Obamacare 2023 Rates for DuPage County

Obamacare > Rates > Illinois > DuPage County

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 Clarendon Hills, IL.

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, 130 Plans and 2023 Rates for DuPage County, Illinois

Below, you’ll find a summary of the 130 plans for DuPage County, Illinois and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Oscar Health Plan, Inc.

Local: | Toll Free:

Toc - Plan #1 Oscar Health Plan, Inc.

Expanded Bronze

(HMO) Bronze Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$250.24
$284.01
$319.79
$446.91
$679.12

$441.66
$475.43
$511.21
$638.33

$633.08
$666.85
$702.63
$829.75

$824.50
$858.27
$894.05
$1,021.17

$191.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$500.48
$568.02
$639.58
$893.82
$1,358.24

$691.90
$759.44
$831.00
$1,085.24

$883.32
$950.86
$1,022.42
$1,276.66

$1,074.74
$1,142.28
$1,213.84
$1,468.08

$191.42

Toc - Plan #2 Oscar Health Plan, Inc.

Expanded Bronze

(HMO) Bronze Elite- Deductible+PCP Saver Plus (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

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

$298.49
$338.77
$381.46
$533.08
$810.07

$526.83
$567.11
$609.80
$761.42

$755.17
$795.45
$838.14
$989.76

$983.51
$1,023.79
$1,066.48
$1,218.10

$228.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$596.98
$677.54
$762.92
$1,066.16
$1,620.14

$825.32
$905.88
$991.26
$1,294.50

$1,053.66
$1,134.22
$1,219.60
$1,522.84

$1,282.00
$1,362.56
$1,447.94
$1,751.18

$228.34

Toc - Plan #3 Oscar Health Plan, Inc.

Silver

(HMO) Silver Classic (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,400 $10,800 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$332.40
$377.26
$424.79
$593.64
$902.10

$586.68
$631.54
$679.07
$847.92

$840.96
$885.82
$933.35
$1,102.20

$1,095.24
$1,140.10
$1,187.63
$1,356.48

$254.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$664.80
$754.52
$849.58
$1,187.28
$1,804.20

$919.08
$1,008.80
$1,103.86
$1,441.56

$1,173.36
$1,263.08
$1,358.14
$1,695.84

$1,427.64
$1,517.36
$1,612.42
$1,950.12

$254.28

Toc - Plan #4 Oscar Health Plan, Inc.

Catastrophic

(HMO) Secure (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

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

$227.58
$258.29
$290.84
$406.44
$617.63

$401.67
$432.38
$464.93
$580.53

$575.76
$606.47
$639.02
$754.62

$749.85
$780.56
$813.11
$928.71

$174.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$455.16
$516.58
$581.68
$812.88
$1,235.26

$629.25
$690.67
$755.77
$986.97

$803.34
$864.76
$929.86
$1,161.06

$977.43
$1,038.85
$1,103.95
$1,335.15

$174.09

Toc - Plan #5 Oscar Health Plan, Inc.

Expanded Bronze

(HMO) Bronze Simple- $5200 Ded (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,200 $10,400 Annual Deductible

$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$262.52
$297.95
$335.49
$468.85
$712.46

$463.34
$498.77
$536.31
$669.67

$664.16
$699.59
$737.13
$870.49

$864.98
$900.41
$937.95
$1,071.31

$200.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$525.04
$595.90
$670.98
$937.70
$1,424.92

$725.86
$796.72
$871.80
$1,138.52

$926.68
$997.54
$1,072.62
$1,339.34

$1,127.50
$1,198.36
$1,273.44
$1,540.16

$200.82

Toc - Plan #6 Oscar Health Plan, Inc.

Silver

(HMO) Silver Simple- Specialist Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$327.28
$371.45
$418.25
$584.50
$888.21

$577.64
$621.81
$668.61
$834.86

$828.00
$872.17
$918.97
$1,085.22

$1,078.36
$1,122.53
$1,169.33
$1,335.58

$250.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$654.56
$742.90
$836.50
$1,169.00
$1,776.42

$904.92
$993.26
$1,086.86
$1,419.36

$1,155.28
$1,243.62
$1,337.22
$1,669.72

$1,405.64
$1,493.98
$1,587.58
$1,920.08

$250.36

Toc - Plan #7 Oscar Health Plan, Inc.

Expanded Bronze

(HMO) Bronze Classic- PCP Saver Plus Rx Copay (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 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

$266.65
$302.64
$340.77
$476.22
$723.66

$470.63
$506.62
$544.75
$680.20

$674.61
$710.60
$748.73
$884.18

$878.59
$914.58
$952.71
$1,088.16

$203.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$533.30
$605.28
$681.54
$952.44
$1,447.32

$737.28
$809.26
$885.52
$1,156.42

$941.26
$1,013.24
$1,089.50
$1,360.40

$1,145.24
$1,217.22
$1,293.48
$1,564.38

$203.98

Toc - Plan #8 Oscar Health Plan, Inc.

Expanded Bronze

(HMO) Bronze Classic- Deductible Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,700 $9,400 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$269.88
$306.31
$344.90
$482.00
$732.44

$476.33
$512.76
$551.35
$688.45

$682.78
$719.21
$757.80
$894.90

$889.23
$925.66
$964.25
$1,101.35

$206.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$539.76
$612.62
$689.80
$964.00
$1,464.88

$746.21
$819.07
$896.25
$1,170.45

$952.66
$1,025.52
$1,102.70
$1,376.90

$1,159.11
$1,231.97
$1,309.15
$1,583.35

$206.45

Toc - Plan #9 Oscar Health Plan, Inc.

Silver

(HMO) Silver Simple- PCP Saver (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$318.93
$361.97
$407.58
$569.59
$865.55

$562.90
$605.94
$651.55
$813.56

$806.87
$849.91
$895.52
$1,057.53

$1,050.84
$1,093.88
$1,139.49
$1,301.50

$243.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$637.86
$723.94
$815.16
$1,139.18
$1,731.10

$881.83
$967.91
$1,059.13
$1,383.15

$1,125.80
$1,211.88
$1,303.10
$1,627.12

$1,369.77
$1,455.85
$1,547.07
$1,871.09

$243.97

Toc - Plan #10 Oscar Health Plan, Inc.

Silver

(HMO) Silver Elite- Deductible Saver Plus Rx Copay (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$337.08
$382.57
$430.77
$602.01
$914.81

$594.94
$640.43
$688.63
$859.87

$852.80
$898.29
$946.49
$1,117.73

$1,110.66
$1,156.15
$1,204.35
$1,375.59

$257.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$674.16
$765.14
$861.54
$1,204.02
$1,829.62

$932.02
$1,023.00
$1,119.40
$1,461.88

$1,189.88
$1,280.86
$1,377.26
$1,719.74

$1,447.74
$1,538.72
$1,635.12
$1,977.60

$257.86

Toc - Plan #11 Oscar Health Plan, Inc.

Silver

(HMO) Silver Simple- For Diabetes (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,450 $12,900 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$329.21
$373.64
$420.72
$587.95
$893.45

$581.05
$625.48
$672.56
$839.79

$832.89
$877.32
$924.40
$1,091.63

$1,084.73
$1,129.16
$1,176.24
$1,343.47

$251.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$658.42
$747.28
$841.44
$1,175.90
$1,786.90

$910.26
$999.12
$1,093.28
$1,427.74

$1,162.10
$1,250.96
$1,345.12
$1,679.58

$1,413.94
$1,502.80
$1,596.96
$1,931.42

$251.84

Toc - Plan #12 Oscar Health Plan, Inc.

Expanded Bronze

(HMO) Bronze Classic- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

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

$264.17
$299.83
$337.60
$471.80
$716.94

$466.26
$501.92
$539.69
$673.89

$668.35
$704.01
$741.78
$875.98

$870.44
$906.10
$943.87
$1,078.07

$202.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$528.34
$599.66
$675.20
$943.60
$1,433.88

$730.43
$801.75
$877.29
$1,145.69

$932.52
$1,003.84
$1,079.38
$1,347.78

$1,134.61
$1,205.93
$1,281.47
$1,549.87

$202.09

Toc - Plan #13 Oscar Health Plan, Inc.

Bronze

(HMO) Bronze Simple- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$238.14
$270.28
$304.33
$425.30
$646.28

$420.31
$452.45
$486.50
$607.47

$602.48
$634.62
$668.67
$789.64

$784.65
$816.79
$850.84
$971.81

$182.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$476.28
$540.56
$608.66
$850.60
$1,292.56

$658.45
$722.73
$790.83
$1,032.77

$840.62
$904.90
$973.00
$1,214.94

$1,022.79
$1,087.07
$1,155.17
$1,397.11

$182.17

Toc - Plan #14 Oscar Health Plan, Inc.

Silver

(HMO) Silver Classic- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

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

$321.56
$364.96
$410.95
$574.30
$872.70

$567.55
$610.95
$656.94
$820.29

$813.54
$856.94
$902.93
$1,066.28

$1,059.53
$1,102.93
$1,148.92
$1,312.27

$245.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$643.12
$729.92
$821.90
$1,148.60
$1,745.40

$889.11
$975.91
$1,067.89
$1,394.59

$1,135.10
$1,221.90
$1,313.88
$1,640.58

$1,381.09
$1,467.89
$1,559.87
$1,886.57

$245.99

Toc - Plan #15 Oscar Health Plan, Inc.

