Obamacare 2023 Rates for Guilford County

Obamacare > Rates > North Carolina > Guilford 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 Greensboro, NC.

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, 124 Plans and 2023 Rates for Guilford County, North Carolina

Below, you’ll find a summary of the 124 plans for Guilford County, North Carolina 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 |

Guilford County Resources

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Blue Cross and Blue Shield of NC

Local: 1-800-324-4973 | Toll Free: 1-800-324-4973

Toc - Plan #1 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Simple | $0 Deductible | 3 Free PCP | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$540.34
$613.29
$690.55
$965.05
$1,466.48 		$953.70
$1,026.65
$1,103.91
$1,378.41 		$1,367.06
$1,440.01
$1,517.27
$1,791.77 		$1,780.42
$1,853.37
$1,930.63
$2,205.13 		$413.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,080.68
$1,226.58
$1,381.10
$1,930.10
$2,932.96 		$1,494.04
$1,639.94
$1,794.46
$2,343.46 		$1,907.40
$2,053.30
$2,207.82
$2,756.82 		$2,320.76
$2,466.66
$2,621.18
$3,170.18 		$413.36
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 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 		$500.28
$567.82
$639.36
$893.50
$1,357.76 		$882.99
$950.53
$1,022.07
$1,276.21 		$1,265.70
$1,333.24
$1,404.78
$1,658.92 		$1,648.41
$1,715.95
$1,787.49
$2,041.63 		$382.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,000.56
$1,135.64
$1,278.72
$1,787.00
$2,715.52 		$1,383.27
$1,518.35
$1,661.43
$2,169.71 		$1,765.98
$1,901.06
$2,044.14
$2,552.42 		$2,148.69
$2,283.77
$2,426.85
$2,935.13 		$382.71
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$520.20
$590.43
$664.82
$929.08
$1,411.82 		$918.15
$988.38
$1,062.77
$1,327.03 		$1,316.10
$1,386.33
$1,460.72
$1,724.98 		$1,714.05
$1,784.28
$1,858.67
$2,122.93 		$397.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,040.40
$1,180.86
$1,329.64
$1,858.16
$2,823.64 		$1,438.35
$1,578.81
$1,727.59
$2,256.11 		$1,836.30
$1,976.76
$2,125.54
$2,654.06 		$2,234.25
$2,374.71
$2,523.49
$3,052.01 		$397.95
Toc - Plan #4 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$365.18
$414.48
$466.70
$652.21
$991.10 		$644.54
$693.84
$746.06
$931.57 		$923.90
$973.20
$1,025.42
$1,210.93 		$1,203.26
$1,252.56
$1,304.78
$1,490.29 		$279.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.36
$828.96
$933.40
$1,304.42
$1,982.20 		$1,009.72
$1,108.32
$1,212.76
$1,583.78 		$1,289.08
$1,387.68
$1,492.12
$1,863.14 		$1,568.44
$1,667.04
$1,771.48
$2,142.50 		$279.36
Toc - Plan #5 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$513.97
$583.36
$656.85
$917.95
$1,394.91 		$907.16
$976.55
$1,050.04
$1,311.14 		$1,300.35
$1,369.74
$1,443.23
$1,704.33 		$1,693.54
$1,762.93
$1,836.42
$2,097.52 		$393.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,027.94
$1,166.72
$1,313.70
$1,835.90
$2,789.82 		$1,421.13
$1,559.91
$1,706.89
$2,229.09 		$1,814.32
$1,953.10
$2,100.08
$2,622.28 		$2,207.51
$2,346.29
$2,493.27
$3,015.47 		$393.19
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$528.32
$599.64
$675.19
$943.58
$1,433.86 		$932.48
$1,003.80
$1,079.35
$1,347.74 		$1,336.64
$1,407.96
$1,483.51
$1,751.90 		$1,740.80
$1,812.12
$1,887.67
$2,156.06 		$404.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,056.64
$1,199.28
$1,350.38
$1,887.16
$2,867.72 		$1,460.80
$1,603.44
$1,754.54
$2,291.32 		$1,864.96
$2,007.60
$2,158.70
$2,695.48 		$2,269.12
$2,411.76
$2,562.86
$3,099.64 		$404.16
Toc - Plan #7 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$383.21
$434.94
$489.74
$684.41
$1,040.03 		$676.37
$728.10
$782.90
$977.57 		$969.53
$1,021.26
$1,076.06
$1,270.73 		$1,262.69
$1,314.42
$1,369.22
$1,563.89 		$293.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$766.42
$869.88
$979.48
$1,368.82
$2,080.06 		$1,059.58
$1,163.04
$1,272.64
$1,661.98 		$1,352.74
$1,456.20
$1,565.80
$1,955.14 		$1,645.90
$1,749.36
$1,858.96
$2,248.30 		$293.16
Toc - Plan #8 Blue Cross and Blue Shield of NC
Catastrophic

(PPO) Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$268.34
$304.57
$342.94
$479.26
$728.27 		$473.62
$509.85
$548.22
$684.54 		$678.90
$715.13
$753.50
$889.82 		$884.18
$920.41
$958.78
$1,095.10 		$205.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$536.68
$609.14
$685.88
$958.52
$1,456.54 		$741.96
$814.42
$891.16
$1,163.80 		$947.24
$1,019.70
$1,096.44
$1,369.08 		$1,152.52
$1,224.98
$1,301.72
$1,574.36 		$205.28
Toc - Plan #9 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$522.31
$592.82
$667.51
$932.85
$1,417.55 		$921.88
$992.39
$1,067.08
$1,332.42 		$1,321.45
$1,391.96
$1,466.65
$1,731.99 		$1,721.02
$1,791.53
$1,866.22
$2,131.56 		$399.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,044.62
$1,185.64
$1,335.02
$1,865.70
$2,835.10 		$1,444.19
$1,585.21
$1,734.59
$2,265.27 		$1,843.76
$1,984.78
$2,134.16
$2,664.84 		$2,243.33
$2,384.35
$2,533.73
$3,064.41 		$399.57
Toc - Plan #10 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$385.91
$438.01
$493.19
$689.24
$1,047.36 		$681.13
$733.23
$788.41
$984.46 		$976.35
$1,028.45
$1,083.63
$1,279.68 		$1,271.57
$1,323.67
$1,378.85
$1,574.90 		$295.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.82
$876.02
$986.38
$1,378.48
$2,094.72 		$1,067.04
$1,171.24
$1,281.60
$1,673.70 		$1,362.26
$1,466.46
$1,576.82
$1,968.92 		$1,657.48
$1,761.68
$1,872.04
$2,264.14 		$295.22
Toc - Plan #11 Blue Cross and Blue Shield of NC
Bronze

