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Highmark Blue Cross Blue Shield West Virginia

Local: 1-888-601-2109 | Toll Free: 1-888-601-2109 | TTY: 1-888-601-2109
Toc - Plan #1 Highmark Blue Cross Blue Shield West Virginia
Expanded Bronze

(PPO) my Blue Access WV PPO Bronze 3800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$543.55
$616.93
$694.66
$970.78
$1,475.19 		$959.37
$1,032.75
$1,110.48
$1,386.60 		$1,375.19
$1,448.57
$1,526.30
$1,802.42 		$1,791.01
$1,864.39
$1,942.12
$2,218.24 		$415.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,087.10
$1,233.86
$1,389.32
$1,941.56
$2,950.38 		$1,502.92
$1,649.68
$1,805.14
$2,357.38 		$1,918.74
$2,065.50
$2,220.96
$2,773.20 		$2,334.56
$2,481.32
$2,636.78
$3,189.02 		$415.82
Toc - Plan #2 Highmark Blue Cross Blue Shield West Virginia
Silver

(PPO) my Blue Access WV PPO Silver 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$680.17
$771.99
$869.26
$1,214.78
$1,845.98 		$1,200.50
$1,292.32
$1,389.59
$1,735.11 		$1,720.83
$1,812.65
$1,909.92
$2,255.44 		$2,241.16
$2,332.98
$2,430.25
$2,775.77 		$520.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,360.34
$1,543.98
$1,738.52
$2,429.56
$3,691.96 		$1,880.67
$2,064.31
$2,258.85
$2,949.89 		$2,401.00
$2,584.64
$2,779.18
$3,470.22 		$2,921.33
$3,104.97
$3,299.51
$3,990.55 		$520.33
Toc - Plan #3 Highmark Blue Cross Blue Shield West Virginia
Gold

(PPO) my Blue Access WV PPO Gold 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$711.12
$807.12
$908.81
$1,270.06
$1,929.98 		$1,255.13
$1,351.13
$1,452.82
$1,814.07 		$1,799.14
$1,895.14
$1,996.83
$2,358.08 		$2,343.15
$2,439.15
$2,540.84
$2,902.09 		$544.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,422.24
$1,614.24
$1,817.62
$2,540.12
$3,859.96 		$1,966.25
$2,158.25
$2,361.63
$3,084.13 		$2,510.26
$2,702.26
$2,905.64
$3,628.14 		$3,054.27
$3,246.27
$3,449.65
$4,172.15 		$544.01
Toc - Plan #4 Highmark Blue Cross Blue Shield West Virginia
Expanded Bronze

(PPO) my Blue Access WV PPO Bronze 3800 + Adult Dental and Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$566.06
$642.48
$723.42
$1,010.98
$1,536.29 		$999.10
$1,075.52
$1,156.46
$1,444.02 		$1,432.14
$1,508.56
$1,589.50
$1,877.06 		$1,865.18
$1,941.60
$2,022.54
$2,310.10 		$433.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,132.12
$1,284.96
$1,446.84
$2,021.96
$3,072.58 		$1,565.16
$1,718.00
$1,879.88
$2,455.00 		$1,998.20
$2,151.04
$2,312.92
$2,888.04 		$2,431.24
$2,584.08
$2,745.96
$3,321.08 		$433.04
Toc - Plan #5 Highmark Blue Cross Blue Shield West Virginia
Gold

(PPO) my Blue Access WV PPO Gold 0 + Adult Dental and Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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 		$733.63
$832.67
$937.58
$1,310.26
$1,991.07 		$1,294.86
$1,393.90
$1,498.81
$1,871.49 		$1,856.09
$1,955.13
$2,060.04
$2,432.72 		$2,417.32
$2,516.36
$2,621.27
$2,993.95 		$561.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,467.26
$1,665.34
$1,875.16
$2,620.52
$3,982.14 		$2,028.49
$2,226.57
$2,436.39
$3,181.75 		$2,589.72
$2,787.80
$2,997.62
$3,742.98 		$3,150.95
$3,349.03
$3,558.85
$4,304.21 		$561.23
Toc - Plan #6 Highmark Blue Cross Blue Shield West Virginia
Expanded Bronze

(PPO) my Blue Access WV PPO Bronze 6900 HSA - Custom Drug Benefit

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$557.34
$632.58
$712.28
$995.41
$1,512.62 		$983.71
$1,058.95
$1,138.65
$1,421.78 		$1,410.08
$1,485.32
$1,565.02
$1,848.15 		$1,836.45
$1,911.69
$1,991.39
$2,274.52 		$426.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,114.68
$1,265.16
$1,424.56
$1,990.82
$3,025.24 		$1,541.05
$1,691.53
$1,850.93
$2,417.19 		$1,967.42
$2,117.90
$2,277.30
$2,843.56 		$2,393.79
$2,544.27
$2,703.67
$3,269.93 		$426.37
Toc - Plan #7 Highmark Blue Cross Blue Shield West Virginia
Gold