Gold

(HMO) Gold Classic- Standard (Choice)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$347.71
$394.64
$444.36
$621.00
$943.67

$613.70
$660.63
$710.35
$886.99

$879.69
$926.62
$976.34
$1,152.98

$1,145.68
$1,192.61
$1,242.33
$1,418.97

$265.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$695.42
$789.28
$888.72
$1,242.00
$1,887.34

$961.41
$1,055.27
$1,154.71
$1,507.99

$1,227.40
$1,321.26
$1,420.70
$1,773.98

$1,493.39
$1,587.25
$1,686.69
$2,039.97

$265.99

Ambetter of Illinois

Local: 1-855-745-5507 | Toll Free: 1-855-745-5507 | TTY: 1-844-517-3431

Toc - Plan #16 Ambetter of Illinois

Silver

(HMO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$7,550 $15,100 Annual Deductible

$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$358.84
$407.27
$458.58
$640.87
$973.86

$633.34
$681.77
$733.08
$915.37

$907.84
$956.27
$1,007.58
$1,189.87

$1,182.34
$1,230.77
$1,282.08
$1,464.37

$274.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$717.68
$814.54
$917.16
$1,281.74
$1,947.72

$992.18
$1,089.04
$1,191.66
$1,556.24

$1,266.68
$1,363.54
$1,466.16
$1,830.74

$1,541.18
$1,638.04
$1,740.66
$2,105.24

$274.50

Toc - Plan #17 Ambetter of Illinois

Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$419.23
$475.81
$535.76
$748.72
$1,137.76

$739.93
$796.51
$856.46
$1,069.42

$1,060.63
$1,117.21
$1,177.16
$1,390.12

$1,381.33
$1,437.91
$1,497.86
$1,710.82

$320.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$838.46
$951.62
$1,071.52
$1,497.44
$2,275.52

$1,159.16
$1,272.32
$1,392.22
$1,818.14

$1,479.86
$1,593.02
$1,712.92
$2,138.84

$1,800.56
$1,913.72
$2,033.62
$2,459.54

$320.70

Toc - Plan #18 Ambetter of Illinois

Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$358.34
$406.70
$457.94
$639.97
$972.49

$632.46
$680.82
$732.06
$914.09

$906.58
$954.94
$1,006.18
$1,188.21

$1,180.70
$1,229.06
$1,280.30
$1,462.33

$274.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$716.68
$813.40
$915.88
$1,279.94
$1,944.98

$990.80
$1,087.52
$1,190.00
$1,554.06

$1,264.92
$1,361.64
$1,464.12
$1,828.18

$1,539.04
$1,635.76
$1,738.24
$2,102.30

$274.12

Toc - Plan #19 Ambetter of Illinois

Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$298.20
$338.44
$381.08
$532.56
$809.28

$526.31
$566.55
$609.19
$760.67

$754.42
$794.66
$837.30
$988.78

$982.53
$1,022.77
$1,065.41
$1,216.89

$228.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$596.40
$676.88
$762.16
$1,065.12
$1,618.56

$824.51
$904.99
$990.27
$1,293.23

$1,052.62
$1,133.10
$1,218.38
$1,521.34

$1,280.73
$1,361.21
$1,446.49
$1,749.45

$228.11

Toc - Plan #20 Ambetter of Illinois

Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$352.77
$400.39
$450.83
$630.04
$957.40

$622.63
$670.25
$720.69
$899.90

$892.49
$940.11
$990.55
$1,169.76

$1,162.35
$1,209.97
$1,260.41
$1,439.62

$269.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$705.54
$800.78
$901.66
$1,260.08
$1,914.80

$975.40
$1,070.64
$1,171.52
$1,529.94

$1,245.26
$1,340.50
$1,441.38
$1,799.80

$1,515.12
$1,610.36
$1,711.24
$2,069.66

$269.86

Toc - Plan #21 Ambetter of Illinois

Silver

(HMO) Elite Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$378.00
$429.02
$483.07
$675.09
$1,025.86

$667.16
$718.18
$772.23
$964.25

$956.32
$1,007.34
$1,061.39
$1,253.41

$1,245.48
$1,296.50
$1,350.55
$1,542.57

$289.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$756.00
$858.04
$966.14
$1,350.18
$2,051.72

$1,045.16
$1,147.20
$1,255.30
$1,639.34

$1,334.32
$1,436.36
$1,544.46
$1,928.50

$1,623.48
$1,725.52
$1,833.62
$2,217.66

$289.16

Toc - Plan #22 Ambetter of Illinois

Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$289.26
$328.30
$369.66
$516.60
$785.03

$510.54
$549.58
$590.94
$737.88

$731.82
$770.86
$812.22
$959.16

$953.10
$992.14
$1,033.50
$1,180.44

$221.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.52
$656.60
$739.32
$1,033.20
$1,570.06

$799.80
$877.88
$960.60
$1,254.48

$1,021.08
$1,099.16
$1,181.88
$1,475.76

$1,242.36
$1,320.44
$1,403.16
$1,697.04

$221.28

Toc - Plan #23 Ambetter of Illinois

Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$346.39
$393.14
$442.67
$618.63
$940.06

$611.37
$658.12
$707.65
$883.61

$876.35
$923.10
$972.63
$1,148.59

$1,141.33
$1,188.08
$1,237.61
$1,413.57

$264.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$692.78
$786.28
$885.34
$1,237.26
$1,880.12

$957.76
$1,051.26
$1,150.32
$1,502.24

$1,222.74
$1,316.24
$1,415.30
$1,767.22

$1,487.72
$1,581.22
$1,680.28
$2,032.20

$264.98

Toc - Plan #24 Ambetter of Illinois

Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$342.08
$388.25
$437.17
$610.94
$928.38

$603.76
$649.93
$698.85
$872.62

$865.44
$911.61
$960.53
$1,134.30

$1,127.12
$1,173.29
$1,222.21
$1,395.98

$261.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$684.16
$776.50
$874.34
$1,221.88
$1,856.76

$945.84
$1,038.18
$1,136.02
$1,483.56

$1,207.52
$1,299.86
$1,397.70
$1,745.24

$1,469.20
$1,561.54
$1,659.38
$2,006.92

$261.68

Toc - Plan #25 Ambetter of Illinois

Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$348.25
$395.25
$445.05
$621.96
$945.13

$614.66
$661.66
$711.46
$888.37

$881.07
$928.07
$977.87
$1,154.78

$1,147.48
$1,194.48
$1,244.28
$1,421.19

$266.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$696.50
$790.50
$890.10
$1,243.92
$1,890.26

$962.91
$1,056.91
$1,156.51
$1,510.33

$1,229.32
$1,323.32
$1,422.92
$1,776.74

$1,495.73
$1,589.73
$1,689.33
$2,043.15

$266.41

Toc - Plan #26 Ambetter of Illinois

Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$750 $1,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$397.41
$451.05
$507.88
$709.76
$1,078.55

$701.42
$755.06
$811.89
$1,013.77

$1,005.43
$1,059.07
$1,115.90
$1,317.78

$1,309.44
$1,363.08
$1,419.91
$1,621.79

$304.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$794.82
$902.10
$1,015.76
$1,419.52
$2,157.10

$1,098.83
$1,206.11
$1,319.77
$1,723.53

$1,402.84
$1,510.12
$1,623.78
$2,027.54

$1,706.85
$1,814.13
$1,927.79
$2,331.55

$304.01

Toc - Plan #27 Ambetter of Illinois

Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$266.04
$301.95
$339.99
$475.14
$722.02

$469.56
$505.47
$543.51
$678.66

$673.08
$708.99
$747.03
$882.18

$876.60
$912.51
$950.55
$1,085.70

$203.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$532.08
$603.90
$679.98
$950.28
$1,444.04

$735.60
$807.42
$883.50
$1,153.80

$939.12
$1,010.94
$1,087.02
$1,357.32

$1,142.64
$1,214.46
$1,290.54
$1,560.84

$203.52

Toc - Plan #28 Ambetter of Illinois

Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$470.36
$533.85
$601.11
$840.05
$1,276.53

$830.18
$893.67
$960.93
$1,199.87

$1,190.00
$1,253.49
$1,320.75
$1,559.69

$1,549.82
$1,613.31
$1,680.57
$1,919.51

$359.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$940.72
$1,067.70
$1,202.22
$1,680.10
$2,553.06

$1,300.54
$1,427.52
$1,562.04
$2,039.92

$1,660.36
$1,787.34
$1,921.86
$2,399.74

$2,020.18
$2,147.16
$2,281.68
$2,759.56

$359.82

Toc - Plan #29 Ambetter of Illinois

Expanded Bronze

(HMO) Central Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$294.61
$334.37
$376.50
$526.15
$799.54

$519.98
$559.74
$601.87
$751.52

$745.35
$785.11
$827.24
$976.89

$970.72
$1,010.48
$1,052.61
$1,202.26

$225.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$589.22
$668.74
$753.00
$1,052.30
$1,599.08

$814.59
$894.11
$978.37
$1,277.67

$1,039.96
$1,119.48
$1,203.74
$1,503.04

$1,265.33
$1,344.85
$1,429.11
$1,728.41

$225.37

Toc - Plan #30 Ambetter of Illinois

Silver

(HMO) Central Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$368.20
$417.90
$470.55
$657.59
$999.28

$649.87
$699.57
$752.22
$939.26

$931.54
$981.24
$1,033.89
$1,220.93

$1,213.21
$1,262.91
$1,315.56
$1,502.60

$281.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$736.40
$835.80
$941.10
$1,315.18
$1,998.56

$1,018.07
$1,117.47
$1,222.77
$1,596.85

$1,299.74
$1,399.14
$1,504.44
$1,878.52

$1,581.41
$1,680.81
$1,786.11
$2,160.19

$281.67

Toc - Plan #31 Ambetter of Illinois

Gold

(HMO) Central Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$406.13
$460.95
$519.02
$725.33
$1,102.21

$716.81
$771.63
$829.70
$1,036.01

$1,027.49
$1,082.31
$1,140.38
$1,346.69

$1,338.17
$1,392.99
$1,451.06
$1,657.37

$310.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$812.26
$921.90
$1,038.04
$1,450.66
$2,204.42

$1,122.94
$1,232.58
$1,348.72
$1,761.34

$1,433.62
$1,543.26
$1,659.40
$2,072.02

$1,744.30
$1,853.94
$1,970.08
$2,382.70

$310.68

Toc - Plan #32 Ambetter of Illinois

Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$249.72
$283.42
$319.13
$445.98
$677.71

$440.75
$474.45
$510.16
$637.01

$631.78
$665.48
$701.19
$828.04

$822.81
$856.51
$892.22
$1,019.07

$191.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$499.44
$566.84
$638.26
$891.96
$1,355.42

$690.47
$757.87
$829.29
$1,082.99

$881.50
$948.90
$1,020.32
$1,274.02

$1,072.53
$1,139.93
$1,211.35
$1,465.05

$191.03

Toc - Plan #33 Ambetter of Illinois

Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$289.51
$328.58
$369.98
$517.05
$785.71

$510.98
$550.05
$591.45
$738.52

$732.45
$771.52
$812.92
$959.99

$953.92
$992.99
$1,034.39
$1,181.46

$221.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$579.02
$657.16
$739.96
$1,034.10
$1,571.42

$800.49
$878.63
$961.43
$1,255.57

$1,021.96
$1,100.10
$1,182.90
$1,477.04

$1,243.43
$1,321.57
$1,404.37
$1,698.51

$221.47

Toc - Plan #34 Ambetter of Illinois

Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$345.70
$392.36
$441.80
$617.41
$938.21

$610.16
$656.82
$706.26
$881.87

$874.62
$921.28
$970.72
$1,146.33

$1,139.08
$1,185.74
$1,235.18
$1,410.79

$264.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$691.40
$784.72
$883.60
$1,234.82
$1,876.42