(PPO) Blue Advantage Bronze 9100 | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$365.88
$415.27
$467.59
$653.46
$993.00 		$645.78
$695.17
$747.49
$933.36 		$925.68
$975.07
$1,027.39
$1,213.26 		$1,205.58
$1,254.97
$1,307.29
$1,493.16 		$279.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.76
$830.54
$935.18
$1,306.92
$1,986.00 		$1,011.66
$1,110.44
$1,215.08
$1,586.82 		$1,291.56
$1,390.34
$1,494.98
$1,866.72 		$1,571.46
$1,670.24
$1,774.88
$2,146.62 		$279.90
Toc - Plan #12 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold Standard 2000 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$512.08
$581.21
$654.44
$914.57
$1,389.79 		$903.82
$972.95
$1,046.18
$1,306.31 		$1,295.56
$1,364.69
$1,437.92
$1,698.05 		$1,687.30
$1,756.43
$1,829.66
$2,089.79 		$391.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,024.16
$1,162.42
$1,308.88
$1,829.14
$2,779.58 		$1,415.90
$1,554.16
$1,700.62
$2,220.88 		$1,807.64
$1,945.90
$2,092.36
$2,612.62 		$2,199.38
$2,337.64
$2,484.10
$3,004.36 		$391.74
Toc - Plan #13 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Standard 5800 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$518.04
$587.98
$662.06
$925.22
$1,405.96 		$914.34
$984.28
$1,058.36
$1,321.52 		$1,310.64
$1,380.58
$1,454.66
$1,717.82 		$1,706.94
$1,776.88
$1,850.96
$2,114.12 		$396.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,036.08
$1,175.96
$1,324.12
$1,850.44
$2,811.92 		$1,432.38
$1,572.26
$1,720.42
$2,246.74 		$1,828.68
$1,968.56
$2,116.72
$2,643.04 		$2,224.98
$2,364.86
$2,513.02
$3,039.34 		$396.30
Toc - Plan #14 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze Standard 7500 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$365.62
$414.98
$467.26
$653.00
$992.29 		$645.32
$694.68
$746.96
$932.70 		$925.02
$974.38
$1,026.66
$1,212.40 		$1,204.72
$1,254.08
$1,306.36
$1,492.10 		$279.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$731.24
$829.96
$934.52
$1,306.00
$1,984.58 		$1,010.94
$1,109.66
$1,214.22
$1,585.70 		$1,290.64
$1,389.36
$1,493.92
$1,865.40 		$1,570.34
$1,669.06
$1,773.62
$2,145.10 		$279.70
Toc - Plan #15 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$379.34
$430.55
$484.80
$677.50
$1,029.53 		$669.54
$720.75
$775.00
$967.70 		$959.74
$1,010.95
$1,065.20
$1,257.90 		$1,249.94
$1,301.15
$1,355.40
$1,548.10 		$290.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.68
$861.10
$969.60
$1,355.00
$2,059.06 		$1,048.88
$1,151.30
$1,259.80
$1,645.20 		$1,339.08
$1,441.50
$1,550.00
$1,935.40 		$1,629.28
$1,731.70
$1,840.20
$2,225.60 		$290.20
Toc - Plan #16 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold Standard 2000 | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$377.95
$428.97
$483.02
$675.02
$1,025.76 		$667.08
$718.10
$772.15
$964.15 		$956.21
$1,007.23
$1,061.28
$1,253.28 		$1,245.34
$1,296.36
$1,350.41
$1,542.41 		$289.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.90
$857.94
$966.04
$1,350.04
$2,051.52 		$1,045.03
$1,147.07
$1,255.17
$1,639.17 		$1,334.16
$1,436.20
$1,544.30
$1,928.30 		$1,623.29
$1,725.33
$1,833.43
$2,217.43 		$289.13
Toc - Plan #17 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$390.02
$442.67
$498.45
$696.58
$1,058.51 		$688.39
$741.04
$796.82
$994.95 		$986.76
$1,039.41
$1,095.19
$1,293.32 		$1,285.13
$1,337.78
$1,393.56
$1,591.69 		$298.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$780.04
$885.34
$996.90
$1,393.16
$2,117.02 		$1,078.41
$1,183.71
$1,295.27
$1,691.53 		$1,376.78
$1,482.08
$1,593.64
$1,989.90 		$1,675.15
$1,780.45
$1,892.01
$2,288.27 		$298.37
Toc - Plan #18 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Simple | $0 Deductible | 3 Free PCP | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$398.90
$452.75
$509.79
$712.44
$1,082.61 		$704.06
$757.91
$814.95
$1,017.60 		$1,009.22
$1,063.07
$1,120.11
$1,322.76 		$1,314.38
$1,368.23
$1,425.27
$1,627.92 		$305.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$797.80
$905.50
$1,019.58
$1,424.88
$2,165.22 		$1,102.96
$1,210.66
$1,324.74
$1,730.04 		$1,408.12
$1,515.82
$1,629.90
$2,035.20 		$1,713.28
$1,820.98
$1,935.06
$2,340.36 		$305.16
Toc - Plan #19 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 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 		$369.33
$419.19
$472.00
$659.62
$1,002.36 		$651.87
$701.73
$754.54
$942.16 		$934.41
$984.27
$1,037.08
$1,224.70 		$1,216.95
$1,266.81
$1,319.62
$1,507.24 		$282.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.66
$838.38
$944.00
$1,319.24
$2,004.72 		$1,021.20
$1,120.92
$1,226.54
$1,601.78 		$1,303.74
$1,403.46
$1,509.08
$1,884.32 		$1,586.28
$1,686.00
$1,791.62
$2,166.86 		$282.54
Toc - Plan #20 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$384.01
$435.85
$490.76
$685.84
$1,042.20 		$677.78
$729.62
$784.53
$979.61 		$971.55
$1,023.39
$1,078.30
$1,273.38 		$1,265.32
$1,317.16
$1,372.07
$1,567.15 		$293.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$768.02
$871.70
$981.52
$1,371.68
$2,084.40 		$1,061.79
$1,165.47
$1,275.29
$1,665.45 		$1,355.56
$1,459.24
$1,569.06
$1,959.22 		$1,649.33
$1,753.01
$1,862.83
$2,252.99 		$293.77
Toc - Plan #21 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$385.53
$437.58
$492.71
$688.56
$1,046.33 		$680.46
$732.51
$787.64
$983.49 		$975.39
$1,027.44
$1,082.57
$1,278.42 		$1,270.32
$1,322.37
$1,377.50
$1,573.35 		$294.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.06
$875.16
$985.42
$1,377.12
$2,092.66 		$1,065.99
$1,170.09
$1,280.35
$1,672.05 		$1,360.92
$1,465.02
$1,575.28
$1,966.98 		$1,655.85
$1,759.95
$1,870.21
$2,261.91 		$294.93
Toc - Plan #22 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Standard 5800 | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$382.41
$434.04
$488.72
$682.98
$1,037.86 		$674.95
$726.58
$781.26
$975.52 		$967.49
$1,019.12
$1,073.80
$1,268.06 		$1,260.03
$1,311.66
$1,366.34
$1,560.60 		$292.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.82
$868.08
$977.44
$1,365.96
$2,075.72 		$1,057.36
$1,160.62
$1,269.98
$1,658.50 		$1,349.90
$1,453.16
$1,562.52
$1,951.04 		$1,642.44
$1,745.70
$1,855.06
$2,243.58 		$292.54
Toc - Plan #23 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$284.88
$323.34
$364.08
$508.80
$773.16 		$502.81
$541.27
$582.01
$726.73 		$720.74
$759.20
$799.94
$944.66 		$938.67
$977.13
$1,017.87
$1,162.59 		$217.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.76
$646.68
$728.16
$1,017.60
$1,546.32 		$787.69
$864.61
$946.09
$1,235.53 		$1,005.62
$1,082.54
$1,164.02
$1,453.46 		$1,223.55
$1,300.47
$1,381.95
$1,671.39 		$217.93
Toc - Plan #24 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$269.53
$305.92
$344.46
$481.38
$731.50 		$475.72
$512.11
$550.65
$687.57 		$681.91
$718.30
$756.84
$893.76 		$888.10
$924.49
$963.03
$1,099.95 		$206.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.06
$611.84
$688.92
$962.76
$1,463.00 		$745.25
$818.03
$895.11
$1,168.95 		$951.44
$1,024.22
$1,101.30
$1,375.14 		$1,157.63
$1,230.41
$1,307.49
$1,581.33 		$206.19
Toc - Plan #25 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze Standard 7500 | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$269.87
$306.30
$344.89
$481.99
$732.43 		$476.32
$512.75
$551.34
$688.44 		$682.77
$719.20
$757.79
$894.89 		$889.22
$925.65
$964.24
$1,101.34 		$206.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.74
$612.60
$689.78
$963.98
$1,464.86 		$746.19
$819.05
$896.23
$1,170.43 		$952.64
$1,025.50
$1,102.68
$1,376.88 		$1,159.09
$1,231.95
$1,309.13
$1,583.33 		$206.45
Toc - Plan #26 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 7500 | HSA Eligible | Integrated | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.86
$321.05
$361.50
$505.19
$767.68 		$499.25
$537.44
$577.89
$721.58 		$715.64
$753.83
$794.28
$937.97 		$932.03
$970.22
$1,010.67
$1,154.36 		$216.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.72
$642.10
$723.00
$1,010.38
$1,535.36 		$782.11
$858.49
$939.39
$1,226.77 		$998.50
$1,074.88
$1,155.78
$1,443.16 		$1,214.89
$1,291.27
$1,372.17
$1,659.55 		$216.39
Toc - Plan #27 Blue Cross and Blue Shield of NC
Bronze

(EPO) Blue Local Bronze 9100 | Integrated | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$270.08
$306.54
$345.16
$482.36
$733.00 		$476.69
$513.15
$551.77
$688.97 		$683.30
$719.76
$758.38
$895.58 		$889.91
$926.37
$964.99
$1,102.19 		$206.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$540.16
$613.08
$690.32
$964.72
$1,466.00 		$746.77
$819.69
$896.93
$1,171.33 		$953.38
$1,026.30
$1,103.54
$1,377.94 		$1,159.99
$1,232.91
$1,310.15
$1,584.55 		$206.61
Toc - Plan #28 Blue Cross and Blue Shield of NC
Catastrophic

(EPO) Blue Local Catastrophic 9100 | 3 PCP $35 | Integrated | with Wake Forest Baptist Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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 		$198.07
$224.81
$253.13
$353.75
$537.56 		$349.59
$376.33
$404.65
$505.27 		$501.11
$527.85
$556.17
$656.79 		$652.63
$679.37
$707.69
$808.31 		$151.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$396.14
$449.62
$506.26
$707.50
$1,075.12 		$547.66
$601.14
$657.78
$859.02 		$699.18
$752.66
$809.30
$1,010.54 		$850.70
$904.18
$960.82
$1,162.06 		$151.52

ADVERTISEMENT

AmeriHealth Caritas Next

Local: 1-984-245-3613 | Toll Free: 1-833-613-2262 | TTY: 1-844-214-2471
Toc - Plan #29 AmeriHealth Caritas Next
Bronze

(HMO) AmeriHealth Caritas Next Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$241.79
$274.43
$309.00
$431.83
$656.21 		$426.76
$459.40
$493.97
$616.80 		$611.73
$644.37
$678.94
$801.77 		$796.70
$829.34
$863.91
$986.74 		$184.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$483.58
$548.86
$618.00
$863.66
$1,312.42 		$668.55
$733.83
$802.97
$1,048.63 		$853.52
$918.80
$987.94
$1,233.60 		$1,038.49
$1,103.77
$1,172.91
$1,418.57 		$184.97
Toc - Plan #30 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$272.24
$308.99
$347.92
$486.22
$738.86 		$480.51
$517.26
$556.19
$694.49 		$688.78
$725.53
$764.46
$902.76 		$897.05
$933.80
$972.73
$1,111.03 		$208.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$544.48
$617.98
$695.84
$972.44
$1,477.72 		$752.75
$826.25
$904.11
$1,180.71 		$961.02
$1,034.52
$1,112.38
$1,388.98 		$1,169.29
$1,242.79
$1,320.65
$1,597.25 		$208.27
Toc - Plan #31 AmeriHealth Caritas Next
Silver

(HMO) AmeriHealth Caritas Next Silver + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$370.96
$421.04
$474.08
$662.53
$1,006.77 		$654.74
$704.82
$757.86
$946.31 		$938.52
$988.60
$1,041.64
$1,230.09 		$1,222.30
$1,272.38
$1,325.42
$1,513.87 		$283.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$741.92
$842.08
$948.16
$1,325.06
$2,013.54 		$1,025.70
$1,125.86
$1,231.94
$1,608.84 		$1,309.48
$1,409.64
$1,515.72
$1,892.62 		$1,593.26
$1,693.42
$1,799.50
$2,176.40 		$283.78
Toc - Plan #32 AmeriHealth Caritas Next
Gold

