.50
$1,537.00
$1,601.07
$1,828.71 		$342.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.20
$1,017.20
$1,145.34
$1,600.62
$2,432.28 		$1,239.00
$1,360.00
$1,488.14
$1,943.42 		$1,581.80
$1,702.80
$1,830.94
$2,286.22 		$1,924.60
$2,045.60
$2,173.74
$2,629.02 		$342.80
Toc - Plan #70 Blue Cross Blue Shield of Arizona
Silver

(HMO) Blue Standardized Silver - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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 		$336.11
$381.49
$429.55
$600.29
$912.20 		$593.24
$638.62
$686.68
$857.42 		$850.37
$895.75
$943.81
$1,114.55 		$1,107.50
$1,152.88
$1,200.94
$1,371.68 		$257.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.22
$762.98
$859.10
$1,200.58
$1,824.40 		$929.35
$1,020.11
$1,116.23
$1,457.71 		$1,186.48
$1,277.24
$1,373.36
$1,714.84 		$1,443.61
$1,534.37
$1,630.49
$1,971.97 		$257.13
Toc - Plan #71 Blue Cross Blue Shield of Arizona
Expanded Bronze

(HMO) Blue Standardized Bronze - MaricopaFocus Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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 		$302.36
$343.18
$386.41
$540.01
$820.59 		$533.67
$574.49
$617.72
$771.32 		$764.98
$805.80
$849.03
$1,002.63 		$996.29
$1,037.11
$1,080.34
$1,233.94 		$231.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.72
$686.36
$772.82
$1,080.02
$1,641.18 		$836.03
$917.67
$1,004.13
$1,311.33 		$1,067.34
$1,148.98
$1,235.44
$1,542.64 		$1,298.65
$1,380.29
$1,466.75
$1,773.95 		$231.31
Toc - Plan #72 Blue Cross Blue Shield of Arizona
Gold

(PPO) Blue PPO Gold - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$1,250 $2,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$635.61
$721.41
$812.30
$1,135.19
$1,725.03 		$1,121.85
$1,207.65
$1,298.54
$1,621.43 		$1,608.09
$1,693.89
$1,784.78
$2,107.67 		$2,094.33
$2,180.13
$2,271.02
$2,593.91 		$486.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,271.22
$1,442.82
$1,624.60
$2,270.38
$3,450.06 		$1,757.46
$1,929.06
$2,110.84
$2,756.62 		$2,243.70
$2,415.30
$2,597.08
$3,242.86 		$2,729.94
$2,901.54
$3,083.32
$3,729.10 		$486.24
Toc - Plan #73 Blue Cross Blue Shield of Arizona
Silver

(PPO) Blue PPO Silver - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 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 		$512.35
$581.52
$654.78
$915.05
$1,390.51 		$904.30
$973.47
$1,046.73
$1,307.00 		$1,296.25
$1,365.42
$1,438.68
$1,698.95 		$1,688.20
$1,757.37
$1,830.63
$2,090.90 		$391.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.70
$1,163.04
$1,309.56
$1,830.10
$2,781.02 		$1,416.65
$1,554.99
$1,701.51
$2,222.05 		$1,808.60
$1,946.94
$2,093.46
$2,614.00 		$2,200.55
$2,338.89
$2,485.41
$3,005.95 		$391.95
Toc - Plan #74 Blue Cross Blue Shield of Arizona
Gold

(PPO) Blue PPO Standardized Gold - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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 		$606.99
$688.93
$775.73
$1,084.08
$1,647.36 		$1,071.34
$1,153.28
$1,240.08
$1,548.43 		$1,535.69
$1,617.63
$1,704.43
$2,012.78 		$2,000.04
$2,081.98
$2,168.78
$2,477.13 		$464.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,213.98
$1,377.86
$1,551.46
$2,168.16
$3,294.72 		$1,678.33
$1,842.21
$2,015.81
$2,632.51 		$2,142.68
$2,306.56
$2,480.16
$3,096.86 		$2,607.03
$2,770.91
$2,944.51
$3,561.21 		$464.35
Toc - Plan #75 Blue Cross Blue Shield of Arizona
Silver

(PPO) Blue PPO Standardized Silver - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

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 		$496.27
$563.26
$634.23
$886.33
$1,346.86 		$875.92
$942.91
$1,013.88
$1,265.98 		$1,255.57
$1,322.56
$1,393.53
$1,645.63 		$1,635.22
$1,702.21
$1,773.18
$2,025.28 		$379.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$992.54
$1,126.52
$1,268.46
$1,772.66
$2,693.72 		$1,372.19
$1,506.17
$1,648.11
$2,152.31 		$1,751.84
$1,885.82
$2,027.76
$2,531.96 		$2,131.49
$2,265.47
$2,407.41
$2,911.61 		$379.65
Toc - Plan #76 Blue Cross Blue Shield of Arizona
Gold

(PPO) Blue Portfolio HSA Gold - Statewide PPO Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-341-5837

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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 		$655.92
$744.46
$838.26
$1,171.46
$1,780.15 		$1,157.70
$1,246.24
$1,340.04
$1,673.24 		$1,659.48
$1,748.02
$1,841.82
$2,175.02 		$2,161.26
$2,249.80
$2,343.60
$2,676.80 		$501.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,311.84
$1,488.92
$1,676.52
$2,342.92
$3,560.30 		$1,813.62
$1,990.70
$2,178.30
$2,844.70 		$2,315.40
$2,492.48
$2,680.08
$3,346.48 		$2,817.18
$2,994.26
$3,181.86
$3,848.26 		$501.78

ADVERTISEMENT

Imperial Insurance Companies, Inc.