(PPO) my Blue Access WV PPO Premier Gold 0

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$729.84
$828.37
$932.74
$1,303.49
$1,980.79 		$1,288.17
$1,386.70
$1,491.07
$1,861.82 		$1,846.50
$1,945.03
$2,049.40
$2,420.15 		$2,404.83
$2,503.36
$2,607.73
$2,978.48 		$558.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,459.68
$1,656.74
$1,865.48
$2,606.98
$3,961.58 		$2,018.01
$2,215.07
$2,423.81
$3,165.31 		$2,576.34
$2,773.40
$2,982.14
$3,723.64 		$3,134.67
$3,331.73
$3,540.47
$4,281.97 		$558.33
Toc - Plan #8 Highmark Blue Cross Blue Shield West Virginia
Gold

(PPO) my Blue Access WV PPO Premier Gold 0 + Adult Dental and Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$752.35
$853.92
$961.50
$1,343.70
$2,041.88 		$1,327.90
$1,429.47
$1,537.05
$1,919.25 		$1,903.45
$2,005.02
$2,112.60
$2,494.80 		$2,479.00
$2,580.57
$2,688.15
$3,070.35 		$575.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,504.70
$1,707.84
$1,923.00
$2,687.40
$4,083.76 		$2,080.25
$2,283.39
$2,498.55
$3,262.95 		$2,655.80
$2,858.94
$3,074.10
$3,838.50 		$3,231.35
$3,434.49
$3,649.65
$4,414.05 		$575.55
Toc - Plan #9 Highmark Blue Cross Blue Shield West Virginia
Catastrophic

(PPO) my Blue Access WV Major Events PPO Catastrophic 9100 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$391.76
$444.65
$500.67
$699.68
$1,063.24 		$691.46
$744.35
$800.37
$999.38 		$991.16
$1,044.05
$1,100.07
$1,299.08 		$1,290.86
$1,343.75
$1,399.77
$1,598.78 		$299.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$783.52
$889.30
$1,001.34
$1,399.36
$2,126.48 		$1,083.22
$1,189.00
$1,301.04
$1,699.06 		$1,382.92
$1,488.70
$1,600.74
$1,998.76 		$1,682.62
$1,788.40
$1,900.44
$2,298.46 		$299.70
Toc - Plan #10 Highmark Blue Cross Blue Shield West Virginia
Bronze

(PPO) my Blue Access WV PPO Standard Bronze 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$508.00
$576.58
$649.22
$907.29
$1,378.71 		$896.62
$965.20
$1,037.84
$1,295.91 		$1,285.24
$1,353.82
$1,426.46
$1,684.53 		$1,673.86
$1,742.44
$1,815.08
$2,073.15 		$388.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,016.00
$1,153.16
$1,298.44
$1,814.58
$2,757.42 		$1,404.62
$1,541.78
$1,687.06
$2,203.20 		$1,793.24
$1,930.40
$2,075.68
$2,591.82 		$2,181.86
$2,319.02
$2,464.30
$2,980.44 		$388.62
Toc - Plan #11 Highmark Blue Cross Blue Shield West Virginia
Silver

(PPO) my Blue Access WV PPO Standard Silver 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$683.56
$775.84
$873.59
$1,220.84
$1,855.18 		$1,206.48
$1,298.76
$1,396.51
$1,743.76 		$1,729.40
$1,821.68
$1,919.43
$2,266.68 		$2,252.32
$2,344.60
$2,442.35
$2,789.60 		$522.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,367.12
$1,551.68
$1,747.18
$2,441.68
$3,710.36 		$1,890.04
$2,074.60
$2,270.10
$2,964.60 		$2,412.96
$2,597.52
$2,793.02
$3,487.52 		$2,935.88
$3,120.44
$3,315.94
$4,010.44 		$522.92
Toc - Plan #12 Highmark Blue Cross Blue Shield West Virginia
Gold

(PPO) my Blue Access WV PPO Standard Gold 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$674.65
$765.73
$862.20
$1,204.92
$1,831.00 		$1,190.76
$1,281.84
$1,378.31
$1,721.03 		$1,706.87
$1,797.95
$1,894.42
$2,237.14 		$2,222.98
$2,314.06
$2,410.53
$2,753.25 		$516.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,349.30
$1,531.46
$1,724.40
$2,409.84
$3,662.00 		$1,865.41
$2,047.57
$2,240.51
$2,925.95 		$2,381.52
$2,563.68
$2,756.62
$3,442.06 		$2,897.63
$3,079.79
$3,272.73
$3,958.17 		$516.11
Toc - Plan #13 Highmark Blue Cross Blue Shield West Virginia
Silver