(HMO) AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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 		$455.35
$516.82
$581.94
$813.25
$1,235.81 		$803.69
$865.16
$930.28
$1,161.59 		$1,152.03
$1,213.50
$1,278.62
$1,509.93 		$1,500.37
$1,561.84
$1,626.96
$1,858.27 		$348.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$910.70
$1,033.64
$1,163.88
$1,626.50
$2,471.62 		$1,259.04
$1,381.98
$1,512.22
$1,974.84 		$1,607.38
$1,730.32
$1,860.56
$2,323.18 		$1,955.72
$2,078.66
$2,208.90
$2,671.52 		$348.34

ADVERTISEMENT

WellCare of North Carolina

Local: 1-833-705-2175 | Toll Free: 1-833-705-2175

Toc - Plan #33 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 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 		$589.00
$668.50
$752.72
$1,051.93
$1,598.51 		$1,039.57
$1,119.07
$1,203.29
$1,502.50 		$1,490.14
$1,569.64
$1,653.86
$1,953.07 		$1,940.71
$2,020.21
$2,104.43
$2,403.64 		$450.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,178.00
$1,337.00
$1,505.44
$2,103.86
$3,197.02 		$1,628.57
$1,787.57
$1,956.01
$2,554.43 		$2,079.14
$2,238.14
$2,406.58
$3,005.00 		$2,529.71
$2,688.71
$2,857.15
$3,455.57 		$450.57
Toc - Plan #34 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,100 $16,200 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 		$755.60
$857.60
$965.65
$1,349.49
$2,050.68 		$1,333.63
$1,435.63
$1,543.68
$1,927.52 		$1,911.66
$2,013.66
$2,121.71
$2,505.55 		$2,489.69
$2,591.69
$2,699.74
$3,083.58 		$578.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,511.20
$1,715.20
$1,931.30
$2,698.98
$4,101.36 		$2,089.23
$2,293.23
$2,509.33
$3,277.01 		$2,667.26
$2,871.26
$3,087.36
$3,855.04 		$3,245.29
$3,449.29
$3,665.39
$4,433.07 		$578.03
Toc - Plan #35 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 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 		$781.82
$887.36
$999.16
$1,396.32
$2,121.84 		$1,379.91
$1,485.45
$1,597.25
$1,994.41 		$1,978.00
$2,083.54
$2,195.34
$2,592.50 		$2,576.09
$2,681.63
$2,793.43
$3,190.59 		$598.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,563.64
$1,774.72
$1,998.32
$2,792.64
$4,243.68 		$2,161.73
$2,372.81
$2,596.41
$3,390.73 		$2,759.82
$2,970.90
$3,194.50
$3,988.82 		$3,357.91
$3,568.99
$3,792.59
$4,586.91 		$598.09
Toc - Plan #36 WellCare of North Carolina
Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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 		$589.98
$669.61
$753.98
$1,053.68
$1,601.17 		$1,041.31
$1,120.94
$1,205.31
$1,505.01 		$1,492.64
$1,572.27
$1,656.64
$1,956.34 		$1,943.97
$2,023.60
$2,107.97
$2,407.67 		$451.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,179.96
$1,339.22
$1,507.96
$2,107.36
$3,202.34 		$1,631.29
$1,790.55
$1,959.29
$2,558.69 		$2,082.62
$2,241.88
$2,410.62
$3,010.02 		$2,533.95
$2,693.21
$2,861.95
$3,461.35 		$451.33
Toc - Plan #37 WellCare of North Carolina
Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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 		$746.46
$847.22
$953.97
$1,333.16
$2,025.87 		$1,317.50
$1,418.26
$1,525.01
$1,904.20 		$1,888.54
$1,989.30
$2,096.05
$2,475.24 		$2,459.58
$2,560.34
$2,667.09
$3,046.28 		$571.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,492.92
$1,694.44
$1,907.94
$2,666.32
$4,051.74 		$2,063.96
$2,265.48
$2,478.98
$3,237.36 		$2,635.00
$2,836.52
$3,050.02
$3,808.40 		$3,206.04
$3,407.56
$3,621.06
$4,379.44 		$571.04
Toc - Plan #38 WellCare of North Carolina
Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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 		$760.21
$862.83
$971.54
$1,357.72
$2,063.19 		$1,341.77
$1,444.39
$1,553.10
$1,939.28 		$1,923.33
$2,025.95
$2,134.66
$2,520.84 		$2,504.89
$2,607.51
$2,716.22
$3,102.40 		$581.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,520.42
$1,725.66
$1,943.08
$2,715.44
$4,126.38 		$2,101.98
$2,307.22
$2,524.64
$3,297.00 		$2,683.54
$2,888.78
$3,106.20
$3,878.56 		$3,265.10
$3,470.34
$3,687.76
$4,460.12 		$581.56

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5357 | Toll Free: 1-800-980-5357 | TTY: 1-800-980-5357
Toc - Plan #39 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$647.26
$734.64
$827.20
$1,156.01
$1,756.67 		$1,142.42
$1,229.80
$1,322.36
$1,651.17 		$1,637.58
$1,724.96
$1,817.52
$2,146.33 		$2,132.74
$2,220.12
$2,312.68
$2,641.49 		$495.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,294.52
$1,469.28
$1,654.40
$2,312.02
$3,513.34 		$1,789.68
$1,964.44
$2,149.56
$2,807.18 		$2,284.84
$2,459.60
$2,644.72
$3,302.34 		$2,780.00
$2,954.76
$3,139.88
$3,797.50 		$495.16
Toc - Plan #40 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$639.01
$725.28
$816.65
$1,141.27
$1,734.27 		$1,127.85
$1,214.12
$1,305.49
$1,630.11 		$1,616.69
$1,702.96
$1,794.33
$2,118.95 		$2,105.53
$2,191.80
$2,283.17
$2,607.79 		$488.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,278.02
$1,450.56
$1,633.30
$2,282.54
$3,468.54 		$1,766.86
$1,939.40
$2,122.14
$2,771.38 		$2,255.70
$2,428.24
$2,610.98
$3,260.22 		$2,744.54
$2,917.08
$3,099.82
$3,749.06 		$488.84
Toc - Plan #41 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$637.98
$724.11
$815.34
$1,139.44
$1,731.48 		$1,126.04
$1,212.17
$1,303.40
$1,627.50 		$1,614.10
$1,700.23
$1,791.46
$2,115.56 		$2,102.16
$2,188.29
$2,279.52
$2,603.62 		$488.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,275.96
$1,448.22
$1,630.68
$2,278.88
$3,462.96 		$1,764.02
$1,936.28
$2,118.74
$2,766.94 		$2,252.08
$2,424.34
$2,606.80
$3,255.00 		$2,740.14
$2,912.40
$3,094.86
$3,743.06 		$488.06
Toc - Plan #42 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded Saver ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$450.77
$511.62
$576.08
$805.07
$1,223.38 		$795.61
$856.46
$920.92
$1,149.91 		$1,140.45
$1,201.30
$1,265.76
$1,494.75 		$1,485.29
$1,546.14
$1,610.60
$1,839.59 		$344.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$901.54
$1,023.24
$1,152.16
$1,610.14
$2,446.76 		$1,246.38
$1,368.08
$1,497.00
$1,954.98 		$1,591.22
$1,712.92
$1,841.84
$2,299.82 		$1,936.06
$2,057.76
$2,186.68
$2,644.66 		$344.84
Toc - Plan #43 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$672.30
$763.06
$859.20
$1,200.73
$1,824.63 		$1,186.61
$1,277.37
$1,373.51
$1,715.04 		$1,700.92
$1,791.68
$1,887.82
$2,229.35 		$2,215.23
$2,305.99
$2,402.13
$2,743.66 		$514.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,344.60
$1,526.12
$1,718.40
$2,401.46
$3,649.26 		$1,858.91
$2,040.43
$2,232.71
$2,915.77 		$2,373.22
$2,554.74
$2,747.02
$3,430.08 		$2,887.53
$3,069.05
$3,261.33
$3,944.39 		$514.31
Toc - Plan #44 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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 		$697.30
$791.44
$891.15
$1,245.38
$1,892.48 		$1,230.74
$1,324.88
$1,424.59
$1,778.82 		$1,764.18
$1,858.32
$1,958.03
$2,312.26 		$2,297.62
$2,391.76
$2,491.47
$2,845.70 		$533.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,394.60
$1,582.88
$1,782.30
$2,490.76
$3,784.96 		$1,928.04
$2,116.32
$2,315.74
$3,024.20 		$2,461.48
$2,649.76
$2,849.18
$3,557.64 		$2,994.92
$3,183.20
$3,382.62
$4,091.08 		$533.44
Toc - Plan #45 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$479.41
$544.13
$612.68
$856.22
$1,301.11 		$846.16
$910.88
$979.43
$1,222.97 		$1,212.91
$1,277.63
$1,346.18
$1,589.72 		$1,579.66
$1,644.38
$1,712.93
$1,956.47 		$366.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.82
$1,088.26
$1,225.36
$1,712.44
$2,602.22 		$1,325.57
$1,455.01
$1,592.11
$2,079.19 		$1,692.32
$1,821.76
$1,958.86
$2,445.94 		$2,059.07
$2,188.51
$2,325.61
$2,812.69 		$366.75
Toc - Plan #46 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$638.39
$724.57
$815.86
$1,140.16
$1,732.59 		$1,126.76
$1,212.94
$1,304.23
$1,628.53 		$1,615.13
$1,701.31
$1,792.60
$2,116.90 		$2,103.50
$2,189.68
$2,280.97
$2,605.27 		$488.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,276.78
$1,449.14
$1,631.72
$2,280.32
$3,465.18 		$1,765.15
$1,937.51
$2,120.09
$2,768.69 		$2,253.52
$2,425.88
$2,608.46
$3,257.06 		$2,741.89
$2,914.25
$3,096.83
$3,745.43 		$488.37
Toc - Plan #47 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$456.29
$517.89
$583.14
$814.94
$1,238.38 		$805.35
$866.95
$932.20
$1,164.00 		$1,154.41
$1,216.01
$1,281.26
$1,513.06 		$1,503.47
$1,565.07
$1,630.32
$1,862.12 		$349.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$912.58
$1,035.78
$1,166.28
$1,629.88
$2,476.76 		$1,261.64
$1,384.84
$1,515.34
$1,978.94 		$1,610.70
$1,733.90
$1,864.40
$2,328.00 		$1,959.76
$2,082.96
$2,213.46
$2,677.06 		$349.06
Toc - Plan #48 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$658.82
$747.77
$841.98
$1,176.66
$1,788.05 		$1,162.82
$1,251.77
$1,345.98
$1,680.66 		$1,666.82
$1,755.77
$1,849.98
$2,184.66 		$2,170.82
$2,259.77
$2,353.98
$2,688.66 		$504.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,317.64
$1,495.54
$1,683.96
$2,353.32
$3,576.10 		$1,821.64
$1,999.54
$2,187.96
$2,857.32 		$2,325.64
$2,503.54
$2,691.96
$3,361.32 		$2,829.64
$3,007.54
$3,195.96
$3,865.32 		$504.00
Toc - Plan #49 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$647.95
$735.42
$828.08
$1,157.23
$1,758.53 		$1,143.63
$1,231.10
$1,323.76
$1,652.91 		$1,639.31
$1,726.78
$1,819.44
$2,148.59 		$2,134.99
$2,222.46
$2,315.12
$2,644.27 		$495.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,295.90
$1,470.84
$1,656.16
$2,314.46
$3,517.06 		$1,791.58
$1,966.52
$2,151.84
$2,810.14 		$2,287.26
$2,462.20
$2,647.52
$3,305.82 		$2,782.94
$2,957.88
$3,143.20
$3,801.50 		$495.68
Toc - Plan #50 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $2,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$632.66
$718.07
$808.54
$1,129.93
$1,717.03 		$1,116.64
$1,202.05
$1,292.52
$1,613.91 		$1,600.62
$1,686.03
$1,776.50
$2,097.89 		$2,084.60
$2,170.01
$2,260.48
$2,581.87 		$483.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,265.32
$1,436.14
$1,617.08
$2,259.86
$3,434.06 		$1,749.30
$1,920.12
$2,101.06
$2,743.84 		$2,233.28
$2,404.10
$2,585.04
$3,227.82 		$2,717.26
$2,888.08
$3,069.02
$3,711.80 		$483.98
Toc - Plan #51 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$667.04
$757.09
$852.48
$1,191.33
$1,810.35 		$1,177.33
$1,267.38
$1,362.77
$1,701.62 		$1,687.62
$1,777.67
$1,873.06
$2,211.91 		$2,197.91
$2,287.96
$2,383.35
$2,722.20 		$510.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,334.08
$1,514.18
$1,704.96
$2,382.66
$3,620.70 		$1,844.37
$2,024.47
$2,215.25
$2,892.95 		$2,354.66
$2,534.76
$2,725.54
$3,403.24 		$2,864.95
$3,045.05
$3,235.83
$3,913.53 		$510.29
Toc - Plan #52 UnitedHealthcare
Silver