Local: 1-626-838-5100x8 | Toll Free: 1-800-595-0619 | TTY: 1-800-595-0619
Toc - Plan #77 Imperial Insurance Companies, Inc.
Bronze

(HMO) Imperial Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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 		$301.37
$342.06
$385.15
$538.25
$817.92 		$531.92
$572.61
$615.70
$768.80 		$762.47
$803.16
$846.25
$999.35 		$993.02
$1,033.71
$1,076.80
$1,229.90 		$230.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.74
$684.12
$770.30
$1,076.50
$1,635.84 		$833.29
$914.67
$1,000.85
$1,307.05 		$1,063.84
$1,145.22
$1,231.40
$1,537.60 		$1,294.39
$1,375.77
$1,461.95
$1,768.15 		$230.55
Toc - Plan #78 Imperial Insurance Companies, Inc.
Silver

(HMO) Imperial Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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 		$367.38
$416.97
$469.51
$656.13
$997.06 		$648.42
$698.01
$750.55
$937.17 		$929.46
$979.05
$1,031.59
$1,218.21 		$1,210.50
$1,260.09
$1,312.63
$1,499.25 		$281.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.76
$833.94
$939.02
$1,312.26
$1,994.12 		$1,015.80
$1,114.98
$1,220.06
$1,593.30 		$1,296.84
$1,396.02
$1,501.10
$1,874.34 		$1,577.88
$1,677.06
$1,782.14
$2,155.38 		$281.04
Toc - Plan #79 Imperial Insurance Companies, Inc.
Gold

(HMO) Imperial Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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 		$431.43
$489.68
$551.37
$770.54
$1,170.91 		$761.48
$819.73
$881.42
$1,100.59 		$1,091.53
$1,149.78
$1,211.47
$1,430.64 		$1,421.58
$1,479.83
$1,541.52
$1,760.69 		$330.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.86
$979.36
$1,102.74
$1,541.08
$2,341.82 		$1,192.91
$1,309.41
$1,432.79
$1,871.13 		$1,522.96
$1,639.46
$1,762.84
$2,201.18 		$1,853.01
$1,969.51
$2,092.89
$2,531.23 		$330.05
Toc - Plan #80 Imperial Insurance Companies, Inc.
Silver

(HMO) Imperial Preferred Silver 4000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

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 		$367.15
$416.71
$469.22
$655.73
$996.44 		$648.02
$697.58
$750.09
$936.60 		$928.89
$978.45
$1,030.96
$1,217.47 		$1,209.76
$1,259.32
$1,311.83
$1,498.34 		$280.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.30
$833.42
$938.44
$1,311.46
$1,992.88 		$1,015.17
$1,114.29
$1,219.31
$1,592.33 		$1,296.04
$1,395.16
$1,500.18
$1,873.20 		$1,576.91
$1,676.03
$1,781.05
$2,154.07 		$280.87
Toc - Plan #81 Imperial Insurance Companies, Inc.
Gold

(HMO) Imperial Preferred Gold 950

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-595-0619

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 Annual Deductible
$7,700 $15,400 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 		$447.51
$507.92
$571.91
$799.25
$1,214.53 		$789.85
$850.26
$914.25
$1,141.59 		$1,132.19
$1,192.60
$1,256.59
$1,483.93 		$1,474.53
$1,534.94
$1,598.93
$1,826.27 		$342.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.02
$1,015.84
$1,143.82
$1,598.50
$2,429.06 		$1,237.36
$1,358.18
$1,486.16
$1,940.84 		$1,579.70
$1,700.52
$1,828.50
$2,283.18 		$1,922.04
$2,042.86
$2,170.84
$2,625.52 		$342.34

ADVERTISEMENT

Ambetter from Arizona Complete Health

Local: 1-888-926-5057 | Toll Free: 1-888-926-5057 | TTY: 1-888-926-5180
Toc - Plan #82 Ambetter from Arizona Complete Health
Silver