$955.86
$1,049.18
$1,148.06
$1,499.28

$1,220.32
$1,313.64
$1,412.52
$1,763.74

$1,484.78
$1,578.10
$1,676.98
$2,028.20

$264.46

Toc - Plan #35 Ambetter of Illinois

Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$387.69
$440.01
$495.45
$692.39
$1,052.16

$684.26
$736.58
$792.02
$988.96

$980.83
$1,033.15
$1,088.59
$1,285.53

$1,277.40
$1,329.72
$1,385.16
$1,582.10

$296.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.38
$880.02
$990.90
$1,384.78
$2,104.32

$1,071.95
$1,176.59
$1,287.47
$1,681.35

$1,368.52
$1,473.16
$1,584.04
$1,977.92

$1,665.09
$1,769.73
$1,880.61
$2,274.49

$296.57

Toc - Plan #36 Ambetter of Illinois

Silver

(HMO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$7,550 $15,100 Annual Deductible

$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$372.64
$422.94
$476.22
$665.52
$1,011.32

$657.70
$708.00
$761.28
$950.58

$942.76
$993.06
$1,046.34
$1,235.64

$1,227.82
$1,278.12
$1,331.40
$1,520.70

$285.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$745.28
$845.88
$952.44
$1,331.04
$2,022.64

$1,030.34
$1,130.94
$1,237.50
$1,616.10

$1,315.40
$1,416.00
$1,522.56
$1,901.16

$1,600.46
$1,701.06
$1,807.62
$2,186.22

$285.06

Toc - Plan #37 Ambetter of Illinois

Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$435.36
$494.12
$556.37
$777.53
$1,181.53

$768.40
$827.16
$889.41
$1,110.57

$1,101.44
$1,160.20
$1,222.45
$1,443.61

$1,434.48
$1,493.24
$1,555.49
$1,776.65

$333.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$870.72
$988.24
$1,112.74
$1,555.06
$2,363.06

$1,203.76
$1,321.28
$1,445.78
$1,888.10

$1,536.80
$1,654.32
$1,778.82
$2,221.14

$1,869.84
$1,987.36
$2,111.86
$2,554.18

$333.04

Toc - Plan #38 Ambetter of Illinois

Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$372.12
$422.35
$475.56
$664.59
$1,009.91

$656.78
$707.01
$760.22
$949.25

$941.44
$991.67
$1,044.88
$1,233.91

$1,226.10
$1,276.33
$1,329.54
$1,518.57

$284.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$744.24
$844.70
$951.12
$1,329.18
$2,019.82

$1,028.90
$1,129.36
$1,235.78
$1,613.84

$1,313.56
$1,414.02
$1,520.44
$1,898.50

$1,598.22
$1,698.68
$1,805.10
$2,183.16

$284.66

Toc - Plan #39 Ambetter of Illinois

Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$309.67
$351.46
$395.74
$553.05
$840.41

$546.56
$588.35
$632.63
$789.94

$783.45
$825.24
$869.52
$1,026.83

$1,020.34
$1,062.13
$1,106.41
$1,263.72

$236.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$619.34
$702.92
$791.48
$1,106.10
$1,680.82

$856.23
$939.81
$1,028.37
$1,342.99

$1,093.12
$1,176.70
$1,265.26
$1,579.88

$1,330.01
$1,413.59
$1,502.15
$1,816.77

$236.89

Toc - Plan #40 Ambetter of Illinois

Silver

(HMO) Elite Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$392.54
$445.52
$501.65
$701.06
$1,065.33

$692.83
$745.81
$801.94
$1,001.35

$993.12
$1,046.10
$1,102.23
$1,301.64

$1,293.41
$1,346.39
$1,402.52
$1,601.93

$300.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$785.08
$891.04
$1,003.30
$1,402.12
$2,130.66

$1,085.37
$1,191.33
$1,303.59
$1,702.41

$1,385.66
$1,491.62
$1,603.88
$2,002.70

$1,685.95
$1,791.91
$1,904.17
$2,302.99

$300.29

Toc - Plan #41 Ambetter of Illinois

Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$300.39
$340.93
$383.88
$536.48
$815.23

$530.18
$570.72
$613.67
$766.27

$759.97
$800.51
$843.46
$996.06

$989.76
$1,030.30
$1,073.25
$1,225.85

$229.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$600.78
$681.86
$767.76
$1,072.96
$1,630.46

$830.57
$911.65
$997.55
$1,302.75

$1,060.36
$1,141.44
$1,227.34
$1,532.54

$1,290.15
$1,371.23
$1,457.13
$1,762.33

$229.79

Toc - Plan #42 Ambetter of Illinois

Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$359.71
$408.26
$459.70
$642.43
$976.23

$634.88
$683.43
$734.87
$917.60

$910.05
$958.60
$1,010.04
$1,192.77

$1,185.22
$1,233.77
$1,285.21
$1,467.94

$275.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$719.42
$816.52
$919.40
$1,284.86
$1,952.46

$994.59
$1,091.69
$1,194.57
$1,560.03

$1,269.76
$1,366.86
$1,469.74
$1,835.20

$1,544.93
$1,642.03
$1,744.91
$2,110.37

$275.17

Toc - Plan #43 Ambetter of Illinois

Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$361.65
$410.46
$462.18
$645.89
$981.49

$638.30
$687.11
$738.83
$922.54

$914.95
$963.76
$1,015.48
$1,199.19

$1,191.60
$1,240.41
$1,292.13
$1,475.84

$276.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$723.30
$820.92
$924.36
$1,291.78
$1,962.98

$999.95
$1,097.57
$1,201.01
$1,568.43

$1,276.60
$1,374.22
$1,477.66
$1,845.08

$1,553.25
$1,650.87
$1,754.31
$2,121.73

$276.65

Toc - Plan #44 Ambetter of Illinois

Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$750 $1,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$412.70
$468.40
$527.42
$737.07
$1,120.04

$728.41
$784.11
$843.13
$1,052.78

$1,044.12
$1,099.82
$1,158.84
$1,368.49

$1,359.83
$1,415.53
$1,474.55
$1,684.20

$315.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$825.40
$936.80
$1,054.84
$1,474.14
$2,240.08

$1,141.11
$1,252.51
$1,370.55
$1,789.85

$1,456.82
$1,568.22
$1,686.26
$2,105.56

$1,772.53
$1,883.93
$2,001.97
$2,421.27

$315.71

Toc - Plan #45 Ambetter of Illinois

Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$366.34
$415.79
$468.18
$654.27
$994.23

$646.59
$696.04
$748.43
$934.52

$926.84
$976.29
$1,028.68
$1,214.77

$1,207.09
$1,256.54
$1,308.93
$1,495.02

$280.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$732.68
$831.58
$936.36
$1,308.54
$1,988.46

$1,012.93
$1,111.83
$1,216.61
$1,588.79

$1,293.18
$1,392.08
$1,496.86
$1,869.04

$1,573.43
$1,672.33
$1,777.11
$2,149.29

$280.25

Toc - Plan #46 Ambetter of Illinois

Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$355.24
$403.19
$453.98
$634.44
$964.10

$626.99
$674.94
$725.73
$906.19

$898.74
$946.69
$997.48
$1,177.94

$1,170.49
$1,218.44
$1,269.23
$1,449.69

$271.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$710.48
$806.38
$907.96
$1,268.88
$1,928.20

$982.23
$1,078.13
$1,179.71
$1,540.63

$1,253.98
$1,349.88
$1,451.46
$1,812.38

$1,525.73
$1,621.63
$1,723.21
$2,084.13

$271.75

Toc - Plan #47 Ambetter of Illinois

Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

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

$276.28
$313.57
$353.07
$493.42
$749.80

$487.63
$524.92
$564.42
$704.77

$698.98
$736.27
$775.77
$916.12

$910.33
$947.62
$987.12
$1,127.47

$211.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$552.56
$627.14
$706.14
$986.84
$1,499.60

$763.91
$838.49
$917.49
$1,198.19

$975.26
$1,049.84
$1,128.84
$1,409.54

$1,186.61
$1,261.19
$1,340.19
$1,620.89

$211.35

Toc - Plan #48 Ambetter of Illinois

Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$488.46
$554.39
$624.23
$872.37
$1,325.64

$862.12
$928.05
$997.89
$1,246.03

$1,235.78
$1,301.71
$1,371.55
$1,619.69

$1,609.44
$1,675.37
$1,745.21
$1,993.35

$373.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$976.92
$1,108.78
$1,248.46
$1,744.74
$2,651.28

$1,350.58
$1,482.44
$1,622.12
$2,118.40

$1,724.24
$1,856.10
$1,995.78
$2,492.06

$2,097.90
$2,229.76
$2,369.44
$2,865.72

$373.66

Toc - Plan #49 Ambetter of Illinois

Expanded Bronze

(HMO) Central Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$305.94
$347.23
$390.98
$546.39
$830.30

$539.98
$581.27
$625.02
$780.43

$774.02
$815.31
$859.06
$1,014.47

$1,008.06
$1,049.35
$1,093.10
$1,248.51

$234.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$611.88
$694.46
$781.96
$1,092.78
$1,660.60

$845.92
$928.50
$1,016.00
$1,326.82

$1,079.96
$1,162.54
$1,250.04
$1,560.86

$1,314.00
$1,396.58
$1,484.08
$1,794.90

$234.04

Toc - Plan #50 Ambetter of Illinois

Silver

(HMO) Central Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$382.37
$433.98
$488.65
$682.89
$1,037.72

$674.87
$726.48
$781.15
$975.39

$967.37
$1,018.98
$1,073.65
$1,267.89

$1,259.87
$1,311.48
$1,366.15
$1,560.39

$292.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$764.74
$867.96
$977.30
$1,365.78
$2,075.44

$1,057.24
$1,160.46
$1,269.80
$1,658.28

$1,349.74
$1,452.96
$1,562.30
$1,950.78

$1,642.24
$1,745.46
$1,854.80
$2,243.28

$292.50

Toc - Plan #51 Ambetter of Illinois

Gold

(HMO) Central Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$421.76
$478.68
$538.99
$753.24
$1,144.62

$744.40
$801.32
$861.63
$1,075.88

$1,067.04
$1,123.96
$1,184.27
$1,398.52

$1,389.68
$1,446.60
$1,506.91
$1,721.16

$322.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$843.52
$957.36
$1,077.98
$1,506.48
$2,289.24

$1,166.16
$1,280.00
$1,400.62
$1,829.12

$1,488.80
$1,602.64
$1,723.26
$2,151.76

$1,811.44
$1,925.28
$2,045.90
$2,474.40

$322.64

Molina Healthcare

Local: 1-833-644-1623 | Toll Free: 1-833-644-1623 | TTY: 1-800-877-8339

Toc - Plan #52 Molina Healthcare

Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-644-1623

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

$318.47
$361.46
$407.00
$568.78
$864.32

$562.10
$605.09
$650.63
$812.41

$805.73
$848.72
$894.26
$1,056.04

$1,049.36
$1,092.35
$1,137.89
$1,299.67

$243.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$636.94
$722.92
$814.00
$1,137.56
$1,728.64