(HMO) UHC Silver Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$636.21
$722.10
$813.07
$1,136.27
$1,726.67 		$1,122.91
$1,208.80
$1,299.77
$1,622.97 		$1,609.61
$1,695.50
$1,786.47
$2,109.67 		$2,096.31
$2,182.20
$2,273.17
$2,596.37 		$486.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,272.42
$1,444.20
$1,626.14
$2,272.54
$3,453.34 		$1,759.12
$1,930.90
$2,112.84
$2,759.24 		$2,245.82
$2,417.60
$2,599.54
$3,245.94 		$2,732.52
$2,904.30
$3,086.24
$3,732.64 		$486.70
Toc - Plan #53 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$436.01
$494.87
$557.22
$778.71
$1,183.33 		$769.56
$828.42
$890.77
$1,112.26 		$1,103.11
$1,161.97
$1,224.32
$1,445.81 		$1,436.66
$1,495.52
$1,557.87
$1,779.36 		$333.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.02
$989.74
$1,114.44
$1,557.42
$2,366.66 		$1,205.57
$1,323.29
$1,447.99
$1,890.97 		$1,539.12
$1,656.84
$1,781.54
$2,224.52 		$1,872.67
$1,990.39
$2,115.09
$2,558.07 		$333.55
Toc - Plan #54 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$434.50
$493.16
$555.29
$776.02
$1,179.23 		$766.89
$825.55
$887.68
$1,108.41 		$1,099.28
$1,157.94
$1,220.07
$1,440.80 		$1,431.67
$1,490.33
$1,552.46
$1,773.19 		$332.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$869.00
$986.32
$1,110.58
$1,552.04
$2,358.46 		$1,201.39
$1,318.71
$1,442.97
$1,884.43 		$1,533.78
$1,651.10
$1,775.36
$2,216.82 		$1,866.17
$1,983.49
$2,107.75
$2,549.21 		$332.39
Toc - Plan #55 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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 		$457.04
$518.74
$584.10
$816.28
$1,240.41 		$806.68
$868.38
$933.74
$1,165.92 		$1,156.32
$1,218.02
$1,283.38
$1,515.56 		$1,505.96
$1,567.66
$1,633.02
$1,865.20 		$349.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$914.08
$1,037.48
$1,168.20
$1,632.56
$2,480.82 		$1,263.72
$1,387.12
$1,517.84
$1,982.20 		$1,613.36
$1,736.76
$1,867.48
$2,331.84 		$1,963.00
$2,086.40
$2,217.12
$2,681.48 		$349.64
Toc - Plan #56 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $6,350 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$445.05
$505.13
$568.77
$794.86
$1,207.86 		$785.51
$845.59
$909.23
$1,135.32 		$1,125.97
$1,186.05
$1,249.69
$1,475.78 		$1,466.43
$1,526.51
$1,590.15
$1,816.24 		$340.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$890.10
$1,010.26
$1,137.54
$1,589.72
$2,415.72 		$1,230.56
$1,350.72
$1,478.00
$1,930.18 		$1,571.02
$1,691.18
$1,818.46
$2,270.64 		$1,911.48
$2,031.64
$2,158.92
$2,611.10 		$340.46

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #57 Aetna CVS Health
Expanded Bronze

(HMO) Bronze: Aetna network of doctors & hospitals+ Low-cost MinuteClinic+ $0 Telehealth 24/7

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 		$293.79
$333.45
$375.46
$524.70
$797.33 		$518.54
$558.20
$600.21
$749.45 		$743.29
$782.95
$824.96
$974.20 		$968.04
$1,007.70
$1,049.71
$1,198.95 		$224.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.58
$666.90
$750.92
$1,049.40
$1,594.66 		$812.33
$891.65
$975.67
$1,274.15 		$1,037.08
$1,116.40
$1,200.42
$1,498.90 		$1,261.83
$1,341.15
$1,425.17
$1,723.65 		$224.75
Toc - Plan #58 Aetna CVS Health
Expanded Bronze