(HMO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 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 		$319.93
$363.12
$408.87
$571.40
$868.29 		$564.68
$607.87
$653.62
$816.15 		$809.43
$852.62
$898.37
$1,060.90 		$1,054.18
$1,097.37
$1,143.12
$1,305.65 		$244.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.86
$726.24
$817.74
$1,142.80
$1,736.58 		$884.61
$970.99
$1,062.49
$1,387.55 		$1,129.36
$1,215.74
$1,307.24
$1,632.30 		$1,374.11
$1,460.49
$1,551.99
$1,877.05 		$244.75
Toc - Plan #83 Ambetter from Arizona Complete Health
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$259.06
$294.03
$331.08
$462.68
$703.09 		$457.24
$492.21
$529.26
$660.86 		$655.42
$690.39
$727.44
$859.04 		$853.60
$888.57
$925.62
$1,057.22 		$198.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$518.12
$588.06
$662.16
$925.36
$1,406.18 		$716.30
$786.24
$860.34
$1,123.54 		$914.48
$984.42
$1,058.52
$1,321.72 		$1,112.66
$1,182.60
$1,256.70
$1,519.90 		$198.18
Toc - Plan #84 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.55
$321.83
$362.37
$506.42
$769.55 		$500.46
$538.74
$579.28
$723.33 		$717.37
$755.65
$796.19
$940.24 		$934.28
$972.56
$1,013.10
$1,157.15 		$216.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$567.10
$643.66
$724.74
$1,012.84
$1,539.10 		$784.01
$860.57
$941.65
$1,229.75 		$1,000.92
$1,077.48
$1,158.56
$1,446.66 		$1,217.83
$1,294.39
$1,375.47
$1,663.57 		$216.91
Toc - Plan #85 Ambetter from Arizona Complete Health
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.46
$359.18
$404.43
$565.19
$858.87 		$558.55
$601.27
$646.52
$807.28 		$800.64
$843.36
$888.61
$1,049.37 		$1,042.73
$1,085.45
$1,130.70
$1,291.46 		$242.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.92
$718.36
$808.86
$1,130.38
$1,717.74 		$875.01
$960.45
$1,050.95
$1,372.47 		$1,117.10
$1,202.54
$1,293.04
$1,614.56 		$1,359.19
$1,444.63
$1,535.13
$1,856.65 		$242.09
Toc - Plan #86 Ambetter from Arizona Complete Health
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.36
$355.67
$400.48
$559.67
$850.47 		$553.08
$595.39
$640.20
$799.39 		$792.80
$835.11
$879.92
$1,039.11 		$1,032.52
$1,074.83
$1,119.64
$1,278.83 		$239.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$626.72
$711.34
$800.96
$1,119.34
$1,700.94 		$866.44
$951.06
$1,040.68
$1,359.06 		$1,106.16
$1,190.78
$1,280.40
$1,598.78 		$1,345.88
$1,430.50
$1,520.12
$1,838.50 		$239.72
Toc - Plan #87 Ambetter from Arizona Complete Health
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.47
$409.13
$460.67
$643.79
$978.30 		$636.23
$684.89
$736.43
$919.55 		$911.99
$960.65
$1,012.19
$1,195.31 		$1,187.75
$1,236.41
$1,287.95
$1,471.07 		$275.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.94
$818.26
$921.34
$1,287.58
$1,956.60 		$996.70
$1,094.02
$1,197.10
$1,563.34 		$1,272.46
$1,369.78
$1,472.86
$1,839.10 		$1,548.22
$1,645.54
$1,748.62
$2,114.86 		$275.76
Toc - Plan #88 Ambetter from Arizona Complete Health
Silver

(HMO) Elite Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$327.55
$371.77
$418.61
$585.01
$888.97 		$578.13
$622.35
$669.19
$835.59 		$828.71
$872.93
$919.77
$1,086.17 		$1,079.29
$1,123.51
$1,170.35
$1,336.75 		$250.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.10
$743.54
$837.22
$1,170.02
$1,777.94 		$905.68
$994.12
$1,087.80
$1,420.60 		$1,156.26
$1,244.70
$1,338.38
$1,671.18 		$1,406.84
$1,495.28
$1,588.96
$1,921.76 		$250.58
Toc - Plan #89 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312.19
$354.34
$398.98
$557.58
$847.30 		$551.02
$593.17
$637.81
$796.41 		$789.85
$832.00
$876.64
$1,035.24 		$1,028.68
$1,070.83
$1,115.47
$1,274.07 		$238.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.38
$708.68
$797.96
$1,115.16
$1,694.60 		$863.21
$947.51
$1,036.79
$1,353.99 		$1,102.04
$1,186.34
$1,275.62
$1,592.82 		$1,340.87
$1,425.17
$1,514.45
$1,831.65 		$238.83
Toc - Plan #90 Ambetter from Arizona Complete Health
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$296.35
$336.36
$378.73
$529.28
$804.29 		$523.06
$563.07
$605.44
$755.99 		$749.77
$789.78
$832.15
$982.70 		$976.48
$1,016.49
$1,058.86
$1,209.41 		$226.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.70
$672.72
$757.46
$1,058.56
$1,608.58 		$819.41
$899.43
$984.17
$1,285.27 		$1,046.12
$1,126.14
$1,210.88
$1,511.98 		$1,272.83
$1,352.85
$1,437.59
$1,738.69 		$226.71
Toc - Plan #91 Ambetter from Arizona Complete Health
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.90
$344.93
$388.39
$542.77
$824.79 		$536.39
$577.42
$620.88
$775.26 		$768.88
$809.91
$853.37
$1,007.75 		$1,001.37
$1,042.40
$1,085.86
$1,240.24 		$232.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.80
$689.86
$776.78
$1,085.54
$1,649.58 		$840.29
$922.35
$1,009.27
$1,318.03 		$1,072.78
$1,154.84
$1,241.76
$1,550.52 		$1,305.27
$1,387.33
$1,474.25
$1,783.01 		$232.49
Toc - Plan #92 Ambetter from Arizona Complete Health
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$341.29
$387.37
$436.17
$609.55
$926.27 		$602.38
$648.46
$697.26
$870.64 		$863.47
$909.55
$958.35
$1,131.73 		$1,124.56
$1,170.64
$1,219.44
$1,392.82 		$261.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$682.58
$774.74
$872.34
$1,219.10
$1,852.54 		$943.67
$1,035.83
$1,133.43
$1,480.19 		$1,204.76
$1,296.92
$1,394.52
$1,741.28 		$1,465.85
$1,558.01
$1,655.61
$2,002.37 		$261.09
Toc - Plan #93 Ambetter from Arizona Complete Health
Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$395.92
$449.37
$505.99
$707.12
$1,074.54 		$698.80
$752.25
$808.87
$1,010.00 		$1,001.68
$1,055.13
$1,111.75
$1,312.88 		$1,304.56
$1,358.01
$1,414.63
$1,615.76 		$302.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$791.84
$898.74
$1,011.98
$1,414.24
$2,149.08 		$1,094.72
$1,201.62
$1,314.86
$1,717.12 		$1,397.60
$1,504.50
$1,617.74
$2,020.00 		$1,700.48
$1,807.38
$1,920.62
$2,322.88 		$302.88
Toc - Plan #94 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277.45
$314.90
$354.58
$495.52
$753.00 		$489.70
$527.15
$566.83
$707.77 		$701.95
$739.40
$779.08
$920.02 		$914.20
$951.65
$991.33
$1,132.27 		$212.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$554.90
$629.80
$709.16
$991.04
$1,506.00 		$767.15
$842.05
$921.41
$1,203.29 		$979.40
$1,054.30
$1,133.66
$1,415.54 		$1,191.65
$1,266.55
$1,345.91
$1,627.79 		$212.25
Toc - Plan #95 Ambetter from Arizona Complete Health
Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$247.11
$280.47
$315.81
$441.34
$670.67 		$436.15
$469.51
$504.85
$630.38 		$625.19
$658.55
$693.89
$819.42 		$814.23
$847.59
$882.93
$1,008.46 		$189.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$494.22
$560.94
$631.62
$882.68
$1,341.34 		$683.26
$749.98
$820.66
$1,071.72 		$872.30
$939.02
$1,009.70
$1,260.76 		$1,061.34
$1,128.06
$1,198.74
$1,449.80 		$189.04
Toc - Plan #96 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$271.82
$308.52
$347.39
$485.48
$737.73 		$479.77
$516.47
$555.34
$693.43 		$687.72
$724.42
$763.29
$901.38 		$895.67
$932.37
$971.24
$1,109.33 		$207.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$543.64
$617.04
$694.78
$970.96
$1,475.46 		$751.59
$824.99
$902.73
$1,178.91 		$959.54
$1,032.94
$1,110.68
$1,386.86 		$1,167.49
$1,240.89
$1,318.63
$1,594.81 		$207.95
Toc - Plan #97 Ambetter from Arizona Complete Health
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$309.37
$351.13
$395.37
$552.53
$839.62 		$546.03
$587.79
$632.03
$789.19 		$782.69
$824.45
$868.69
$1,025.85 		$1,019.35
$1,061.11
$1,105.35
$1,262.51 		$236.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.74
$702.26
$790.74
$1,105.06
$1,679.24 		$855.40
$938.92
$1,027.40
$1,341.72 		$1,092.06
$1,175.58
$1,264.06
$1,578.38 		$1,328.72
$1,412.24
$1,500.72
$1,815.04 		$236.66
Toc - Plan #98 Ambetter from Arizona Complete Health
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$342.28
$388.49
$437.44
$611.32
$928.96 		$604.13
$650.34
$699.29
$873.17 		$865.98
$912.19
$961.14
$1,135.02 		$1,127.83
$1,174.04
$1,222.99
$1,396.87 		$261.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.56
$776.98
$874.88
$1,222.64
$1,857.92 		$946.41
$1,038.83
$1,136.73
$1,484.49 		$1,208.26
$1,300.68
$1,398.58
$1,746.34 		$1,470.11
$1,562.53
$1,660.43
$2,008.19 		$261.85
Toc - Plan #99 Ambetter from Arizona Complete Health
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$326.08
$370.10
$416.73
$582.38
$884.99 		$575.53
$619.55
$666.18
$831.83 		$824.98
$869.00
$915.63
$1,081.28 		$1,074.43
$1,118.45
$1,165.08
$1,330.73 		$249.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.16
$740.20
$833.46
$1,164.76
$1,769.98 		$901.61
$989.65
$1,082.91
$1,414.21 		$1,151.06
$1,239.10
$1,332.36
$1,663.66 		$1,400.51
$1,488.55
$1,581.81
$1,913.11 		$249.45
Toc - Plan #100 Ambetter from Arizona Complete Health
Silver