$880.57
$966.55
$1,057.63
$1,381.19

$1,124.20
$1,210.18
$1,301.26
$1,624.82

$1,367.83
$1,453.81
$1,544.89
$1,868.45

$243.63

Toc - Plan #53 Molina Healthcare

Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

Individual Family

$2,500 $5,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$307.18
$348.65
$392.57
$548.62
$833.68

$542.17
$583.64
$627.56
$783.61

$777.16
$818.63
$862.55
$1,018.60

$1,012.15
$1,053.62
$1,097.54
$1,253.59

$234.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$614.36
$697.30
$785.14
$1,097.24
$1,667.36

$849.35
$932.29
$1,020.13
$1,332.23

$1,084.34
$1,167.28
$1,255.12
$1,567.22

$1,319.33
$1,402.27
$1,490.11
$1,802.21

$234.99

Toc - Plan #54 Molina Healthcare

Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-644-1623

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

$327.99
$372.26
$419.17
$585.78
$890.15

$578.90
$623.17
$670.08
$836.69

$829.81
$874.08
$920.99
$1,087.60

$1,080.72
$1,124.99
$1,171.90
$1,338.51

$250.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$655.98
$744.52
$838.34
$1,171.56
$1,780.30

$906.89
$995.43
$1,089.25
$1,422.47

$1,157.80
$1,246.34
$1,340.16
$1,673.38

$1,408.71
$1,497.25
$1,591.07
$1,924.29

$250.91

Toc - Plan #55 Molina Healthcare

Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-644-1623

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

$310.60
$352.53
$396.95
$554.73
$842.97

$548.21
$590.14
$634.56
$792.34

$785.82
$827.75
$872.17
$1,029.95

$1,023.43
$1,065.36
$1,109.78
$1,267.56

$237.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$621.20
$705.06
$793.90
$1,109.46
$1,685.94

$858.81
$942.67
$1,031.51
$1,347.07

$1,096.42
$1,180.28
$1,269.12
$1,584.68

$1,334.03
$1,417.89
$1,506.73
$1,822.29

$237.61

Toc - Plan #56 Molina Healthcare

Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-644-1623

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

$316.66
$359.41
$404.69
$565.55
$859.41

$558.90
$601.65
$646.93
$807.79

$801.14
$843.89
$889.17
$1,050.03

$1,043.38
$1,086.13
$1,131.41
$1,292.27

$242.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$633.32
$718.82
$809.38
$1,131.10
$1,718.82

$875.56
$961.06
$1,051.62
$1,373.34

$1,117.80
$1,203.30
$1,293.86
$1,615.58

$1,360.04
$1,445.54
$1,536.10
$1,857.82

$242.24

Toc - Plan #57 Molina Healthcare

Silver

(HMO) Constant Care Silver 1 with RX Copay + Vision

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-644-1623

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$322.98
$366.58
$412.77
$576.84
$876.57

$570.06
$613.66
$659.85
$823.92

$817.14
$860.74
$906.93
$1,071.00

$1,064.22
$1,107.82
$1,154.01
$1,318.08

$247.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$645.96
$733.16
$825.54
$1,153.68
$1,753.14

$893.04
$980.24
$1,072.62
$1,400.76

$1,140.12
$1,227.32
$1,319.70
$1,647.84

$1,387.20
$1,474.40
$1,566.78
$1,894.92

$247.08

Blue Cross and Blue Shield of Illinois

Local: 1-800-538-8833 | Toll Free: 1-800-538-8833 | TTY: 1-800-526-0844

Toc - Plan #58 Blue Cross and Blue Shield of Illinois

Gold

(HMO) Blue Precision Gold HMO? 207

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$750 $2,250 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

$430.52
$488.64
$550.20
$768.91
$1,168.43

$759.87
$817.99
$879.55
$1,098.26

$1,089.22
$1,147.34
$1,208.90
$1,427.61

$1,418.57
$1,476.69
$1,538.25
$1,756.96

$329.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$861.04
$977.28
$1,100.40
$1,537.82
$2,336.86

$1,190.39
$1,306.63
$1,429.75
$1,867.17

$1,519.74
$1,635.98
$1,759.10
$2,196.52

$1,849.09
$1,965.33
$2,088.45
$2,525.87

$329.35

Toc - Plan #59 Blue Cross and Blue Shield of Illinois

Silver

(HMO) Blue Precision Silver HMO? 206

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$4,600 $13,800 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

$353.69
$401.43
$452.01
$631.68
$959.91

$624.26
$672.00
$722.58
$902.25

$894.83
$942.57
$993.15
$1,172.82

$1,165.40
$1,213.14
$1,263.72
$1,443.39

$270.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.38
$802.86
$904.02
$1,263.36
$1,919.82

$977.95
$1,073.43
$1,174.59
$1,533.93

$1,248.52
$1,344.00
$1,445.16
$1,804.50

$1,519.09
$1,614.57
$1,715.73
$2,075.07

$270.57

Toc - Plan #60 Blue Cross and Blue Shield of Illinois

Expanded Bronze

(HMO) Blue Precision Bronze HMO? 205

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$7,400 $17,400 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

$307.86
$349.42
$393.44
$549.83
$835.52

$543.37
$584.93
$628.95
$785.34

$778.88
$820.44
$864.46
$1,020.85

$1,014.39
$1,055.95
$1,099.97
$1,256.36

$235.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$615.72
$698.84
$786.88
$1,099.66
$1,671.04

$851.23
$934.35
$1,022.39
$1,335.17

$1,086.74
$1,169.86
$1,257.90
$1,570.68

$1,322.25
$1,405.37
$1,493.41
$1,806.19

$235.51

Toc - Plan #61 Blue Cross and Blue Shield of Illinois

Gold

(HMO) Blue Precision Gold HMO? 703 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$950 $2,850 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

$459.19
$521.18
$586.84
$820.11
$1,246.23

$810.47
$872.46
$938.12
$1,171.39

$1,161.75
$1,223.74
$1,289.40
$1,522.67

$1,513.03
$1,575.02
$1,640.68
$1,873.95

$351.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$918.38
$1,042.36
$1,173.68
$1,640.22
$2,492.46

$1,269.66
$1,393.64
$1,524.96
$1,991.50

$1,620.94
$1,744.92
$1,876.24
$2,342.78

$1,972.22
$2,096.20
$2,227.52
$2,694.06

$351.28

Toc - Plan #62 Blue Cross and Blue Shield of Illinois

Silver

(HMO) Blue Precision Silver HMO 704? - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$386.49
$438.66
$493.93
$690.26
$1,048.92

$682.15
$734.32
$789.59
$985.92

$977.81
$1,029.98
$1,085.25
$1,281.58

$1,273.47
$1,325.64
$1,380.91
$1,577.24

$295.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$772.98
$877.32
$987.86
$1,380.52
$2,097.84

$1,068.64
$1,172.98
$1,283.52
$1,676.18

$1,364.30
$1,468.64
$1,579.18
$1,971.84

$1,659.96
$1,764.30
$1,874.84
$2,267.50

$295.66

Toc - Plan #63 Blue Cross and Blue Shield of Illinois

Expanded Bronze

(HMO) Blue Precision Bronze HMO? 701 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$303.01
$343.92
$387.25
$541.18
$822.37

$534.81
$575.72
$619.05
$772.98

$766.61
$807.52
$850.85
$1,004.78

$998.41
$1,039.32
$1,082.65
$1,236.58

$231.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$606.02
$687.84
$774.50
$1,082.36
$1,644.74

$837.82
$919.64
$1,006.30
$1,314.16

$1,069.62
$1,151.44
$1,238.10
$1,545.96

$1,301.42
$1,383.24
$1,469.90
$1,777.76

$231.80

Toc - Plan #64 Blue Cross and Blue Shield of Illinois

Gold

(HMO) Blue Precision Gold HMO? 707

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$464.67
$527.40
$593.84
$829.89
$1,261.10

$820.14
$882.87
$949.31
$1,185.36

$1,175.61
$1,238.34
$1,304.78
$1,540.83

$1,531.08
$1,593.81
$1,660.25
$1,896.30

$355.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$929.34
$1,054.80
$1,187.68
$1,659.78
$2,522.20

$1,284.81
$1,410.27
$1,543.15
$2,015.25

$1,640.28
$1,765.74
$1,898.62
$2,370.72

$1,995.75
$2,121.21
$2,254.09
$2,726.19

$355.47

Toc - Plan #65 Blue Cross and Blue Shield of Illinois

Silver

(HMO) Blue Precision Silver HMO? 706

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$423.41
$480.57
$541.11
$756.20
$1,149.12

$747.32
$804.48
$865.02
$1,080.11

$1,071.23
$1,128.39
$1,188.93
$1,404.02

$1,395.14
$1,452.30
$1,512.84
$1,727.93

$323.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$846.82
$961.14
$1,082.22
$1,512.40
$2,298.24

$1,170.73
$1,285.05
$1,406.13
$1,836.31

$1,494.64
$1,608.96
$1,730.04
$2,160.22

$1,818.55
$1,932.87
$2,053.95
$2,484.13

$323.91

Toc - Plan #66 Blue Cross and Blue Shield of Illinois

Expanded Bronze

(HMO) Blue Precision Bronze HMO? 708

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$358.66
$407.08
$458.36
$640.56
$973.40

$633.03
$681.45
$732.73
$914.93

$907.40
$955.82
$1,007.10
$1,189.30

$1,181.77
$1,230.19
$1,281.47
$1,463.67

$274.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$717.32
$814.16
$916.72
$1,281.12
$1,946.80

$991.69
$1,088.53
$1,191.09
$1,555.49

$1,266.06
$1,362.90
$1,465.46
$1,829.86

$1,540.43
$1,637.27
$1,739.83
$2,104.23

$274.37

Toc - Plan #67 Blue Cross and Blue Shield of Illinois

Silver

(HMO) BlueCare Direct Silver? 212 with Advocate

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$4,600 $13,800 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

$337.06
$382.57
$430.77
$601.99
$914.79

$594.91
$640.42
$688.62
$859.84

$852.76
$898.27
$946.47
$1,117.69

$1,110.61
$1,156.12
$1,204.32
$1,375.54

$257.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$674.12
$765.14
$861.54
$1,203.98
$1,829.58