(PPO) my Blue Access WV PPO Standard Silver 5800 + Adult Dental and Vison

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-601-2109

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 		$706.07
$801.39
$902.36
$1,261.04
$1,916.27 		$1,246.21
$1,341.53
$1,442.50
$1,801.18 		$1,786.35
$1,881.67
$1,982.64
$2,341.32 		$2,326.49
$2,421.81
$2,522.78
$2,881.46 		$540.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,412.14
$1,602.78
$1,804.72
$2,522.08
$3,832.54 		$1,952.28
$2,142.92
$2,344.86
$3,062.22 		$2,492.42
$2,683.06
$2,885.00
$3,602.36 		$3,032.56
$3,223.20
$3,425.14
$4,142.50 		$540.14

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-982-8771
Toc - Plan #14 CareSource
Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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 		$598.15
$678.90
$764.44
$1,068.30
$1,623.38 		$1,055.73
$1,136.48
$1,222.02
$1,525.88 		$1,513.31
$1,594.06
$1,679.60
$1,983.46 		$1,970.89
$2,051.64
$2,137.18
$2,441.04 		$457.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,196.30
$1,357.80
$1,528.88
$2,136.60
$3,246.76 		$1,653.88
$1,815.38
$1,986.46
$2,594.18 		$2,111.46
$2,272.96
$2,444.04
$3,051.76 		$2,569.04
$2,730.54
$2,901.62
$3,509.34 		$457.58
Toc - Plan #15 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$664.24
$753.91
$848.90
$1,186.33
$1,802.75 		$1,172.38
$1,262.05
$1,357.04
$1,694.47 		$1,680.52
$1,770.19
$1,865.18
$2,202.61 		$2,188.66
$2,278.33
$2,373.32
$2,710.75 		$508.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,328.48
$1,507.82
$1,697.80
$2,372.66
$3,605.50 		$1,836.62
$2,015.96
$2,205.94
$2,880.80 		$2,344.76
$2,524.10
$2,714.08
$3,388.94 		$2,852.90
$3,032.24
$3,222.22
$3,897.08 		$508.14
Toc - Plan #16 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$766.41
$869.87
$979.47
$1,368.81
$2,080.04 		$1,352.71
$1,456.17
$1,565.77
$1,955.11 		$1,939.01
$2,042.47
$2,152.07
$2,541.41 		$2,525.31
$2,628.77
$2,738.37
$3,127.71 		$586.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,532.82
$1,739.74
$1,958.94
$2,737.62
$4,160.08 		$2,119.12
$2,326.04
$2,545.24
$3,323.92 		$2,705.42
$2,912.34
$3,131.54
$3,910.22 		$3,291.72
$3,498.64
$3,717.84
$4,496.52 		$586.30
Toc - Plan #17 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$672.26
$763.01
$859.14
$1,200.65
$1,824.50 		$1,186.54
$1,277.29
$1,373.42
$1,714.93 		$1,700.82
$1,791.57
$1,887.70
$2,229.21 		$2,215.10
$2,305.85
$2,401.98
$2,743.49 		$514.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,344.52
$1,526.02
$1,718.28
$2,401.30
$3,649.00 		$1,858.80
$2,040.30
$2,232.56
$2,915.58 		$2,373.08
$2,554.58
$2,746.84
$3,429.86 		$2,887.36
$3,068.86
$3,261.12
$3,944.14 		$514.28
Toc - Plan #18 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$539.43
$612.25
$689.38
$963.41
$1,464.00 		$952.09
$1,024.91
$1,102.04
$1,376.07 		$1,364.75
$1,437.57
$1,514.70
$1,788.73 		$1,777.41
$1,850.23
$1,927.36
$2,201.39 		$412.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,078.86
$1,224.50
$1,378.76
$1,926.82
$2,928.00 		$1,491.52
$1,637.16
$1,791.42
$2,339.48 		$1,904.18
$2,049.82
$2,204.08
$2,752.14 		$2,316.84
$2,462.48
$2,616.74
$3,164.80 		$412.66
Toc - Plan #19 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$712.45
$808.63
$910.51
$1,272.44
$1,933.59 		$1,257.47
$1,353.65
$1,455.53
$1,817.46 		$1,802.49
$1,898.67
$2,000.55
$2,362.48 		$2,347.51
$2,443.69
$2,545.57
$2,907.50 		$545.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,424.90
$1,617.26
$1,821.02
$2,544.88
$3,867.18 		$1,969.92
$2,162.28
$2,366.04
$3,089.90 		$2,514.94
$2,707.30
$2,911.06
$3,634.92 		$3,059.96
$3,252.32
$3,456.08
$4,179.94 		$545.02
Toc - Plan #20 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$525.39
$596.31
$671.44
$938.34
$1,425.89 		$927.31
$998.23
$1,073.36
$1,340.26 		$1,329.23
$1,400.15
$1,475.28
$1,742.18 		$1,731.15
$1,802.07
$1,877.20
$2,144.10 		$401.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,050.78
$1,192.62
$1,342.88
$1,876.68
$2,851.78 		$1,452.70
$1,594.54
$1,744.80
$2,278.60 		$1,854.62
$1,996.46
$2,146.72
$2,680.52 		$2,256.54
$2,398.38
$2,548.64
$3,082.44 		$401.92
Toc - Plan #21 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$671.56
$762.22
$858.25
$1,199.40
$1,822.60 		$1,185.30
$1,275.96
$1,371.99
$1,713.14 		$1,699.04
$1,789.70
$1,885.73
$2,226.88 		$2,212.78
$2,303.44
$2,399.47
$2,740.62 		$513.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,343.12
$1,524.44
$1,716.50
$2,398.80
$3,645.20 		$1,856.86
$2,038.18
$2,230.24
$2,912.54 		$2,370.60
$2,551.92
$2,743.98
$3,426.28 		$2,884.34
$3,065.66
$3,257.72
$3,940.02 		$513.74
Toc - Plan #22 CareSource
Gold