(HMO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 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 		$332.92
$377.86
$425.47
$594.59
$903.54 		$587.60
$632.54
$680.15
$849.27 		$842.28
$887.22
$934.83
$1,103.95 		$1,096.96
$1,141.90
$1,189.51
$1,358.63 		$254.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.84
$755.72
$850.94
$1,189.18
$1,807.08 		$920.52
$1,010.40
$1,105.62
$1,443.86 		$1,175.20
$1,265.08
$1,360.30
$1,698.54 		$1,429.88
$1,519.76
$1,614.98
$1,953.22 		$254.68
Toc - Plan #101 Ambetter from Arizona Complete Health
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$269.58
$305.97
$344.52
$481.46
$731.63 		$475.81
$512.20
$550.75
$687.69 		$682.04
$718.43
$756.98
$893.92 		$888.27
$924.66
$963.21
$1,100.15 		$206.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.16
$611.94
$689.04
$962.92
$1,463.26 		$745.39
$818.17
$895.27
$1,169.15 		$951.62
$1,024.40
$1,101.50
$1,375.38 		$1,157.85
$1,230.63
$1,307.73
$1,581.61 		$206.23
Toc - Plan #102 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$295.06
$334.89
$377.08
$526.97
$800.79 		$520.78
$560.61
$602.80
$752.69 		$746.50
$786.33
$828.52
$978.41 		$972.22
$1,012.05
$1,054.24
$1,204.13 		$225.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.12
$669.78
$754.16
$1,053.94
$1,601.58 		$815.84
$895.50
$979.88
$1,279.66 		$1,041.56
$1,121.22
$1,205.60
$1,505.38 		$1,267.28
$1,346.94
$1,431.32
$1,731.10 		$225.72
Toc - Plan #103 Ambetter from Arizona Complete Health
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$329.30
$373.76
$420.85
$588.14
$893.73 		$581.22
$625.68
$672.77
$840.06 		$833.14
$877.60
$924.69
$1,091.98 		$1,085.06
$1,129.52
$1,176.61
$1,343.90 		$251.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.60
$747.52
$841.70
$1,176.28
$1,787.46 		$910.52
$999.44
$1,093.62
$1,428.20 		$1,162.44
$1,251.36
$1,345.54
$1,680.12 		$1,414.36
$1,503.28
$1,597.46
$1,932.04 		$251.92
Toc - Plan #104 Ambetter from Arizona Complete Health
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.10
$425.74
$479.37
$669.92
$1,018.01 		$662.05
$712.69
$766.32
$956.87 		$949.00
$999.64
$1,053.27
$1,243.82 		$1,235.95
$1,286.59
$1,340.22
$1,530.77 		$286.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.20
$851.48
$958.74
$1,339.84
$2,036.02 		$1,037.15
$1,138.43
$1,245.69
$1,626.79 		$1,324.10
$1,425.38
$1,532.64
$1,913.74 		$1,611.05
$1,712.33
$1,819.59
$2,200.69 		$286.95
Toc - Plan #105 Ambetter from Arizona Complete Health
Silver