$931.97
$1,022.99
$1,119.39
$1,461.83

$1,189.82
$1,280.84
$1,377.24
$1,719.68

$1,447.67
$1,538.69
$1,635.09
$1,977.53

$257.85

Toc - Plan #68 Blue Cross and Blue Shield of Illinois

Gold

(HMO) BlueCare Direct Gold? 409 with Advocate

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$750 $2,250 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

$405.86
$460.65
$518.69
$724.86
$1,101.50

$716.34
$771.13
$829.17
$1,035.34

$1,026.82
$1,081.61
$1,139.65
$1,345.82

$1,337.30
$1,392.09
$1,450.13
$1,656.30

$310.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.72
$921.30
$1,037.38
$1,449.72
$2,203.00

$1,122.20
$1,231.78
$1,347.86
$1,760.20

$1,432.68
$1,542.26
$1,658.34
$2,070.68

$1,743.16
$1,852.74
$1,968.82
$2,381.16

$310.48

Toc - Plan #69 Blue Cross and Blue Shield of Illinois

Expanded Bronze

(HMO) BlueCare Direct Bronze? 401 with Advocate

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$7,400 $17,400 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

$289.07
$328.10
$369.44
$516.29
$784.55

$510.21
$549.24
$590.58
$737.43

$731.35
$770.38
$811.72
$958.57

$952.49
$991.52
$1,032.86
$1,179.71

$221.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.14
$656.20
$738.88
$1,032.58
$1,569.10

$799.28
$877.34
$960.02
$1,253.72

$1,020.42
$1,098.48
$1,181.16
$1,474.86

$1,241.56
$1,319.62
$1,402.30
$1,696.00

$221.14

Toc - Plan #70 Blue Cross and Blue Shield of Illinois

Gold

(PPO) Blue Choice Preferred Gold PPO? 204

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$750 $2,250 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

$529.09
$600.51
$676.17
$944.95
$1,435.94

$933.84
$1,005.26
$1,080.92
$1,349.70

$1,338.59
$1,410.01
$1,485.67
$1,754.45

$1,743.34
$1,814.76
$1,890.42
$2,159.20

$404.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,058.18
$1,201.02
$1,352.34
$1,889.90
$2,871.88

$1,462.93
$1,605.77
$1,757.09
$2,294.65

$1,867.68
$2,010.52
$2,161.84
$2,699.40

$2,272.43
$2,415.27
$2,566.59
$3,104.15

$404.75

Toc - Plan #71 Blue Cross and Blue Shield of Illinois

Silver

(PPO) Blue Choice Preferred Silver PPO? 203

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$2,250 $6,750 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

$440.33
$499.77
$562.74
$786.42
$1,195.05

$777.18
$836.62
$899.59
$1,123.27

$1,114.03
$1,173.47
$1,236.44
$1,460.12

$1,450.88
$1,510.32
$1,573.29
$1,796.97

$336.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$880.66
$999.54
$1,125.48
$1,572.84
$2,390.10

$1,217.51
$1,336.39
$1,462.33
$1,909.69

$1,554.36
$1,673.24
$1,799.18
$2,246.54

$1,891.21
$2,010.09
$2,136.03
$2,583.39

$336.85

Toc - Plan #72 Blue Cross and Blue Shield of Illinois

Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 202

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$4,500 $13,500 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$385.10
$437.09
$492.16
$687.80
$1,045.17

$679.70
$731.69
$786.76
$982.40

$974.30
$1,026.29
$1,081.36
$1,277.00

$1,268.90
$1,320.89
$1,375.96
$1,571.60

$294.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$770.20
$874.18
$984.32
$1,375.60
$2,090.34

$1,064.80
$1,168.78
$1,278.92
$1,670.20

$1,359.40
$1,463.38
$1,573.52
$1,964.80

$1,654.00
$1,757.98
$1,868.12
$2,259.40

$294.60

Toc - Plan #73 Blue Cross and Blue Shield of Illinois

Catastrophic

(PPO) Blue Choice Preferred Security PPO? 200

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$315.84
$358.48
$403.65
$564.10
$857.20

$557.46
$600.10
$645.27
$805.72

$799.08
$841.72
$886.89
$1,047.34

$1,040.70
$1,083.34
$1,128.51
$1,288.96

$241.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$631.68
$716.96
$807.30
$1,128.20
$1,714.40

$873.30
$958.58
$1,048.92
$1,369.82

$1,114.92
$1,200.20
$1,290.54
$1,611.44

$1,356.54
$1,441.82
$1,532.16
$1,853.06

$241.62

Toc - Plan #74 Blue Cross and Blue Shield of Illinois

Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 201

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$7,000 $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

$345.64
$392.30
$441.72
$617.31
$938.06

$610.05
$656.71
$706.13
$881.72

$874.46
$921.12
$970.54
$1,146.13

$1,138.87
$1,185.53
$1,234.95
$1,410.54

$264.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$691.28
$784.60
$883.44
$1,234.62
$1,876.12

$955.69
$1,049.01
$1,147.85
$1,499.03

$1,220.10
$1,313.42
$1,412.26
$1,763.44

$1,484.51
$1,577.83
$1,676.67
$2,027.85

$264.41

Toc - Plan #75 Blue Cross and Blue Shield of Illinois

Bronze

(PPO) Blue Choice Preferred Bronze PPO? 601

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$7,000 $17,400 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

$338.11
$383.76
$432.11
$603.87
$917.64

$596.77
$642.42
$690.77
$862.53

$855.43
$901.08
$949.43
$1,121.19

$1,114.09
$1,159.74
$1,208.09
$1,379.85

$258.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$676.22
$767.52
$864.22
$1,207.74
$1,835.28

$934.88
$1,026.18
$1,122.88
$1,466.40

$1,193.54
$1,284.84
$1,381.54
$1,725.06

$1,452.20
$1,543.50
$1,640.20
$1,983.72

$258.66

Toc - Plan #76 Blue Cross and Blue Shield of Illinois

Bronze

(PPO) Blue Choice Preferred Bronze PPO? 701

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,400 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

$317.42
$360.28
$405.67
$566.92
$861.49

$560.25
$603.11
$648.50
$809.75

$803.08
$845.94
$891.33
$1,052.58

$1,045.91
$1,088.77
$1,134.16
$1,295.41

$242.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$634.84
$720.56
$811.34
$1,133.84
$1,722.98

$877.67
$963.39
$1,054.17
$1,376.67

$1,120.50
$1,206.22
$1,297.00
$1,619.50

$1,363.33
$1,449.05
$1,539.83
$1,862.33

$242.83

Toc - Plan #77 Blue Cross and Blue Shield of Illinois

Gold

(PPO) Blue Choice Preferred Gold PPO? 707

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$516.38
$586.10
$659.94
$922.26
$1,401.47

$911.41
$981.13
$1,054.97
$1,317.29

$1,306.44
$1,376.16
$1,450.00
$1,712.32

$1,701.47
$1,771.19
$1,845.03
$2,107.35

$395.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,032.76
$1,172.20
$1,319.88
$1,844.52
$2,802.94

$1,427.79
$1,567.23
$1,714.91
$2,239.55

$1,822.82
$1,962.26
$2,109.94
$2,634.58

$2,217.85
$2,357.29
$2,504.97
$3,029.61

$395.03

Toc - Plan #78 Blue Cross and Blue Shield of Illinois

Silver

(PPO) Blue Choice Preferred Silver PPO? 706

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$446.55
$506.84
$570.69
$797.54
$1,211.94

$788.16
$848.45
$912.30
$1,139.15

$1,129.77
$1,190.06
$1,253.91
$1,480.76

$1,471.38
$1,531.67
$1,595.52
$1,822.37

$341.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$893.10
$1,013.68
$1,141.38
$1,595.08
$2,423.88

$1,234.71
$1,355.29
$1,482.99
$1,936.69

$1,576.32
$1,696.90
$1,824.60
$2,278.30

$1,917.93
$2,038.51
$2,166.21
$2,619.91

$341.61

Toc - Plan #79 Blue Cross and Blue Shield of Illinois

Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 708

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$391.95
$444.87
$500.92
$700.03
$1,063.76

$691.79
$744.71
$800.76
$999.87

$991.63
$1,044.55
$1,100.60
$1,299.71

$1,291.47
$1,344.39
$1,400.44
$1,599.55

$299.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$783.90
$889.74
$1,001.84
$1,400.06
$2,127.52

$1,083.74
$1,189.58
$1,301.68
$1,699.90

$1,383.58
$1,489.42
$1,601.52
$1,999.74

$1,683.42
$1,789.26
$1,901.36
$2,299.58

$299.84

Toc - Plan #80 Blue Cross and Blue Shield of Illinois

Bronze

(PPO) Blue Choice Preferred Bronze PPO? 705

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-538-8833

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

$330.73
$375.38
$422.67
$590.68
$897.60

$583.74
$628.39
$675.68
$843.69

$836.75
$881.40
$928.69
$1,096.70

$1,089.76
$1,134.41
$1,181.70
$1,349.71

$253.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.46
$750.76
$845.34
$1,181.36
$1,795.20

$914.47
$1,003.77
$1,098.35
$1,434.37

$1,167.48
$1,256.78
$1,351.36
$1,687.38

$1,420.49
$1,509.79
$1,604.37
$1,940.39

$253.01

UnitedHealthcare

Local: 1-888-200-0325 | Toll Free: 1-888-200-0325 | TTY: 1-888-200-0325

Toc - Plan #81 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited App-based Care, Preferred Rx) (Disponible en espa�ol)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family

$7,250 $14,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$295.63
$335.54
$377.82
$528.00
$802.35

$521.79
$561.70
$603.98
$754.16

$747.95
$787.86
$830.14
$980.32

$974.11
$1,014.02
$1,056.30
$1,206.48

$226.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$591.26
$671.08
$755.64
$1,056.00
$1,604.70

$817.42
$897.24
$981.80
$1,282.16

$1,043.58
$1,123.40
$1,207.96
$1,508.32

$1,269.74
$1,349.56
$1,434.12
$1,734.48

$226.16

Toc - Plan #82 UnitedHealthcare

Silver

(HMO) UHC Silver Value 1 (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family

$3,450 $6,900 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$357.72
$406.01
$457.17
$638.89
$970.86

$631.38
$679.67
$730.83
$912.55

$905.04
$953.33
$1,004.49
$1,186.21

$1,178.70
$1,226.99
$1,278.15
$1,459.87

$273.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.44
$812.02
$914.34
$1,277.78
$1,941.72

$989.10
$1,085.68
$1,188.00
$1,551.44

$1,262.76
$1,359.34
$1,461.66
$1,825.10

$1,536.42
$1,633.00
$1,735.32
$2,098.76

$273.66

Toc - Plan #83 UnitedHealthcare

Silver

(HMO) UHC Silver Virtual First (Unlimited App-based Care, Preferred Rx) (Disponible en espa�ol)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family