(HMO) CareSource Marketplace Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$774.64
$879.22
$989.99
$1,383.51
$2,102.37 		$1,367.24
$1,471.82
$1,582.59
$1,976.11 		$1,959.84
$2,064.42
$2,175.19
$2,568.71 		$2,552.44
$2,657.02
$2,767.79
$3,161.31 		$592.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,549.28
$1,758.44
$1,979.98
$2,767.02
$4,204.74 		$2,141.88
$2,351.04
$2,572.58
$3,359.62 		$2,734.48
$2,943.64
$3,165.18
$3,952.22 		$3,327.08
$3,536.24
$3,757.78
$4,544.82 		$592.60
Toc - Plan #23 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$679.58
$771.31
$868.49
$1,213.72
$1,844.36 		$1,199.45
$1,291.18
$1,388.36
$1,733.59 		$1,719.32
$1,811.05
$1,908.23
$2,253.46 		$2,239.19
$2,330.92
$2,428.10
$2,773.33 		$519.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,359.16
$1,542.62
$1,736.98
$2,427.44
$3,688.72 		$1,879.03
$2,062.49
$2,256.85
$2,947.31 		$2,398.90
$2,582.36
$2,776.72
$3,467.18 		$2,918.77
$3,102.23
$3,296.59
$3,987.05 		$519.87
Toc - Plan #24 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$546.73
$620.54
$698.72
$976.46
$1,483.83 		$964.98
$1,038.79
$1,116.97
$1,394.71 		$1,383.23
$1,457.04
$1,535.22
$1,812.96 		$1,801.48
$1,875.29
$1,953.47
$2,231.21 		$418.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,093.46
$1,241.08
$1,397.44
$1,952.92
$2,967.66 		$1,511.71
$1,659.33
$1,815.69
$2,371.17 		$1,929.96
$2,077.58
$2,233.94
$2,789.42 		$2,348.21
$2,495.83
$2,652.19
$3,207.67 		$418.25
Toc - Plan #25 CareSource
Silver

(HMO) CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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 		$719.77
$816.93
$919.86
$1,285.50
$1,953.44 		$1,270.39
$1,367.55
$1,470.48
$1,836.12 		$1,821.01
$1,918.17
$2,021.10
$2,386.74 		$2,371.63
$2,468.79
$2,571.72
$2,937.36 		$550.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,439.54
$1,633.86
$1,839.72
$2,571.00
$3,906.88 		$1,990.16
$2,184.48
$2,390.34
$3,121.62 		$2,540.78
$2,735.10
$2,940.96
$3,672.24 		$3,091.40
$3,285.72
$3,491.58
$4,222.86 		$550.62
Toc - Plan #26 CareSource
Bronze

(HMO) CareSource Marketplace Bronze Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

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 		$532.33
$604.19
$680.31
$950.73
$1,444.72 		$939.56
$1,011.42
$1,087.54
$1,357.96 		$1,346.79
$1,418.65
$1,494.77
$1,765.19 		$1,754.02
$1,825.88
$1,902.00
$2,172.42 		$407.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,064.66
$1,208.38
$1,360.62
$1,901.46
$2,889.44 		$1,471.89
$1,615.61
$1,767.85
$2,308.69 		$1,879.12
$2,022.84
$2,175.08
$2,715.92 		$2,286.35
$2,430.07
$2,582.31
$3,123.15 		$407.23

‡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 Kanawha County here.

Kanawha County is in “Rating Area 2” of West Virginia.

Currently, there are 26 plans offered in Rating Area 2.

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2023 Obamacare Plans for Kanawha County, WV

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