(HMO) Elite Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$340.85
$386.86
$435.60
$608.75
$925.06 		$601.60
$647.61
$696.35
$869.50 		$862.35
$908.36
$957.10
$1,130.25 		$1,123.10
$1,169.11
$1,217.85
$1,391.00 		$260.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.70
$773.72
$871.20
$1,217.50
$1,850.12 		$942.45
$1,034.47
$1,131.95
$1,478.25 		$1,203.20
$1,295.22
$1,392.70
$1,739.00 		$1,463.95
$1,555.97
$1,653.45
$1,999.75 		$260.75
Toc - Plan #106 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.87
$368.72
$415.18
$580.21
$881.69 		$573.39
$617.24
$663.70
$828.73 		$821.91
$865.76
$912.22
$1,077.25 		$1,070.43
$1,114.28
$1,160.74
$1,325.77 		$248.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.74
$737.44
$830.36
$1,160.42
$1,763.38 		$898.26
$985.96
$1,078.88
$1,408.94 		$1,146.78
$1,234.48
$1,327.40
$1,657.46 		$1,395.30
$1,483.00
$1,575.92
$1,905.98 		$248.52
Toc - Plan #107 Ambetter from Arizona Complete Health
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$308.38
$350.01
$394.11
$550.76
$836.94 		$544.29
$585.92
$630.02
$786.67 		$780.20
$821.83
$865.93
$1,022.58 		$1,016.11
$1,057.74
$1,101.84
$1,258.49 		$235.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.76
$700.02
$788.22
$1,101.52
$1,673.88 		$852.67
$935.93
$1,024.13
$1,337.43 		$1,088.58
$1,171.84
$1,260.04
$1,573.34 		$1,324.49
$1,407.75
$1,495.95
$1,809.25 		$235.91
Toc - Plan #108 Ambetter from Arizona Complete Health
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$316.24
$358.93
$404.15
$564.80
$858.27 		$558.16
$600.85
$646.07
$806.72 		$800.08
$842.77
$887.99
$1,048.64 		$1,042.00
$1,084.69
$1,129.91
$1,290.56 		$241.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.48
$717.86
$808.30
$1,129.60
$1,716.54 		$874.40
$959.78
$1,050.22
$1,371.52 		$1,116.32
$1,201.70
$1,292.14
$1,613.44 		$1,358.24
$1,443.62
$1,534.06
$1,855.36 		$241.92
Toc - Plan #109 Ambetter from Arizona Complete Health
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$355.15
$403.09
$453.88
$634.29
$963.87 		$626.84
$674.78
$725.57
$905.98 		$898.53
$946.47
$997.26
$1,177.67 		$1,170.22
$1,218.16
$1,268.95
$1,449.36 		$271.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.30
$806.18
$907.76
$1,268.58
$1,927.74 		$981.99
$1,077.87
$1,179.45
$1,540.27 		$1,253.68
$1,349.56
$1,451.14
$1,811.96 		$1,525.37
$1,621.25
$1,722.83
$2,083.65 		$271.69
Toc - Plan #110 Ambetter from Arizona Complete Health
Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.99
$467.61
$526.53
$735.82
$1,118.15 		$727.17
$782.79
$841.71
$1,051.00 		$1,042.35
$1,097.97
$1,156.89
$1,366.18 		$1,357.53
$1,413.15
$1,472.07
$1,681.36 		$315.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.98
$935.22
$1,053.06
$1,471.64
$2,236.30 		$1,139.16
$1,250.40
$1,368.24
$1,786.82 		$1,454.34
$1,565.58
$1,683.42
$2,102.00 		$1,769.52
$1,880.76
$1,998.60
$2,417.18 		$315.18
Toc - Plan #111 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.71
$327.69
$368.97
$515.64
$783.56 		$509.57
$548.55
$589.83
$736.50 		$730.43
$769.41
$810.69
$957.36 		$951.29
$990.27
$1,031.55
$1,178.22 		$220.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.42
$655.38
$737.94
$1,031.28
$1,567.12 		$798.28
$876.24
$958.80
$1,252.14 		$1,019.14
$1,097.10
$1,179.66
$1,473.00 		$1,240.00
$1,317.96
$1,400.52
$1,693.86 		$220.86
Toc - Plan #112 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) Elite SELECT Bronze with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$299.79
$340.26
$383.13
$535.42
$813.62 		$529.13
$569.60
$612.47
$764.76 		$758.47
$798.94
$841.81
$994.10 		$987.81
$1,028.28
$1,071.15
$1,223.44 		$229.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.58
$680.52
$766.26
$1,070.84
$1,627.24 		$828.92
$909.86
$995.60
$1,300.18 		$1,058.26
$1,139.20
$1,224.94
$1,529.52 		$1,287.60
$1,368.54
$1,454.28
$1,758.86 		$229.34
Toc - Plan #113 Ambetter from Arizona Complete Health
Silver