(HMO) Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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 		$264.36
$300.05
$337.86
$472.15
$717.48 		$466.60
$502.29
$540.10
$674.39 		$668.84
$704.53
$742.34
$876.63 		$871.08
$906.77
$944.58
$1,078.87 		$202.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$528.72
$600.10
$675.72
$944.30
$1,434.96 		$730.96
$802.34
$877.96
$1,146.54 		$933.20
$1,004.58
$1,080.20
$1,348.78 		$1,135.44
$1,206.82
$1,282.44
$1,551.02 		$202.24
Toc - Plan #59 Aetna CVS Health
Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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 		$433.56
$492.09
$554.09
$774.34
$1,176.68 		$765.23
$823.76
$885.76
$1,106.01 		$1,096.90
$1,155.43
$1,217.43
$1,437.68 		$1,428.57
$1,487.10
$1,549.10
$1,769.35 		$331.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.12
$984.18
$1,108.18
$1,548.68
$2,353.36 		$1,198.79
$1,315.85
$1,439.85
$1,880.35 		$1,530.46
$1,647.52
$1,771.52
$2,212.02 		$1,862.13
$1,979.19
$2,103.19
$2,543.69 		$331.67
Toc - Plan #60 Aetna CVS Health
Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$406.86
$461.79
$519.97
$726.66
$1,104.23 		$718.11
$773.04
$831.22
$1,037.91 		$1,029.36
$1,084.29
$1,142.47
$1,349.16 		$1,340.61
$1,395.54
$1,453.72
$1,660.41 		$311.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.72
$923.58
$1,039.94
$1,453.32
$2,208.46 		$1,124.97
$1,234.83
$1,351.19
$1,764.57 		$1,436.22
$1,546.08
$1,662.44
$2,075.82 		$1,747.47
$1,857.33
$1,973.69
$2,387.07 		$311.25
Toc - Plan #61 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$386.18
$438.32
$493.54
$689.72
$1,048.10 		$681.61
$733.75
$788.97
$985.15 		$977.04
$1,029.18
$1,084.40
$1,280.58 		$1,272.47
$1,324.61
$1,379.83
$1,576.01 		$295.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.36
$876.64
$987.08
$1,379.44
$2,096.20 		$1,067.79
$1,172.07
$1,282.51
$1,674.87 		$1,363.22
$1,467.50
$1,577.94
$1,970.30 		$1,658.65
$1,762.93
$1,873.37
$2,265.73 		$295.43
Toc - Plan #62 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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 		$274.00
$310.98
$350.17
$489.36
$743.62 		$483.61
$520.59
$559.78
$698.97 		$693.22
$730.20
$769.39
$908.58 		$902.83
$939.81
$979.00
$1,118.19 		$209.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$548.00
$621.96
$700.34
$978.72
$1,487.24 		$757.61
$831.57
$909.95
$1,188.33 		$967.22
$1,041.18
$1,119.56
$1,397.94 		$1,176.83
$1,250.79
$1,329.17
$1,607.55 		$209.61
Toc - Plan #63 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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 		$425.57
$483.03
$543.88
$760.08
$1,155.01 		$751.13
$808.59
$869.44
$1,085.64 		$1,076.69
$1,134.15
$1,195.00
$1,411.20 		$1,402.25
$1,459.71
$1,520.56
$1,736.76 		$325.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$851.14
$966.06
$1,087.76
$1,520.16
$2,310.02 		$1,176.70
$1,291.62
$1,413.32
$1,845.72 		$1,502.26
$1,617.18
$1,738.88
$2,171.28 		$1,827.82
$1,942.74
$2,064.44
$2,496.84 		$325.56
Toc - Plan #64 Aetna CVS Health
Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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 		$399.46
$453.38
$510.51
$713.43
$1,084.13 		$705.04
$758.96
$816.09
$1,019.01 		$1,010.62
$1,064.54
$1,121.67
$1,324.59 		$1,316.20
$1,370.12
$1,427.25
$1,630.17 		$305.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$798.92
$906.76
$1,021.02
$1,426.86
$2,168.26 		$1,104.50
$1,212.34
$1,326.60
$1,732.44 		$1,410.08
$1,517.92
$1,632.18
$2,038.02 		$1,715.66
$1,823.50
$1,937.76
$2,343.60 		$305.58
Toc - Plan #65 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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 		$377.15
$428.07
$482.00
$673.59
$1,023.59 		$665.67
$716.59
$770.52
$962.11 		$954.19
$1,005.11
$1,059.04
$1,250.63 		$1,242.71
$1,293.63
$1,347.56
$1,539.15 		$288.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.30
$856.14
$964.00
$1,347.18
$2,047.18 		$1,042.82
$1,144.66
$1,252.52
$1,635.70 		$1,331.34
$1,433.18
$1,541.04
$1,924.22 		$1,619.86
$1,721.70
$1,829.56
$2,212.74 		$288.52

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #66 Cigna Healthcare
Gold

(HMO) Cigna Connect 2100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$508.57
$577.23
$649.96
$908.31
$1,380.27 		$897.63
$966.29
$1,039.02
$1,297.37 		$1,286.69
$1,355.35
$1,428.08
$1,686.43 		$1,675.75
$1,744.41
$1,817.14
$2,075.49 		$389.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,017.14
$1,154.46
$1,299.92
$1,816.62
$2,760.54 		$1,406.20
$1,543.52
$1,688.98
$2,205.68 		$1,795.26
$1,932.58
$2,078.04
$2,594.74 		$2,184.32
$2,321.64
$2,467.10
$2,983.80 		$389.06
Toc - Plan #67 Cigna Healthcare
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 		$299.21
$339.60
$382.39
$534.39
$812.06 		$528.11
$568.50
$611.29
$763.29 		$757.01
$797.40
$840.19
$992.19 		$985.91
$1,026.30
$1,069.09
$1,221.09 		$228.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$598.42
$679.20
$764.78
$1,068.78
$1,624.12 		$827.32
$908.10
$993.68
$1,297.68 		$1,056.22
$1,137.00
$1,222.58
$1,526.58 		$1,285.12
$1,365.90
$1,451.48
$1,755.48 		$228.90
Toc - Plan #68 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7800

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$314.97
$357.49
$402.53
$562.54
$854.83 		$555.92
$598.44
$643.48
$803.49 		$796.87
$839.39
$884.43
$1,044.44 		$1,037.82
$1,080.34
$1,125.38
$1,285.39 		$240.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$629.94
$714.98
$805.06
$1,125.08
$1,709.66 		$870.89
$955.93
$1,046.01
$1,366.03 		$1,111.84
$1,196.88
$1,286.96
$1,606.98 		$1,352.79
$1,437.83
$1,527.91
$1,847.93 		$240.95
Toc - Plan #69 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5900

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.89
$352.86
$397.32
$555.26
$843.76 		$548.72
$590.69
$635.15
$793.09 		$786.55
$828.52
$872.98
$1,030.92 		$1,024.38
$1,066.35
$1,110.81
$1,268.75 		$237.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.78
$705.72
$794.64
$1,110.52
$1,687.52 		$859.61
$943.55
$1,032.47
$1,348.35 		$1,097.44
$1,181.38
$1,270.30
$1,586.18 		$1,335.27
$1,419.21
$1,508.13
$1,824.01 		$237.83
Toc - Plan #70 Cigna Healthcare
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 		$367.04
$416.59
$469.07
$655.53
$996.14 		$647.82
$697.37
$749.85
$936.31 		$928.60
$978.15
$1,030.63
$1,217.09 		$1,209.38
$1,258.93
$1,311.41
$1,497.87 		$280.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.08
$833.18
$938.14
$1,311.06
$1,992.28 		$1,014.86
$1,113.96
$1,218.92
$1,591.84 		$1,295.64
$1,394.74
$1,499.70
$1,872.62 		$1,576.42
$1,675.52
$1,780.48
$2,153.40 		$280.78
Toc - Plan #71 Cigna Healthcare
Silver

(HMO) Cigna Connect 4500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.53
$416.02
$468.43
$654.63
$994.77 		$646.93
$696.42
$748.83
$935.03 		$927.33
$976.82
$1,029.23
$1,215.43 		$1,207.73
$1,257.22
$1,309.63
$1,495.83 		$280.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.06
$832.04
$936.86
$1,309.26
$1,989.54 		$1,013.46
$1,112.44
$1,217.26
$1,589.66 		$1,293.86
$1,392.84
$1,497.66
$1,870.06 		$1,574.26
$1,673.24
$1,778.06
$2,150.46 		$280.40
Toc - Plan #72 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$368.09
$417.78
$470.42
$657.41
$998.99 		$649.68
$699.37
$752.01
$939.00 		$931.27
$980.96
$1,033.60
$1,220.59 		$1,212.86
$1,262.55
$1,315.19
$1,502.18 		$281.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.18
$835.56
$940.84
$1,314.82
$1,997.98 		$1,017.77
$1,117.15
$1,222.43
$1,596.41 		$1,299.36
$1,398.74
$1,504.02
$1,878.00 		$1,580.95
$1,680.33
$1,785.61
$2,159.59 		$281.59
Toc - Plan #73 Cigna Healthcare
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 		$369.98
$419.93
$472.83
$660.78
$1,004.12 		$653.01
$702.96
$755.86
$943.81 		$936.04
$985.99
$1,038.89
$1,226.84 		$1,219.07
$1,269.02
$1,321.92
$1,509.87 		$283.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.96
$839.86
$945.66
$1,321.56
$2,008.24 		$1,022.99
$1,122.89
$1,228.69
$1,604.59 		$1,306.02
$1,405.92
$1,511.72
$1,887.62 		$1,589.05
$1,688.95
$1,794.75
$2,170.65 		$283.03
Toc - Plan #74 Cigna Healthcare
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 		$312.36
$354.53
$399.20
$557.88
$847.76 		$551.32
$593.49
$638.16
$796.84 		$790.28
$832.45
$877.12
$1,035.80 		$1,029.24
$1,071.41
$1,116.08
$1,274.76 		$238.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$624.72
$709.06
$798.40
$1,115.76
$1,695.52 		$863.68
$948.02
$1,037.36
$1,354.72 		$1,102.64
$1,186.98
$1,276.32
$1,593.68 		$1,341.60
$1,425.94
$1,515.28
$1,832.64 		$238.96
Toc - Plan #75 Cigna Healthcare
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 		$368.89
$418.69
$471.44
$658.83
$1,001.16 		$651.09
$700.89
$753.64
$941.03 		$933.29
$983.09
$1,035.84
$1,223.23 		$1,215.49
$1,265.29
$1,318.04
$1,505.43 		$282.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.78
$837.38
$942.88
$1,317.66
$2,002.32 		$1,019.98
$1,119.58
$1,225.08
$1,599.86 		$1,302.18
$1,401.78
$1,507.28
$1,882.06 		$1,584.38
$1,683.98
$1,789.48
$2,164.26 		$282.20
Toc - Plan #76 Cigna Healthcare
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 		$296.27
$336.27
$378.63
$529.14
$804.07 		$522.92
$562.92
$605.28
$755.79 		$749.57
$789.57
$831.93
$982.44 		$976.22
$1,016.22
$1,058.58
$1,209.09 		$226.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$592.54
$672.54
$757.26
$1,058.28
$1,608.14 		$819.19
$899.19
$983.91
$1,284.93 		$1,045.84
$1,125.84
$1,210.56
$1,511.58 		$1,272.49
$1,352.49
$1,437.21
$1,738.23 		$226.65
Toc - Plan #77 Cigna Healthcare
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 		$308.83
$350.53
$394.69
$551.58
$838.18 		$545.09
$586.79
$630.95
$787.84 		$781.35
$823.05
$867.21
$1,024.10 		$1,017.61
$1,059.31
$1,103.47
$1,260.36 		$236.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$617.66
$701.06
$789.38
$1,103.16
$1,676.36 		$853.92
$937.32
$1,025.64
$1,339.42 		$1,090.18
$1,173.58
$1,261.90
$1,575.68 		$1,326.44
$1,409.84
$1,498.16
$1,811.94 		$236.26
Toc - Plan #78 Cigna Healthcare
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 		$330.14
$374.71
$421.92
$589.63
$896.00 		$582.70
$627.27
$674.48
$842.19 		$835.26
$879.83
$927.04
$1,094.75 		$1,087.82
$1,132.39
$1,179.60
$1,347.31 		$252.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$660.28
$749.42
$843.84
$1,179.26
$1,792.00 		$912.84
$1,001.98
$1,096.40
$1,431.82 		$1,165.40
$1,254.54
$1,348.96
$1,684.38 		$1,417.96
$1,507.10
$1,601.52
$1,936.94 		$252.56
Toc - Plan #79 Cigna Healthcare
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 		$366.70
$416.21
$468.64
$654.93
$995.23 		$647.23
$696.74
$749.17
$935.46 		$927.76
$977.27
$1,029.70
$1,215.99 		$1,208.29
$1,257.80
$1,310.23
$1,496.52 		$280.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.40
$832.42
$937.28
$1,309.86
$1,990.46 		$1,013.93
$1,112.95
$1,217.81
$1,590.39 		$1,294.46
$1,393.48
$1,498.34
$1,870.92 		$1,574.99
$1,674.01
$1,778.87
$2,151.45 		$280.53
Toc - Plan #80 Cigna Healthcare
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 		$511.22
$580.24
$653.34
$913.04
$1,387.46 		$902.30
$971.32
$1,044.42
$1,304.12 		$1,293.38
$1,362.40
$1,435.50
$1,695.20 		$1,684.46
$1,753.48
$1,826.58
$2,086.28 		$391.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,022.44
$1,160.48
$1,306.68
$1,826.08
$2,774.92 		$1,413.52
$1,551.56
$1,697.76
$2,217.16 		$1,804.60
$1,942.64
$2,088.84
$2,608.24 		$2,195.68
$2,333.72
$2,479.92
$2,999.32 		$391.08
Toc - Plan #81 Cigna Healthcare
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 		$311.15
$353.15
$397.64
$555.71
$844.45 		$549.18
$591.18
$635.67
$793.74 		$787.21
$829.21
$873.70
$1,031.77 		$1,025.24
$1,067.24
$1,111.73
$1,269.80 		$238.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$622.30
$706.30
$795.28
$1,111.42
$1,688.90 		$860.33
$944.33
$1,033.31
$1,349.45 		$1,098.36
$1,182.36
$1,271.34
$1,587.48 		$1,336.39
$1,420.39
$1,509.37
$1,825.51 		$238.03