$4,100 $8,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$352.43
$400.01
$450.41
$629.45
$956.51

$622.04
$669.62
$720.02
$899.06

$891.65
$939.23
$989.63
$1,168.67

$1,161.26
$1,208.84
$1,259.24
$1,438.28

$269.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$704.86
$800.02
$900.82
$1,258.90
$1,913.02

$974.47
$1,069.63
$1,170.43
$1,528.51

$1,244.08
$1,339.24
$1,440.04
$1,798.12

$1,513.69
$1,608.85
$1,709.65
$2,067.73

$269.61

Toc - Plan #84 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$418.11
$474.56
$534.35
$746.75
$1,134.76

$737.97
$794.42
$854.21
$1,066.61

$1,057.83
$1,114.28
$1,174.07
$1,386.47

$1,377.69
$1,434.14
$1,493.93
$1,706.33

$319.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$836.22
$949.12
$1,068.70
$1,493.50
$2,269.52

$1,156.08
$1,268.98
$1,388.56
$1,813.36

$1,475.94
$1,588.84
$1,708.42
$2,133.22

$1,795.80
$1,908.70
$2,028.28
$2,453.08

$319.86

Toc - Plan #85 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family

$1,200 $2,400 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

$437.57
$496.64
$559.21
$781.50
$1,187.56

$772.31
$831.38
$893.95
$1,116.24

$1,107.05
$1,166.12
$1,228.69
$1,450.98

$1,441.79
$1,500.86
$1,563.43
$1,785.72

$334.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$875.14
$993.28
$1,118.42
$1,563.00
$2,375.12

$1,209.88
$1,328.02
$1,453.16
$1,897.74

$1,544.62
$1,662.76
$1,787.90
$2,232.48

$1,879.36
$1,997.50
$2,122.64
$2,567.22

$334.74

Toc - Plan #86 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family

$1,200 $2,400 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

$457.14
$518.86
$584.23
$816.46
$1,240.68

$806.85
$868.57
$933.94
$1,166.17

$1,156.56
$1,218.28
$1,283.65
$1,515.88

$1,506.27
$1,567.99
$1,633.36
$1,865.59

$349.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$914.28
$1,037.72
$1,168.46
$1,632.92
$2,481.36

$1,263.99
$1,387.43
$1,518.17
$1,982.63

$1,613.70
$1,737.14
$1,867.88
$2,332.34

$1,963.41
$2,086.85
$2,217.59
$2,682.05

$349.71

Toc - Plan #87 UnitedHealthcare

Gold

(HMO) UHC Gold Standard (Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$425.33
$482.75
$543.57
$759.64
$1,154.35

$750.71
$808.13
$868.95
$1,085.02

$1,076.09
$1,133.51
$1,194.33
$1,410.40

$1,401.47
$1,458.89
$1,519.71
$1,735.78

$325.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$850.66
$965.50
$1,087.14
$1,519.28
$2,308.70

$1,176.04
$1,290.88
$1,412.52
$1,844.66

$1,501.42
$1,616.26
$1,737.90
$2,170.04

$1,826.80
$1,941.64
$2,063.28
$2,495.42

$325.38

Toc - Plan #88 UnitedHealthcare

Silver

(HMO) UHC Silver Advantage 1 (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$364.34
$413.53
$465.63
$650.72
$988.83

$643.06
$692.25
$744.35
$929.44

$921.78
$970.97
$1,023.07
$1,208.16

$1,200.50
$1,249.69
$1,301.79
$1,486.88

$278.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$728.68
$827.06
$931.26
$1,301.44
$1,977.66

$1,007.40
$1,105.78
$1,209.98
$1,580.16

$1,286.12
$1,384.50
$1,488.70
$1,858.88

$1,564.84
$1,663.22
$1,767.42
$2,137.60

$278.72

Toc - Plan #89 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$373.68
$424.13
$477.56
$667.39
$1,014.17

$659.55
$710.00
$763.43
$953.26

$945.42
$995.87
$1,049.30
$1,239.13

$1,231.29
$1,281.74
$1,335.17
$1,525.00

$285.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$747.36
$848.26
$955.12
$1,334.78
$2,028.34

$1,033.23
$1,134.13
$1,240.99
$1,620.65

$1,319.10
$1,420.00
$1,526.86
$1,906.52

$1,604.97
$1,705.87
$1,812.73
$2,192.39

$285.87

Toc - Plan #90 UnitedHealthcare

Silver

(HMO) UHC Silver Value (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$355.91
$403.96
$454.85
$635.65
$965.94

$628.18
$676.23
$727.12
$907.92

$900.45
$948.50
$999.39
$1,180.19

$1,172.72
$1,220.77
$1,271.66
$1,452.46

$272.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$711.82
$807.92
$909.70
$1,271.30
$1,931.88

$984.09
$1,080.19
$1,181.97
$1,543.57

$1,256.36
$1,352.46
$1,454.24
$1,815.84

$1,528.63
$1,624.73
$1,726.51
$2,088.11

$272.27

Toc - Plan #91 UnitedHealthcare

Silver

(HMO) UHC Silver Advantage (Unlimited Virtual Urgent Care + Primary Care Visits, Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$359.59
$408.13
$459.55
$642.22
$975.92

$634.67
$683.21
$734.63
$917.30

$909.75
$958.29
$1,009.71
$1,192.38

$1,184.83
$1,233.37
$1,284.79
$1,467.46

$275.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$719.18
$816.26
$919.10
$1,284.44
$1,951.84

$994.26
$1,091.34
$1,194.18
$1,559.52

$1,269.34
$1,366.42
$1,469.26
$1,834.60

$1,544.42
$1,641.50
$1,744.34
$2,109.68

$275.08

Toc - Plan #92 UnitedHealthcare

Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$360.14
$408.75
$460.25
$643.20
$977.41

$635.64
$684.25
$735.75
$918.70

$911.14
$959.75
$1,011.25
$1,194.20

$1,186.64
$1,235.25
$1,286.75
$1,469.70

$275.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$720.28
$817.50
$920.50
$1,286.40
$1,954.82

$995.78
$1,093.00
$1,196.00
$1,561.90

$1,271.28
$1,368.50
$1,471.50
$1,837.40

$1,546.78
$1,644.00
$1,747.00
$2,112.90

$275.50

Toc - Plan #93 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Value (Unlimited Virtual Urgent Care + Primary Care Visits, Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$306.85
$348.28
$392.16
$548.04
$832.80

$541.59
$583.02
$626.90
$782.78

$776.33
$817.76
$861.64
$1,017.52

$1,011.07
$1,052.50
$1,096.38
$1,252.26

$234.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$613.70
$696.56
$784.32
$1,096.08
$1,665.60

$848.44
$931.30
$1,019.06
$1,330.82

$1,083.18
$1,166.04
$1,253.80
$1,565.56

$1,317.92
$1,400.78
$1,488.54
$1,800.30

$234.74

Toc - Plan #94 UnitedHealthcare

Bronze

(HMO) UHC Bronze Essential (Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$294.36
$334.09
$376.19
$525.72
$798.88

$519.54
$559.27
$601.37
$750.90

$744.72
$784.45
$826.55
$976.08

$969.90
$1,009.63
$1,051.73
$1,201.26

$225.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$588.72
$668.18
$752.38
$1,051.44
$1,597.76

$813.90
$893.36
$977.56
$1,276.62

$1,039.08
$1,118.54
$1,202.74
$1,501.80

$1,264.26
$1,343.72
$1,427.92
$1,726.98

$225.18

Toc - Plan #95 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Value HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$303.68
$344.68
$388.10
$542.37
$824.19

$536.00
$577.00
$620.42
$774.69

$768.32
$809.32
$852.74
$1,007.01

$1,000.64
$1,041.64
$1,085.06
$1,239.33

$232.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$607.36
$689.36
$776.20
$1,084.74
$1,648.38

$839.68
$921.68
$1,008.52
$1,317.06

$1,072.00
$1,154.00
$1,240.84
$1,549.38

$1,304.32
$1,386.32
$1,473.16
$1,781.70

$232.32

Toc - Plan #96 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Standard 1

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$304.85
$346.00
$389.59
$544.45
$827.35

$538.06
$579.21
$622.80
$777.66

$771.27
$812.42
$856.01
$1,010.87

$1,004.48
$1,045.63
$1,089.22
$1,244.08

$233.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$609.70
$692.00
$779.18
$1,088.90
$1,654.70

$842.91
$925.21
$1,012.39
$1,322.11

$1,076.12
$1,158.42
$1,245.60
$1,555.32

$1,309.33
$1,391.63
$1,478.81
$1,788.53

$233.21

Toc - Plan #97 UnitedHealthcare

Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-888-200-0325

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

$285.81
$324.39
$365.26
$510.45
$775.68

$504.45
$543.03
$583.90
$729.09

$723.09
$761.67
$802.54
$947.73

$941.73
$980.31
$1,021.18
$1,166.37

$218.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$571.62
$648.78
$730.52
$1,020.90
$1,551.36

$790.26
$867.42
$949.16
$1,239.54

$1,008.90
$1,086.06
$1,167.80
$1,458.18

$1,227.54
$1,304.70
$1,386.44
$1,676.82

$218.64

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #98 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Connect 5000 Rx Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$293.88
$333.56
$375.58
$524.88
$797.60

$518.70
$558.38
$600.40
$749.70

$743.52
$783.20
$825.22
$974.52

$968.34
$1,008.02
$1,050.04
$1,199.34

$224.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$587.76
$667.12
$751.16
$1,049.76
$1,595.20

$812.58
$891.94
$975.98
$1,274.58

$1,037.40
$1,116.76
$1,200.80
$1,499.40

$1,262.22
$1,341.58
$1,425.62
$1,724.22

$224.82

Toc - Plan #99 Cigna Healthcare

Silver

(HMO) Cigna Connect 3000 Rx Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$335.25
$380.51
$428.45
$598.76
$909.87

$591.72
$636.98
$684.92
$855.23

$848.19
$893.45
$941.39
$1,111.70

$1,104.66
$1,149.92
$1,197.86
$1,368.17

$256.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$670.50
$761.02
$856.90
$1,197.52
$1,819.74

$926.97
$1,017.49
$1,113.37
$1,453.99

$1,183.44
$1,273.96
$1,369.84
$1,710.46

$1,439.91
$1,530.43
$1,626.31
$1,966.93

$256.47

Toc - Plan #100 Cigna Healthcare

Gold

(HMO) Cigna Connect 1000 Rx Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 Annual Deductible

$8,150 $16,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$398.94
$452.80
$509.84
$712.51
$1,082.72