(HMO) Complete SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.88
$344.90
$388.36
$542.73
$824.73 		$536.35
$577.37
$620.83
$775.20 		$768.82
$809.84
$853.30
$1,007.67 		$1,001.29
$1,042.31
$1,085.77
$1,240.14 		$232.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.76
$689.80
$776.72
$1,085.46
$1,649.46 		$840.23
$922.27
$1,009.19
$1,317.93 		$1,072.70
$1,154.74
$1,241.66
$1,550.40 		$1,305.17
$1,387.21
$1,474.13
$1,782.87 		$232.47
Toc - Plan #114 Ambetter from Arizona Complete Health
Silver

(HMO) Clear SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$284.57
$322.99
$363.68
$508.24
$772.32 		$502.27
$540.69
$581.38
$725.94 		$719.97
$758.39
$799.08
$943.64 		$937.67
$976.09
$1,016.78
$1,161.34 		$217.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.14
$645.98
$727.36
$1,016.48
$1,544.64 		$786.84
$863.68
$945.06
$1,234.18 		$1,004.54
$1,081.38
$1,162.76
$1,451.88 		$1,222.24
$1,299.08
$1,380.46
$1,669.58 		$217.70
Toc - Plan #115 Ambetter from Arizona Complete Health
Silver

(HMO) Focused SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.82
$331.22
$372.95
$521.20
$792.01 		$515.06
$554.46
$596.19
$744.44 		$738.30
$777.70
$819.43
$967.68 		$961.54
$1,000.94
$1,042.67
$1,190.92 		$223.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.64
$662.44
$745.90
$1,042.40
$1,584.02 		$806.88
$885.68
$969.14
$1,265.64 		$1,030.12
$1,108.92
$1,192.38
$1,488.88 		$1,253.36
$1,332.16
$1,415.62
$1,712.12 		$223.24
Toc - Plan #116 Ambetter from Arizona Complete Health
Gold

(HMO) Everyday SELECT Gold with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$331.58
$376.34
$423.76
$592.20
$899.91 		$585.24
$630.00
$677.42
$845.86 		$838.90
$883.66
$931.08
$1,099.52 		$1,092.56
$1,137.32
$1,184.74
$1,353.18 		$253.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.16
$752.68
$847.52
$1,184.40
$1,799.82 		$916.82
$1,006.34
$1,101.18
$1,438.06 		$1,170.48
$1,260.00
$1,354.84
$1,691.72 		$1,424.14
$1,513.66
$1,608.50
$1,945.38 		$253.66
Toc - Plan #117 Ambetter from Arizona Complete Health
Gold

(HMO) Clear SELECT Gold with Select Providers

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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 		$327.73
$371.97
$418.84
$585.32
$889.45 		$578.44
$622.68
$669.55
$836.03 		$829.15
$873.39
$920.26
$1,086.74 		$1,079.86
$1,124.10
$1,170.97
$1,337.45 		$250.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.46
$743.94
$837.68
$1,170.64
$1,778.90 		$906.17
$994.65
$1,088.39
$1,421.35 		$1,156.88
$1,245.36
$1,339.10
$1,672.06 		$1,407.59
$1,496.07
$1,589.81
$1,922.77 		$250.71
Toc - Plan #118 Ambetter from Arizona Complete Health
Expanded Bronze

(HMO) CMS Standard Expanded Bronze SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$261.02
$296.26
$333.58
$466.18
$708.41 		$460.70
$495.94
$533.26
$665.86 		$660.38
$695.62
$732.94
$865.54 		$860.06
$895.30
$932.62
$1,065.22 		$199.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$522.04
$592.52
$667.16
$932.36
$1,416.82 		$721.72
$792.20
$866.84
$1,132.04 		$921.40
$991.88
$1,066.52
$1,331.72 		$1,121.08
$1,191.56
$1,266.20
$1,531.40 		$199.68
Toc - Plan #119 Ambetter from Arizona Complete Health
Silver

(HMO) CMS Standard Silver SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$297.07
$337.17
$379.65
$530.57
$806.25 		$524.33
$564.43
$606.91
$757.83 		$751.59
$791.69
$834.17
$985.09 		$978.85
$1,018.95
$1,061.43
$1,212.35 		$227.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$594.14
$674.34
$759.30
$1,061.14
$1,612.50 		$821.40
$901.60
$986.56
$1,288.40 		$1,048.66
$1,128.86
$1,213.82
$1,515.66 		$1,275.92
$1,356.12
$1,441.08
$1,742.92 		$227.26
Toc - Plan #120 Ambetter from Arizona Complete Health
Gold

(HMO) CMS Standard Gold SELECT

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-926-5057

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 		$328.68
$373.05
$420.05
$587.02
$892.04 		$580.12
$624.49
$671.49
$838.46 		$831.56
$875.93
$922.93
$1,089.90 		$1,083.00
$1,127.37
$1,174.37
$1,341.34 		$251.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.36
$746.10
$840.10
$1,174.04
$1,784.08 		$908.80
$997.54
$1,091.54
$1,425.48 		$1,160.24
$1,248.98
$1,342.98
$1,676.92 		$1,411.68
$1,500.42
$1,594.42
$1,928.36 		$251.44