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310 | TTY: 1-833-863-1310
Toc - Plan #82 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$316.42
$359.13
$404.38
$565.11
$858.75 		$558.48
$601.19
$646.44
$807.17 		$800.54
$843.25
$888.50
$1,049.23 		$1,042.60
$1,085.31
$1,130.56
$1,291.29 		$242.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$632.84
$718.26
$808.76
$1,130.22
$1,717.50 		$874.90
$960.32
$1,050.82
$1,372.28 		$1,116.96
$1,202.38
$1,292.88
$1,614.34 		$1,359.02
$1,444.44
$1,534.94
$1,856.40 		$242.06
Toc - Plan #83 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$347.96
$394.93
$444.68
$621.44
$944.34 		$614.14
$661.11
$710.86
$887.62 		$880.32
$927.29
$977.04
$1,153.80 		$1,146.50
$1,193.47
$1,243.22
$1,419.98 		$266.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.92
$789.86
$889.36
$1,242.88
$1,888.68 		$962.10
$1,056.04
$1,155.54
$1,509.06 		$1,228.28
$1,322.22
$1,421.72
$1,775.24 		$1,494.46
$1,588.40
$1,687.90
$2,041.42 		$266.18
Toc - Plan #84 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$337.62
$383.19
$431.47
$602.97
$916.28 		$595.89
$641.46
$689.74
$861.24 		$854.16
$899.73
$948.01
$1,119.51 		$1,112.43
$1,158.00
$1,206.28
$1,377.78 		$258.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$675.24
$766.38
$862.94
$1,205.94
$1,832.56 		$933.51
$1,024.65
$1,121.21
$1,464.21 		$1,191.78
$1,282.92
$1,379.48
$1,722.48 		$1,450.05
$1,541.19
$1,637.75
$1,980.75 		$258.27
Toc - Plan #85 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$379.93
$431.21
$485.54
$678.54
$1,031.10 		$670.57
$721.85
$776.18
$969.18 		$961.21
$1,012.49
$1,066.82
$1,259.82 		$1,251.85
$1,303.13
$1,357.46
$1,550.46 		$290.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$759.86
$862.42
$971.08
$1,357.08
$2,062.20 		$1,050.50
$1,153.06
$1,261.72
$1,647.72 		$1,341.14
$1,443.70
$1,552.36
$1,938.36 		$1,631.78
$1,734.34
$1,843.00
$2,229.00 		$290.64
Toc - Plan #86 Ambetter of North Carolina
Silver

(HMO) Complete Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$429.10
$487.02
$548.38
$766.36
$1,164.56 		$757.36
$815.28
$876.64
$1,094.62 		$1,085.62
$1,143.54
$1,204.90
$1,422.88 		$1,413.88
$1,471.80
$1,533.16
$1,751.14 		$328.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.20
$974.04
$1,096.76
$1,532.72
$2,329.12 		$1,186.46
$1,302.30
$1,425.02
$1,860.98 		$1,514.72
$1,630.56
$1,753.28
$2,189.24 		$1,842.98
$1,958.82
$2,081.54
$2,517.50 		$328.26
Toc - Plan #87 Ambetter of North Carolina
Silver

(HMO) Everyday Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$425.11
$482.49
$543.28
$759.23
$1,153.73 		$750.31
$807.69
$868.48
$1,084.43 		$1,075.51
$1,132.89
$1,193.68
$1,409.63 		$1,400.71
$1,458.09
$1,518.88
$1,734.83 		$325.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$850.22
$964.98
$1,086.56
$1,518.46
$2,307.46 		$1,175.42
$1,290.18
$1,411.76
$1,843.66 		$1,500.62
$1,615.38
$1,736.96
$2,168.86 		$1,825.82
$1,940.58
$2,062.16
$2,494.06 		$325.20
Toc - Plan #88 Ambetter of North Carolina
Silver

(HMO) Clear Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$424.00
$481.23
$541.86
$757.24
$1,150.70 		$748.35
$805.58
$866.21
$1,081.59 		$1,072.70
$1,129.93
$1,190.56
$1,405.94 		$1,397.05
$1,454.28
$1,514.91
$1,730.29 		$324.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.00
$962.46
$1,083.72
$1,514.48
$2,301.40 		$1,172.35
$1,286.81
$1,408.07
$1,838.83 		$1,496.70
$1,611.16
$1,732.42
$2,163.18 		$1,821.05
$1,935.51
$2,056.77
$2,487.53 		$324.35
Toc - Plan #89 Ambetter of North Carolina
Silver

(HMO) Focused Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$424.17
$481.42
$542.08
$757.55
$1,151.17 		$748.65
$805.90
$866.56
$1,082.03 		$1,073.13
$1,130.38
$1,191.04
$1,406.51 		$1,397.61
$1,454.86
$1,515.52
$1,730.99 		$324.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.34
$962.84
$1,084.16
$1,515.10
$2,302.34 		$1,172.82
$1,287.32
$1,408.64
$1,839.58 		$1,497.30
$1,611.80
$1,733.12
$2,164.06 		$1,821.78
$1,936.28
$2,057.60
$2,488.54 		$324.48
Toc - Plan #90 Ambetter of North Carolina
Gold

(HMO) Complete Gold with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$447.64
$508.06
$572.07
$799.47
$1,214.87 		$790.08
$850.50
$914.51
$1,141.91 		$1,132.52
$1,192.94
$1,256.95
$1,484.35 		$1,474.96
$1,535.38
$1,599.39
$1,826.79 		$342.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$895.28
$1,016.12
$1,144.14
$1,598.94
$2,429.74 		$1,237.72
$1,358.56
$1,486.58
$1,941.38 		$1,580.16
$1,701.00
$1,829.02
$2,283.82 		$1,922.60
$2,043.44
$2,171.46
$2,626.26 		$342.44
Toc - Plan #91 Ambetter of North Carolina
Expanded Bronze

(HMO) CMS Standard Expanded Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$331.06
$375.74
$423.08
$591.25
$898.46 		$584.31
$628.99
$676.33
$844.50 		$837.56
$882.24
$929.58
$1,097.75 		$1,090.81
$1,135.49
$1,182.83
$1,351.00 		$253.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.12
$751.48
$846.16
$1,182.50
$1,796.92 		$915.37
$1,004.73
$1,099.41
$1,435.75 		$1,168.62
$1,257.98
$1,352.66
$1,689.00 		$1,421.87
$1,511.23
$1,605.91
$1,942.25 		$253.25
Toc - Plan #92 Ambetter of North Carolina
Silver

(HMO) CMS Standard Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$419.84
$476.50
$536.54
$749.81
$1,139.41 		$741.01
$797.67
$857.71
$1,070.98 		$1,062.18
$1,118.84
$1,178.88
$1,392.15 		$1,383.35
$1,440.01
$1,500.05
$1,713.32 		$321.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.68
$953.00
$1,073.08
$1,499.62
$2,278.82 		$1,160.85
$1,274.17
$1,394.25
$1,820.79 		$1,482.02
$1,595.34
$1,715.42
$2,141.96 		$1,803.19
$1,916.51
$2,036.59
$2,463.13 		$321.17
Toc - Plan #93 Ambetter of North Carolina
Gold