$704.13
$757.99
$815.03
$1,017.70

$1,009.32
$1,063.18
$1,120.22
$1,322.89

$1,314.51
$1,368.37
$1,425.41
$1,628.08

$305.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$797.88
$905.60
$1,019.68
$1,425.02
$2,165.44

$1,103.07
$1,210.79
$1,324.87
$1,730.21

$1,408.26
$1,515.98
$1,630.06
$2,035.40

$1,713.45
$1,821.17
$1,935.25
$2,340.59

$305.19

Toc - Plan #101 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

$313.21
$355.49
$400.28
$559.39
$850.05

$552.82
$595.10
$639.89
$799.00

$792.43
$834.71
$879.50
$1,038.61

$1,032.04
$1,074.32
$1,119.11
$1,278.22

$239.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$626.42
$710.98
$800.56
$1,118.78
$1,700.10

$866.03
$950.59
$1,040.17
$1,358.39

$1,105.64
$1,190.20
$1,279.78
$1,598.00

$1,345.25
$1,429.81
$1,519.39
$1,837.61

$239.61

Toc - Plan #102 Cigna Healthcare

Silver

(HMO) Cigna Connect 6000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$337.85
$383.46
$431.77
$603.39
$916.92

$596.30
$641.91
$690.22
$861.84

$854.75
$900.36
$948.67
$1,120.29

$1,113.20
$1,158.81
$1,207.12
$1,378.74

$258.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.70
$766.92
$863.54
$1,206.78
$1,833.84

$934.15
$1,025.37
$1,121.99
$1,465.23

$1,192.60
$1,283.82
$1,380.44
$1,723.68

$1,451.05
$1,542.27
$1,638.89
$1,982.13

$258.45

Toc - Plan #103 Cigna Healthcare

Silver

(HMO) Cigna Connect 8000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$340.96
$386.99
$435.75
$608.96
$925.37

$601.80
$647.83
$696.59
$869.80

$862.64
$908.67
$957.43
$1,130.64

$1,123.48
$1,169.51
$1,218.27
$1,391.48

$260.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$681.92
$773.98
$871.50
$1,217.92
$1,850.74

$942.76
$1,034.82
$1,132.34
$1,478.76

$1,203.60
$1,295.66
$1,393.18
$1,739.60

$1,464.44
$1,556.50
$1,654.02
$2,000.44

$260.84

Toc - Plan #104 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

$341.52
$387.63
$436.46
$609.95
$926.89

$602.78
$648.89
$697.72
$871.21

$864.04
$910.15
$958.98
$1,132.47

$1,125.30
$1,171.41
$1,220.24
$1,393.73

$261.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$683.04
$775.26
$872.92
$1,219.90
$1,853.78

$944.30
$1,036.52
$1,134.18
$1,481.16

$1,205.56
$1,297.78
$1,395.44
$1,742.42

$1,466.82
$1,559.04
$1,656.70
$2,003.68

$261.26

Toc - Plan #105 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine 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

$360.82
$409.53
$461.13
$644.43
$979.28

$636.85
$685.56
$737.16
$920.46

$912.88
$961.59
$1,013.19
$1,196.49

$1,188.91
$1,237.62
$1,289.22
$1,472.52

$276.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$721.64
$819.06
$922.26
$1,288.86
$1,958.56

$997.67
$1,095.09
$1,198.29
$1,564.89

$1,273.70
$1,371.12
$1,474.32
$1,840.92

$1,549.73
$1,647.15
$1,750.35
$2,116.95

$276.03

Toc - Plan #106 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine 5000 Rx Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$338.56
$384.27
$432.68
$604.67
$918.85

$597.56
$643.27
$691.68
$863.67

$856.56
$902.27
$950.68
$1,122.67

$1,115.56
$1,161.27
$1,209.68
$1,381.67

$259.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$677.12
$768.54
$865.36
$1,209.34
$1,837.70

$936.12
$1,027.54
$1,124.36
$1,468.34

$1,195.12
$1,286.54
$1,383.36
$1,727.34

$1,454.12
$1,545.54
$1,642.36
$1,986.34

$259.00

Toc - Plan #107 Cigna Healthcare

Silver

(HMO) Cigna Plus with Northwestern Medicine 6000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387.27
$439.56
$494.94
$691.67
$1,051.06

$683.53
$735.82
$791.20
$987.93

$979.79
$1,032.08
$1,087.46
$1,284.19

$1,276.05
$1,328.34
$1,383.72
$1,580.45

$296.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$774.54
$879.12
$989.88
$1,383.34
$2,102.12

$1,070.80
$1,175.38
$1,286.14
$1,679.60

$1,367.06
$1,471.64
$1,582.40
$1,975.86

$1,663.32
$1,767.90
$1,878.66
$2,272.12

$296.26

Toc - Plan #108 Cigna Healthcare

Silver

(HMO) Cigna Plus with Northwestern Medicine 3000 Rx Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

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

$384.05
$435.90
$490.82
$685.92
$1,042.32

$677.85
$729.70
$784.62
$979.72

$971.65
$1,023.50
$1,078.42
$1,273.52

$1,265.45
$1,317.30
$1,372.22
$1,567.32

$293.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$768.10
$871.80
$981.64
$1,371.84
$2,084.64

$1,061.90
$1,165.60
$1,275.44
$1,665.64

$1,355.70
$1,459.40
$1,569.24
$1,959.44

$1,649.50
$1,753.20
$1,863.04
$2,253.24

$293.80

Toc - Plan #109 Cigna Healthcare

Silver

(HMO) Cigna Plus with Northwestern Medicine 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

$391.46
$444.31
$500.29
$699.15
$1,062.42

$690.93
$743.78
$799.76
$998.62

$990.40
$1,043.25
$1,099.23
$1,298.09

$1,289.87
$1,342.72
$1,398.70
$1,597.56

$299.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$782.92
$888.62
$1,000.58
$1,398.30
$2,124.84

$1,082.39
$1,188.09
$1,300.05
$1,697.77

$1,381.86
$1,487.56
$1,599.52
$1,997.24

$1,681.33
$1,787.03
$1,898.99
$2,296.71

$299.47

Toc - Plan #110 Cigna Healthcare

Gold

(HMO) Cigna Plus with Northwestern Medicine 750 Rx Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$750 $1,500 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

$470.53
$534.06
$601.34
$840.37
$1,277.03

$830.49
$894.02
$961.30
$1,200.33

$1,190.45
$1,253.98
$1,321.26
$1,560.29

$1,550.41
$1,613.94
$1,681.22
$1,920.25

$359.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$941.06
$1,068.12
$1,202.68
$1,680.74
$2,554.06

$1,301.02
$1,428.08
$1,562.64
$2,040.70

$1,660.98
$1,788.04
$1,922.60
$2,400.66

$2,020.94
$2,148.00
$2,282.56
$2,760.62

$359.96

Toc - Plan #111 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

$290.45
$329.66
$371.19
$518.74
$788.28

$512.64
$551.85
$593.38
$740.93

$734.83
$774.04
$815.57
$963.12

$957.02
$996.23
$1,037.76
$1,185.31

$222.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$580.90
$659.32
$742.38
$1,037.48
$1,576.56

$803.09
$881.51
$964.57
$1,259.67

$1,025.28
$1,103.70
$1,186.76
$1,481.86

$1,247.47
$1,325.89
$1,408.95
$1,704.05

$222.19

Toc - Plan #112 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

$289.13
$328.16
$369.51
$516.39
$784.70

$510.32
$549.35
$590.70
$737.58

$731.51
$770.54
$811.89
$958.77

$952.70
$991.73
$1,033.08
$1,179.96

$221.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.26
$656.32
$739.02
$1,032.78
$1,569.40

$799.45
$877.51
$960.21
$1,253.97

$1,020.64
$1,098.70
$1,181.40
$1,475.16

$1,241.83
$1,319.89
$1,402.59
$1,696.35

$221.19

Toc - Plan #113 Cigna Healthcare

Silver

(HMO) Cigna Connect 0B

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$339.16
$384.95
$433.45
$605.75
$920.49

$598.62
$644.41
$692.91
$865.21

$858.08
$903.87
$952.37
$1,124.67

$1,117.54
$1,163.33
$1,211.83
$1,384.13

$259.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$678.32
$769.90
$866.90
$1,211.50
$1,840.98

$937.78
$1,029.36
$1,126.36
$1,470.96

$1,197.24
$1,288.82
$1,385.82
$1,730.42

$1,456.70
$1,548.28
$1,645.28
$1,989.88

$259.46

Toc - Plan #114 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

$340.16
$386.08
$434.73
$607.53
$923.20

$600.38
$646.30
$694.95
$867.75

$860.60
$906.52
$955.17
$1,127.97

$1,120.82
$1,166.74
$1,215.39
$1,388.19

$260.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$680.32
$772.16
$869.46
$1,215.06
$1,846.40

$940.54
$1,032.38
$1,129.68
$1,475.28

$1,200.76
$1,292.60
$1,389.90
$1,735.50

$1,460.98
$1,552.82
$1,650.12
$1,995.72

$260.22

Toc - Plan #115 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine 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

$334.60
$379.78
$427.62
$597.60
$908.11

$590.57
$635.75
$683.59
$853.57

$846.54
$891.72
$939.56
$1,109.54

$1,102.51
$1,147.69
$1,195.53
$1,365.51

$255.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$669.20
$759.56
$855.24
$1,195.20
$1,816.22

$925.17
$1,015.53
$1,111.21
$1,451.17

$1,181.14
$1,271.50
$1,367.18
$1,707.14

$1,437.11
$1,527.47
$1,623.15
$1,963.11

$255.97

Toc - Plan #116 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine 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

$333.09
$378.05
$425.68
$594.89
$903.99

$587.90
$632.86
$680.49
$849.70

$842.71
$887.67
$935.30
$1,104.51

$1,097.52
$1,142.48
$1,190.11
$1,359.32

$254.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$666.18
$756.10
$851.36
$1,189.78
$1,807.98

$920.99
$1,010.91
$1,106.17
$1,444.59

$1,175.80
$1,265.72
$1,360.98
$1,699.40

$1,430.61
$1,520.53
$1,615.79
$1,954.21

$254.81

Toc - Plan #117 Cigna Healthcare

Silver

(HMO) Cigna Plus with Northwestern Medicine 8000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 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

$390.63
$443.37
$499.23
$697.67
$1,060.17

$689.46
$742.20
$798.06
$996.50

$988.29
$1,041.03
$1,096.89
$1,295.33

$1,287.12
$1,339.86
$1,395.72
$1,594.16

$298.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$781.26
$886.74
$998.46
$1,395.34
$2,120.34