ADVERTISEMENT

Cigna HealthCare of Arizona, Inc

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #121 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.95
$407.40
$458.73
$641.08
$974.18 		$633.54
$681.99
$733.32
$915.67 		$908.13
$956.58
$1,007.91
$1,190.26 		$1,182.72
$1,231.17
$1,282.50
$1,464.85 		$274.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.90
$814.80
$917.46
$1,282.16
$1,948.36 		$992.49
$1,089.39
$1,192.05
$1,556.75 		$1,267.08
$1,363.98
$1,466.64
$1,831.34 		$1,541.67
$1,638.57
$1,741.23
$2,105.93 		$274.59
Toc - Plan #122 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 7000

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.15
$353.16
$397.65
$555.72
$844.47 		$549.18
$591.19
$635.68
$793.75 		$787.21
$829.22
$873.71
$1,031.78 		$1,025.24
$1,067.25
$1,111.74
$1,269.81 		$238.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.30
$706.32
$795.30
$1,111.44
$1,688.94 		$860.33
$944.35
$1,033.33
$1,349.47 		$1,098.36
$1,182.38
$1,271.36
$1,587.50 		$1,336.39
$1,420.41
$1,509.39
$1,825.53 		$238.03
Toc - Plan #123 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 8500

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$320.45
$363.71
$409.54
$572.32
$869.70 		$565.59
$608.85
$654.68
$817.46 		$810.73
$853.99
$899.82
$1,062.60 		$1,055.87
$1,099.13
$1,144.96
$1,307.74 		$245.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.90
$727.42
$819.08
$1,144.64
$1,739.40 		$886.04
$972.56
$1,064.22
$1,389.78 		$1,131.18
$1,217.70
$1,309.36
$1,634.92 		$1,376.32
$1,462.84
$1,554.50
$1,880.06 		$245.14
Toc - Plan #124 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 4000

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

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 		$358.82
$407.26
$458.57
$640.84
$973.83 		$633.31
$681.75
$733.06
$915.33 		$907.80
$956.24
$1,007.55
$1,189.82 		$1,182.29
$1,230.73
$1,282.04
$1,464.31 		$274.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.64
$814.52
$917.14
$1,281.68
$1,947.66 		$992.13
$1,089.01
$1,191.63
$1,556.17 		$1,266.62
$1,363.50
$1,466.12
$1,830.66 		$1,541.11
$1,637.99
$1,740.61
$2,105.15 		$274.49
Toc - Plan #125 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Cigna Connect 1900

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$488.23
$554.14
$623.95
$871.97
$1,325.05 		$861.72
$927.63
$997.44
$1,245.46 		$1,235.21
$1,301.12
$1,370.93
$1,618.95 		$1,608.70
$1,674.61
$1,744.42
$1,992.44 		$373.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976.46
$1,108.28
$1,247.90
$1,743.94
$2,650.10 		$1,349.95
$1,481.77
$1,621.39
$2,117.43 		$1,723.44
$1,855.26
$1,994.88
$2,490.92 		$2,096.93
$2,228.75
$2,368.37
$2,864.41 		$373.49
Toc - Plan #126 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.83
$411.81
$463.70
$648.02
$984.72 		$640.40
$689.38
$741.27
$925.59 		$917.97
$966.95
$1,018.84
$1,203.16 		$1,195.54
$1,244.52
$1,296.41
$1,480.73 		$277.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.66
$823.62
$927.40
$1,296.04
$1,969.44 		$1,003.23
$1,101.19
$1,204.97
$1,573.61 		$1,280.80
$1,378.76
$1,482.54
$1,851.18 		$1,558.37
$1,656.33
$1,760.11
$2,128.75 		$277.57
Toc - Plan #127 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 6500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.43
$407.95
$459.35
$641.94
$975.48 		$634.39
$682.91
$734.31
$916.90 		$909.35
$957.87
$1,009.27
$1,191.86 		$1,184.31
$1,232.83
$1,284.23
$1,466.82 		$274.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.86
$815.90
$918.70
$1,283.88
$1,950.96 		$993.82
$1,090.86
$1,193.66
$1,558.84 		$1,268.78
$1,365.82
$1,468.62
$1,833.80 		$1,543.74
$1,640.78
$1,743.58
$2,108.76 		$274.96
Toc - Plan #128 Cigna HealthCare of Arizona, Inc
Bronze

(HMO) Cigna Connect 8700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$308.49
$350.14
$394.25
$550.97
$837.25 		$544.49
$586.14
$630.25
$786.97 		$780.49
$822.14
$866.25
$1,022.97 		$1,016.49
$1,058.14
$1,102.25
$1,258.97 		$236.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$616.98
$700.28
$788.50
$1,101.94
$1,674.50 		$852.98
$936.28
$1,024.50
$1,337.94 		$1,088.98
$1,172.28
$1,260.50
$1,573.94 		$1,324.98
$1,408.28
$1,496.50
$1,809.94 		$236.00
Toc - Plan #129 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.58
$363.86
$409.70
$572.56
$870.06 		$565.82
$609.10
$654.94
$817.80 		$811.06
$854.34
$900.18
$1,063.04 		$1,056.30
$1,099.58
$1,145.42
$1,308.28 		$245.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.16
$727.72
$819.40
$1,145.12
$1,740.12 		$886.40
$972.96
$1,064.64
$1,390.36 		$1,131.64
$1,218.20
$1,309.88
$1,635.60 		$1,376.88
$1,463.44
$1,555.12
$1,880.84 		$245.24
Toc - Plan #130 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect HSA 7050