(HMO) CMS Standard Gold with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$424.86
$482.20
$542.95
$758.77
$1,153.03 		$749.87
$807.21
$867.96
$1,083.78 		$1,074.88
$1,132.22
$1,192.97
$1,408.79 		$1,399.89
$1,457.23
$1,517.98
$1,733.80 		$325.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.72
$964.40
$1,085.90
$1,517.54
$2,306.06 		$1,174.73
$1,289.41
$1,410.91
$1,842.55 		$1,499.74
$1,614.42
$1,735.92
$2,167.56 		$1,824.75
$1,939.43
$2,060.93
$2,492.57 		$325.01
Toc - Plan #94 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$329.75
$374.26
$421.41
$588.92
$894.92 		$582.00
$626.51
$673.66
$841.17 		$834.25
$878.76
$925.91
$1,093.42 		$1,086.50
$1,131.01
$1,178.16
$1,345.67 		$252.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.50
$748.52
$842.82
$1,177.84
$1,789.84 		$911.75
$1,000.77
$1,095.07
$1,430.09 		$1,164.00
$1,253.02
$1,347.32
$1,682.34 		$1,416.25
$1,505.27
$1,599.57
$1,934.59 		$252.25
Toc - Plan #95 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$362.62
$411.56
$463.41
$647.62
$984.12 		$640.01
$688.95
$740.80
$925.01 		$917.40
$966.34
$1,018.19
$1,202.40 		$1,194.79
$1,243.73
$1,295.58
$1,479.79 		$277.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$725.24
$823.12
$926.82
$1,295.24
$1,968.24 		$1,002.63
$1,100.51
$1,204.21
$1,572.63 		$1,280.02
$1,377.90
$1,481.60
$1,850.02 		$1,557.41
$1,655.29
$1,758.99
$2,127.41 		$277.39
Toc - Plan #96 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$351.84
$399.33
$449.64
$628.37
$954.87 		$620.99
$668.48
$718.79
$897.52 		$890.14
$937.63
$987.94
$1,166.67 		$1,159.29
$1,206.78
$1,257.09
$1,435.82 		$269.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$703.68
$798.66
$899.28
$1,256.74
$1,909.74 		$972.83
$1,067.81
$1,168.43
$1,525.89 		$1,241.98
$1,336.96
$1,437.58
$1,795.04 		$1,511.13
$1,606.11
$1,706.73
$2,064.19 		$269.15
Toc - Plan #97 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$395.93
$449.37
$505.99
$707.12
$1,074.53 		$698.81
$752.25
$808.87
$1,010.00 		$1,001.69
$1,055.13
$1,111.75
$1,312.88 		$1,304.57
$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 		$791.86
$898.74
$1,011.98
$1,414.24
$2,149.06 		$1,094.74
$1,201.62
$1,314.86
$1,717.12 		$1,397.62
$1,504.50
$1,617.74
$2,020.00 		$1,700.50
$1,807.38
$1,920.62
$2,322.88 		$302.88
Toc - Plan #98 Ambetter of North Carolina
Silver

(HMO) Complete Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$447.18
$507.53
$571.48
$798.64
$1,213.61 		$789.26
$849.61
$913.56
$1,140.72 		$1,131.34
$1,191.69
$1,255.64
$1,482.80 		$1,473.42
$1,533.77
$1,597.72
$1,824.88 		$342.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.36
$1,015.06
$1,142.96
$1,597.28
$2,427.22 		$1,236.44
$1,357.14
$1,485.04
$1,939.36 		$1,578.52
$1,699.22
$1,827.12
$2,281.44 		$1,920.60
$2,041.30
$2,169.20
$2,623.52 		$342.08
Toc - Plan #99 Ambetter of North Carolina
Silver

(HMO) Everyday Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$443.02
$502.81
$566.16
$791.21
$1,202.33 		$781.92
$841.71
$905.06
$1,130.11 		$1,120.82
$1,180.61
$1,243.96
$1,469.01 		$1,459.72
$1,519.51
$1,582.86
$1,807.91 		$338.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.04
$1,005.62
$1,132.32
$1,582.42
$2,404.66 		$1,224.94
$1,344.52
$1,471.22
$1,921.32 		$1,563.84
$1,683.42
$1,810.12
$2,260.22 		$1,902.74
$2,022.32
$2,149.02
$2,599.12 		$338.90
Toc - Plan #100 Ambetter of North Carolina
Silver

(HMO) Clear Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$441.86
$501.50
$564.68
$789.14
$1,199.17 		$779.87
$839.51
$902.69
$1,127.15 		$1,117.88
$1,177.52
$1,240.70
$1,465.16 		$1,455.89
$1,515.53
$1,578.71
$1,803.17 		$338.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.72
$1,003.00
$1,129.36
$1,578.28
$2,398.34 		$1,221.73
$1,341.01
$1,467.37
$1,916.29 		$1,559.74
$1,679.02
$1,805.38
$2,254.30 		$1,897.75
$2,017.03
$2,143.39
$2,592.31 		$338.01
Toc - Plan #101 Ambetter of North Carolina
Silver

(HMO) Focused Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$442.03
$501.70
$564.91
$789.46
$1,199.66 		$780.18
$839.85
$903.06
$1,127.61 		$1,118.33
$1,178.00
$1,241.21
$1,465.76 		$1,456.48
$1,516.15
$1,579.36
$1,803.91 		$338.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.06
$1,003.40
$1,129.82
$1,578.92
$2,399.32 		$1,222.21
$1,341.55
$1,467.97
$1,917.07 		$1,560.36
$1,679.70
$1,806.12
$2,255.22 		$1,898.51
$2,017.85
$2,144.27
$2,593.37 		$338.15
Toc - Plan #102 Ambetter of North Carolina
Gold

(HMO) Complete Gold with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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 		$466.49
$529.46
$596.17
$833.14
$1,266.04 		$823.35
$886.32
$953.03
$1,190.00 		$1,180.21
$1,243.18
$1,309.89
$1,546.86 		$1,537.07
$1,600.04
$1,666.75
$1,903.72 		$356.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$932.98
$1,058.92
$1,192.34
$1,666.28
$2,532.08 		$1,289.84
$1,415.78
$1,549.20
$2,023.14 		$1,646.70
$1,772.64
$1,906.06
$2,380.00 		$2,003.56
$2,129.50
$2,262.92
$2,736.86 		$356.86

ADVERTISEMENT

Friday Health Plans

Local: 1-844-465-5500 | Toll Free: 1-844-465-5500 | TTY: 1-800-659-2656
Toc - Plan #103 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$187.95
$213.32
$240.20
$335.68
$510.10 		$331.73
$357.10
$383.98
$479.46 		$475.51
$500.88
$527.76
$623.24 		$619.29
$644.66
$671.54
$767.02 		$143.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$375.90
$426.64
$480.40
$671.36
$1,020.20 		$519.68
$570.42
$624.18
$815.14 		$663.46
$714.20
$767.96
$958.92 		$807.24
$857.98
$911.74
$1,102.70 		$143.78
Toc - Plan #104 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$246.39
$279.65
$314.89
$440.05
$668.71 		$434.88
$468.14
$503.38
$628.54 		$623.37
$656.63
$691.87
$817.03 		$811.86
$845.12
$880.36
$1,005.52 		$188.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.78
$559.30
$629.78
$880.10
$1,337.42 		$681.27
$747.79
$818.27
$1,068.59 		$869.76
$936.28
$1,006.76
$1,257.08 		$1,058.25
$1,124.77
$1,195.25
$1,445.57 		$188.49
Toc - Plan #105 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$248.87
$282.47
$318.05
$444.48
$675.43 		$439.25
$472.85
$508.43
$634.86 		$629.63
$663.23
$698.81
$825.24 		$820.01
$853.61
$889.19
$1,015.62 		$190.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$497.74
$564.94
$636.10
$888.96
$1,350.86 		$688.12
$755.32
$826.48
$1,079.34 		$878.50
$945.70
$1,016.86
$1,269.72 		$1,068.88
$1,136.08
$1,207.24
$1,460.10 		$190.38
Toc - Plan #106 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$263.09
$298.61
$336.23
$469.88
$714.03 		$464.36
$499.88
$537.50
$671.15 		$665.63
$701.15
$738.77
$872.42 		$866.90
$902.42
$940.04
$1,073.69 		$201.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.18
$597.22
$672.46
$939.76
$1,428.06 		$727.45
$798.49
$873.73
$1,141.03 		$928.72
$999.76
$1,075.00
$1,342.30 		$1,129.99
$1,201.03
$1,276.27
$1,543.57 		$201.27
Toc - Plan #107 Friday Health Plans
Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$343.26
$389.60
$438.68
$613.06
$931.60 		$605.85
$652.19
$701.27
$875.65 		$868.44
$914.78
$963.86
$1,138.24 		$1,131.03
$1,177.37
$1,226.45
$1,400.83 		$262.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$686.52
$779.20
$877.36
$1,226.12
$1,863.20 		$949.11
$1,041.79
$1,139.95
$1,488.71 		$1,211.70
$1,304.38
$1,402.54
$1,751.30 		$1,474.29
$1,566.97
$1,665.13
$2,013.89 		$262.59
Toc - Plan #108 Friday Health Plans
Gold

(HMO) Friday Gold + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.87
$409.59
$461.20
$644.52
$979.41 		$636.94
$685.66
$737.27
$920.59 		$913.01
$961.73
$1,013.34
$1,196.66 		$1,189.08
$1,237.80
$1,289.41
$1,472.73 		$276.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.74
$819.18
$922.40
$1,289.04
$1,958.82 		$997.81
$1,095.25
$1,198.47
$1,565.11 		$1,273.88
$1,371.32
$1,474.54
$1,841.18 		$1,549.95
$1,647.39
$1,750.61
$2,117.25 		$276.07
Toc - Plan #109 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$246.21
$279.45
$314.66
$439.74
$668.22 		$434.56
$467.80
$503.01
$628.09 		$622.91
$656.15
$691.36
$816.44 		$811.26
$844.50
$879.71
$1,004.79 		$188.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.42
$558.90
$629.32
$879.48
$1,336.44 		$680.77
$747.25
$817.67
$1,067.83 		$869.12
$935.60
$1,006.02
$1,256.18 		$1,057.47
$1,123.95
$1,194.37
$1,444.53 		$188.35
Toc - Plan #110 Friday Health Plans
Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$352.34
$399.91
$450.29
$629.28
$956.26 		$621.88
$669.45
$719.83
$898.82 		$891.42
$938.99
$989.37
$1,168.36 		$1,160.96
$1,208.53
$1,258.91
$1,437.90 		$269.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.68
$799.82
$900.58
$1,258.56
$1,912.52 		$974.22
$1,069.36
$1,170.12
$1,528.10 		$1,243.76
$1,338.90
$1,439.66
$1,797.64 		$1,513.30
$1,608.44
$1,709.20
$2,067.18 		$269.54
Toc - Plan #111 Friday Health Plans
Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.91
$425.52
$479.13
$669.58
$1,017.50 		$661.71
$712.32
$765.93
$956.38 		$948.51
$999.12
$1,052.73
$1,243.18 		$1,235.31
$1,285.92
$1,339.53
$1,529.98 		$286.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.82
$851.04
$958.26
$1,339.16
$2,035.00 		$1,036.62
$1,137.84
$1,245.06
$1,625.96 		$1,323.42
$1,424.64
$1,531.86
$1,912.76 		$1,610.22
$1,711.44
$1,818.66
$2,199.56 		$286.80
Toc - Plan #112 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$246.08
$279.30
$314.49
$439.50
$667.86 		$434.33
$467.55
$502.74
$627.75 		$622.58
$655.80
$690.99
$816.00 		$810.83
$844.05
$879.24
$1,004.25 		$188.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.16
$558.60
$628.98
$879.00
$1,335.72 		$680.41
$746.85
$817.23
$1,067.25 		$868.66
$935.10
$1,005.48
$1,255.50 		$1,056.91
$1,123.35
$1,193.73
$1,443.75 		$188.25
Toc - Plan #113 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$248.56
$282.11
$317.66
$443.92
$674.58 		$438.71
$472.26
$507.81
$634.07 		$628.86
$662.41
$697.96
$824.22 		$819.01
$852.56
$888.11
$1,014.37 		$190.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$497.12
$564.22
$635.32
$887.84
$1,349.16 		$687.27
$754.37
$825.47
$1,077.99 		$877.42
$944.52
$1,015.62
$1,268.14 		$1,067.57
$1,134.67
$1,205.77
$1,458.29 		$190.15
Toc - Plan #114 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$245.90
$279.10
$314.26
$439.18
$667.38 		$434.02
$467.22
$502.38
$627.30 		$622.14
$655.34
$690.50
$815.42 		$810.26
$843.46
$878.62
$1,003.54 		$188.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$491.80
$558.20
$628.52
$878.36
$1,334.76 		$679.92
$746.32
$816.64
$1,066.48 		$868.04
$934.44
$1,004.76
$1,254.60 		$1,056.16
$1,122.56
$1,192.88
$1,442.72 		$188.12
Toc - Plan #115 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$342.94
$389.24
$438.28
$612.50
$930.75 		$605.29
$651.59
$700.63
$874.85 		$867.64
$913.94
$962.98
$1,137.20 		$1,129.99
$1,176.29
$1,225.33
$1,399.55 		$262.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$685.88
$778.48
$876.56
$1,225.00
$1,861.50 		$948.23
$1,040.83
$1,138.91
$1,487.35 		$1,210.58
$1,303.18
$1,401.26
$1,749.70 		$1,472.93
$1,565.53
$1,663.61
$2,012.05 		$262.35
Toc - Plan #116 Friday Health Plans
Silver

(HMO) Friday Silver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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 		$347.12
$393.98
$443.61
$619.95
$942.07 		$612.66
$659.52
$709.15
$885.49 		$878.20
$925.06
$974.69
$1,151.03 		$1,143.74
$1,190.60
$1,240.23
$1,416.57 		$265.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$694.24
$787.96
$887.22
$1,239.90
$1,884.14 		$959.78
$1,053.50
$1,152.76
$1,505.44 		$1,225.32
$1,319.04
$1,418.30
$1,770.98 		$1,490.86
$1,584.58
$1,683.84
$2,036.52 		$265.54
Toc - Plan #117 Friday Health Plans
Silver

(HMO) Friday Silver Zero Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$354.28
$402.10
$452.76
$632.74
$961.51 		$625.30
$673.12
$723.78
$903.76 		$896.32
$944.14
$994.80
$1,174.78 		$1,167.34
$1,215.16
$1,265.82
$1,445.80 		$271.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.56
$804.20
$905.52
$1,265.48
$1,923.02 		$979.58
$1,075.22
$1,176.54
$1,536.50 		$1,250.60
$1,346.24
$1,447.56
$1,807.52 		$1,521.62
$1,617.26
$1,718.58
$2,078.54 		$271.02
Toc - Plan #118 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$352.03
$399.55
$449.90
$628.73
$955.41 		$621.33
$668.85
$719.20
$898.03 		$890.63
$938.15
$988.50
$1,167.33 		$1,159.93
$1,207.45
$1,257.80
$1,436.63 		$269.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$704.06
$799.10
$899.80
$1,257.46
$1,910.82 		$973.36
$1,068.40
$1,169.10
$1,526.76 		$1,242.66
$1,337.70
$1,438.40
$1,796.06 		$1,511.96
$1,607.00
$1,707.70
$2,065.36 		$269.30
Toc - Plan #119 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$360.56
$409.24
$460.80
$643.96
$978.56 		$636.39
$685.07
$736.63
$919.79 		$912.22
$960.90
$1,012.46
$1,195.62 		$1,188.05
$1,236.73
$1,288.29
$1,471.45 		$275.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.12
$818.48
$921.60
$1,287.92
$1,957.12 		$996.95
$1,094.31
$1,197.43
$1,563.75 		$1,272.78
$1,370.14
$1,473.26
$1,839.58 		$1,548.61
$1,645.97
$1,749.09
$2,115.41 		$275.83
Toc - Plan #120 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.60
$425.17
$478.73
$669.03
$1,016.65 		$661.17
$711.74
$765.30
$955.60 		$947.74
$998.31
$1,051.87
$1,242.17 		$1,234.31
$1,284.88
$1,338.44
$1,528.74 		$286.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.20
$850.34
$957.46
$1,338.06
$2,033.30 		$1,035.77
$1,136.91
$1,244.03
$1,624.63 		$1,322.34
$1,423.48
$1,530.60
$1,911.20 		$1,608.91
$1,710.05
$1,817.17
$2,197.77 		$286.57
Toc - Plan #121 Friday Health Plans
Bronze

(HMO) Friday Standard Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$246.08
$279.30
$314.49
$439.50
$667.86 		$434.33
$467.55
$502.74
$627.75 		$622.58
$655.80
$690.99
$816.00 		$810.83
$844.05
$879.24
$1,004.25 		$188.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$492.16
$558.60
$628.98
$879.00
$1,335.72 		$680.41
$746.85
$817.23
$1,067.25 		$868.66
$935.10
$1,005.48
$1,255.50 		$1,056.91
$1,123.35
$1,193.73
$1,443.75 		$188.25
Toc - Plan #122 Friday Health Plans
Expanded Bronze

(HMO) Friday Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$244.74
$277.78
$312.77
$437.10
$664.21 		$431.96
$465.00
$499.99
$624.32 		$619.18
$652.22
$687.21
$811.54 		$806.40
$839.44
$874.43
$998.76 		$187.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$489.48
$555.56
$625.54
$874.20
$1,328.42 		$676.70
$742.78
$812.76
$1,061.42 		$863.92
$930.00
$999.98
$1,248.64 		$1,051.14
$1,117.22
$1,187.20
$1,435.86 		$187.22
Toc - Plan #123 Friday Health Plans
Silver

(HMO) Friday Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$340.23
$386.16
$434.81
$607.65
$923.39 		$600.51
$646.44
$695.09
$867.93 		$860.79
$906.72
$955.37
$1,128.21 		$1,121.07
$1,167.00
$1,215.65
$1,388.49 		$260.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.46
$772.32
$869.62
$1,215.30
$1,846.78 		$940.74
$1,032.60
$1,129.90
$1,475.58 		$1,201.02
$1,292.88
$1,390.18
$1,735.86 		$1,461.30
$1,553.16
$1,650.46
$1,996.14 		$260.28
Toc - Plan #124 Friday Health Plans
Gold

(HMO) Friday Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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 		$373.03
$423.38
$476.73
$666.22
$1,012.39 		$658.40
$708.75
$762.10
$951.59 		$943.77
$994.12
$1,047.47
$1,236.96 		$1,229.14
$1,279.49
$1,332.84
$1,522.33 		$285.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.06
$846.76
$953.46
$1,332.44
$2,024.78 		$1,031.43
$1,132.13
$1,238.83
$1,617.81 		$1,316.80
$1,417.50
$1,524.20
$1,903.18 		$1,602.17
$1,702.87
$1,809.57
$2,188.55 		$285.37

‡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 Guilford County here.

Guilford County is in “Rating Area 7” of North Carolina.

Currently, there are 124 plans offered in Rating Area 7.

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2023 Obamacare Plans for Guilford County, NC

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