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.80
$364.11
$409.98
$572.95
$870.65 		$566.21
$609.52
$655.39
$818.36 		$811.62
$854.93
$900.80
$1,063.77 		$1,057.03
$1,100.34
$1,146.21
$1,309.18 		$245.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.60
$728.22
$819.96
$1,145.90
$1,741.30 		$887.01
$973.63
$1,065.37
$1,391.31 		$1,132.42
$1,219.04
$1,310.78
$1,636.72 		$1,377.83
$1,464.45
$1,556.19
$1,882.13 		$245.41
Toc - Plan #131 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.09
$410.97
$462.75
$646.69
$982.71 		$639.09
$687.97
$739.75
$923.69 		$916.09
$964.97
$1,016.75
$1,200.69 		$1,193.09
$1,241.97
$1,293.75
$1,477.69 		$277.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.18
$821.94
$925.50
$1,293.38
$1,965.42 		$1,001.18
$1,098.94
$1,202.50
$1,570.38 		$1,278.18
$1,375.94
$1,479.50
$1,847.38 		$1,555.18
$1,652.94
$1,756.50
$2,124.38 		$277.00
Toc - Plan #132 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$491.85
$558.25
$628.58
$878.44
$1,334.88 		$868.11
$934.51
$1,004.84
$1,254.70 		$1,244.37
$1,310.77
$1,381.10
$1,630.96 		$1,620.63
$1,687.03
$1,757.36
$2,007.22 		$376.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.70
$1,116.50
$1,257.16
$1,756.88
$2,669.76 		$1,359.96
$1,492.76
$1,633.42
$2,133.14 		$1,736.22
$1,869.02
$2,009.68
$2,509.40 		$2,112.48
$2,245.28
$2,385.94
$2,885.66 		$376.26
Toc - Plan #133 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Connect 0A

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$339.87
$385.76
$434.36
$607.01
$922.42 		$599.87
$645.76
$694.36
$867.01 		$859.87
$905.76
$954.36
$1,127.01 		$1,119.87
$1,165.76
$1,214.36
$1,387.01 		$260.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.74
$771.52
$868.72
$1,214.02
$1,844.84 		$939.74
$1,031.52
$1,128.72
$1,474.02 		$1,199.74
$1,291.52
$1,388.72
$1,734.02 		$1,459.74
$1,551.52
$1,648.72
$1,994.02 		$260.00
Toc - Plan #134 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Connect 0B

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.21
$407.70
$459.07
$641.55
$974.89 		$634.00
$682.49
$733.86
$916.34 		$908.79
$957.28
$1,008.65
$1,191.13 		$1,183.58
$1,232.07
$1,283.44
$1,465.92 		$274.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.42
$815.40
$918.14
$1,283.10
$1,949.78 		$993.21
$1,090.19
$1,192.93
$1,557.89 		$1,268.00
$1,364.98
$1,467.72
$1,832.68 		$1,542.79
$1,639.77
$1,742.51
$2,107.47 		$274.79
Toc - Plan #135 Cigna HealthCare of Arizona, Inc
Expanded Bronze

(HMO) Cigna Simple Choice 7500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$318.14
$361.09
$406.58
$568.19
$863.42 		$561.51
$604.46
$649.95
$811.56 		$804.88
$847.83
$893.32
$1,054.93 		$1,048.25
$1,091.20
$1,136.69
$1,298.30 		$243.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.28
$722.18
$813.16
$1,136.38
$1,726.84 		$879.65
$965.55
$1,056.53
$1,379.75 		$1,123.02
$1,208.92
$1,299.90
$1,623.12 		$1,366.39
$1,452.29
$1,543.27
$1,866.49 		$243.37
Toc - Plan #136 Cigna HealthCare of Arizona, Inc
Bronze

(HMO) Cigna Simple Choice 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$305.48
$346.72
$390.40
$545.59
$829.07 		$539.17
$580.41
$624.09
$779.28 		$772.86
$814.10
$857.78
$1,012.97 		$1,006.55
$1,047.79
$1,091.47
$1,246.66 		$233.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$610.96
$693.44
$780.80
$1,091.18
$1,658.14 		$844.65
$927.13
$1,014.49
$1,324.87 		$1,078.34
$1,160.82
$1,248.18
$1,558.56 		$1,312.03
$1,394.51
$1,481.87
$1,792.25 		$233.69
Toc - Plan #137 Cigna HealthCare of Arizona, Inc
Silver

(HMO) Cigna Simple Choice 5800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$358.86
$407.31
$458.62
$640.92
$973.94 		$633.39
$681.84
$733.15
$915.45 		$907.92
$956.37
$1,007.68
$1,189.98 		$1,182.45
$1,230.90
$1,282.21
$1,464.51 		$274.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$717.72
$814.62
$917.24
$1,281.84
$1,947.88 		$992.25
$1,089.15
$1,191.77
$1,556.37 		$1,266.78
$1,363.68
$1,466.30
$1,830.90 		$1,541.31
$1,638.21
$1,740.83
$2,105.43 		$274.53
Toc - Plan #138 Cigna HealthCare of Arizona, Inc
Gold

(HMO) Cigna Simple Choice 2000

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$487.05
$552.80
$622.45
$869.87
$1,321.85 		$859.64
$925.39
$995.04
$1,242.46 		$1,232.23
$1,297.98
$1,367.63
$1,615.05 		$1,604.82
$1,670.57
$1,740.22
$1,987.64 		$372.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$974.10
$1,105.60
$1,244.90
$1,739.74
$2,643.70 		$1,346.69
$1,478.19
$1,617.49
$2,112.33 		$1,719.28
$1,850.78
$1,990.08
$2,484.92 		$2,091.87
$2,223.37
$2,362.67
$2,857.51 		$372.59

‡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 Maricopa County here.

Maricopa County is in “Rating Area 4” of Arizona.

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

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2023 Obamacare Plans for Maricopa County, AZ

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