$1,080.09
$1,185.57
$1,297.29
$1,694.17

$1,378.92
$1,484.40
$1,596.12
$1,993.00

$1,677.75
$1,783.23
$1,894.95
$2,291.83

$298.83

Toc - Plan #118 Cigna Healthcare

Silver

(HMO) Cigna Plus with Northwestern Medicine 0B

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$388.61
$441.07
$496.64
$694.05
$1,054.68

$685.89
$738.35
$793.92
$991.33

$983.17
$1,035.63
$1,091.20
$1,288.61

$1,280.45
$1,332.91
$1,388.48
$1,585.89

$297.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$777.22
$882.14
$993.28
$1,388.10
$2,109.36

$1,074.50
$1,179.42
$1,290.56
$1,685.38

$1,371.78
$1,476.70
$1,587.84
$1,982.66

$1,669.06
$1,773.98
$1,885.12
$2,279.94

$297.28

Toc - Plan #119 Cigna Healthcare

Silver

(HMO) Cigna Plus with Northwestern Medicine 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

$389.57
$442.17
$497.88
$695.78
$1,057.30

$687.59
$740.19
$795.90
$993.80

$985.61
$1,038.21
$1,093.92
$1,291.82

$1,283.63
$1,336.23
$1,391.94
$1,589.84

$298.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$779.14
$884.34
$995.76
$1,391.56
$2,114.60

$1,077.16
$1,182.36
$1,293.78
$1,689.58

$1,375.18
$1,480.38
$1,591.80
$1,987.60

$1,673.20
$1,778.40
$1,889.82
$2,285.62

$298.02

Toc - Plan #120 Cigna Healthcare

Gold

(HMO) Cigna Plus with Northwestern Medicine 1900 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$457.15
$518.86
$584.23
$816.47
$1,240.70

$806.87
$868.58
$933.95
$1,166.19

$1,156.59
$1,218.30
$1,283.67
$1,515.91

$1,506.31
$1,568.02
$1,633.39
$1,865.63

$349.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$914.30
$1,037.72
$1,168.46
$1,632.94
$2,481.40

$1,264.02
$1,387.44
$1,518.18
$1,982.66

$1,613.74
$1,737.16
$1,867.90
$2,332.38

$1,963.46
$2,086.88
$2,217.62
$2,682.10

$349.72

Toc - Plan #121 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

$276.19
$313.48
$352.98
$493.28
$749.59

$487.48
$524.77
$564.27
$704.57

$698.77
$736.06
$775.56
$915.86

$910.06
$947.35
$986.85
$1,127.15

$211.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$552.38
$626.96
$705.96
$986.56
$1,499.18

$763.67
$838.25
$917.25
$1,197.85

$974.96
$1,049.54
$1,128.54
$1,409.14

$1,186.25
$1,260.83
$1,339.83
$1,620.43

$211.29

Toc - Plan #122 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

$318.18
$361.14
$406.64
$568.27
$863.55

$561.59
$604.55
$650.05
$811.68

$805.00
$847.96
$893.46
$1,055.09

$1,048.41
$1,091.37
$1,136.87
$1,298.50

$243.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$636.36
$722.28
$813.28
$1,136.54
$1,727.10

$879.77
$965.69
$1,056.69
$1,379.95

$1,123.18
$1,209.10
$1,300.10
$1,623.36

$1,366.59
$1,452.51
$1,543.51
$1,866.77

$243.41

Toc - Plan #123 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

$286.98
$325.72
$366.76
$512.54
$778.85

$506.52
$545.26
$586.30
$732.08

$726.06
$764.80
$805.84
$951.62

$945.60
$984.34
$1,025.38
$1,171.16

$219.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$573.96
$651.44
$733.52
$1,025.08
$1,557.70

$793.50
$870.98
$953.06
$1,244.62

$1,013.04
$1,090.52
$1,172.60
$1,464.16

$1,232.58
$1,310.06
$1,392.14
$1,683.70

$219.54

Toc - Plan #124 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

$330.60
$375.23
$422.51
$590.45
$897.25

$583.51
$628.14
$675.42
$843.36

$836.42
$881.05
$928.33
$1,096.27

$1,089.33
$1,133.96
$1,181.24
$1,349.18

$252.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.20
$750.46
$845.02
$1,180.90
$1,794.50

$914.11
$1,003.37
$1,097.93
$1,433.81

$1,167.02
$1,256.28
$1,350.84
$1,686.72

$1,419.93
$1,509.19
$1,603.75
$1,939.63

$252.91

Toc - Plan #125 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

$334.25
$379.38
$427.18
$596.98
$907.16

$589.95
$635.08
$682.88
$852.68

$845.65
$890.78
$938.58
$1,108.38

$1,101.35
$1,146.48
$1,194.28
$1,364.08

$255.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$668.50
$758.76
$854.36
$1,193.96
$1,814.32

$924.20
$1,014.46
$1,110.06
$1,449.66

$1,179.90
$1,270.16
$1,365.76
$1,705.36

$1,435.60
$1,525.86
$1,621.46
$1,961.06

$255.70

Toc - Plan #126 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

$382.90
$434.60
$489.35
$683.87
$1,039.20

$675.82
$727.52
$782.27
$976.79

$968.74
$1,020.44
$1,075.19
$1,269.71

$1,261.66
$1,313.36
$1,368.11
$1,562.63

$292.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$765.80
$869.20
$978.70
$1,367.74
$2,078.40

$1,058.72
$1,162.12
$1,271.62
$1,660.66

$1,351.64
$1,455.04
$1,564.54
$1,953.58

$1,644.56
$1,747.96
$1,857.46
$2,246.50

$292.92

Toc - Plan #127 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

$391.87
$444.77
$500.81
$699.88
$1,063.54

$691.65
$744.55
$800.59
$999.66

$991.43
$1,044.33
$1,100.37
$1,299.44

$1,291.21
$1,344.11
$1,400.15
$1,599.22

$299.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$783.74
$889.54
$1,001.62
$1,399.76
$2,127.08

$1,083.52
$1,189.32
$1,301.40
$1,699.54

$1,383.30
$1,489.10
$1,601.18
$1,999.32

$1,683.08
$1,788.88
$1,900.96
$2,299.10

$299.78

Toc - Plan #128 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

$451.44
$512.39
$576.95
$806.28
$1,225.22

$796.79
$857.74
$922.30
$1,151.63

$1,142.14
$1,203.09
$1,267.65
$1,496.98

$1,487.49
$1,548.44
$1,613.00
$1,842.33

$345.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$902.88
$1,024.78
$1,153.90
$1,612.56
$2,450.44

$1,248.23
$1,370.13
$1,499.25
$1,957.91

$1,593.58
$1,715.48
$1,844.60
$2,303.26

$1,938.93
$2,060.83
$2,189.95
$2,648.61

$345.35

Toc - Plan #129 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,600 $15,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$288.89
$327.89
$369.20
$515.96
$784.05

$509.89
$548.89
$590.20
$736.96

$730.89
$769.89
$811.20
$957.96

$951.89
$990.89
$1,032.20
$1,178.96

$221.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$577.78
$655.78
$738.40
$1,031.92
$1,568.10

$798.78
$876.78
$959.40
$1,252.92

$1,019.78
$1,097.78
$1,180.40
$1,473.92

$1,240.78
$1,318.78
$1,401.40
$1,694.92

$221.00

Toc - Plan #130 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Plus with Northwestern Medicine 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,600 $15,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$332.81
$377.74
$425.33
$594.40
$903.25

$587.41
$632.34
$679.93
$849.00

$842.01
$886.94
$934.53
$1,103.60

$1,096.61
$1,141.54
$1,189.13
$1,358.20

$254.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$665.62
$755.48
$850.66
$1,188.80
$1,806.50

$920.22
$1,010.08
$1,105.26
$1,443.40

$1,174.82
$1,264.68
$1,359.86
$1,698.00

$1,429.42
$1,519.28
$1,614.46
$1,952.60

$254.60

‡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 DuPage County here.

DuPage County is in “Rating Area 3” of Illinois.

Currently, there are 130 plans offered in Rating Area 3.

Top

2023 Obamacare Plans for DuPage County, IL

Plan Browser: 130 Plans

Oscar Health Plan, Inc.

Local: | Toll Free:

1. Expanded Bronze Bronze Classic (Choice)

2. Expanded Bronze Bronze Elite- Deductible+PCP Saver Plus (Choice)

3. Silver Silver Classic (Choice)

4. Catastrophic Secure (Choice)

5. Expanded Bronze Bronze Simple- $5200 Ded (Choice)

6. Silver Silver Simple- Specialist Saver (Choice)

7. Expanded Bronze Bronze Classic- PCP Saver Plus Rx Copay (Choice)

8. Expanded Bronze Bronze Classic- Deductible Saver (Choice)

9. Silver Silver Simple- PCP Saver (Choice)

10. Silver Silver Elite- Deductible Saver Plus Rx Copay (Choice)

11. Silver Silver Simple- For Diabetes (Choice)

12. Expanded Bronze Bronze Classic- Standard (Choice)

13. Bronze Bronze Simple- Standard (Choice)

14. Silver Silver Classic- Standard (Choice)

15. Gold Gold Classic- Standard (Choice)

Ambetter of Illinois

Local: 1-855-745-5507 | Toll Free: 1-855-745-5507 | TTY: 1-844-517-3431

16. Silver Premier Silver

17. Gold Complete Gold

18. Silver Complete Silver

19. Expanded Bronze Everyday Bronze

20. Silver Everyday Silver

21. Silver Elite Silver

22. Expanded Bronze Choice Bronze HSA

23. Expanded Bronze Elite Bronze

24. Silver Clear Silver

25. Silver Focused Silver

26. Gold Everyday Gold

27. Bronze Clear Bronze

28. Gold Elite Gold

29. Expanded Bronze Central Bronze

30. Silver Central Silver

31. Gold Central Gold

32. Bronze CMS Standard Bronze

33. Expanded Bronze CMS Standard Expanded Bronze

34. Silver CMS Standard Silver

35. Gold CMS Standard Gold

36. Silver Premier Silver + Vision + Adult Dental

37. Gold Complete Gold + Vision + Adult Dental

38. Silver Complete Silver + Vision + Adult Dental

39. Expanded Bronze Everyday Bronze + Vision + Adult Dental

40. Silver Elite Silver + Vision + Adult Dental

41. Expanded Bronze Choice Bronze HSA + Vision + Adult Dental

42. Expanded Bronze Elite Bronze + Vision + Adult Dental

43. Silver Focused Silver + Vision + Adult Dental

44. Gold Everyday Gold + Vision + Adult Dental

45. Silver Everyday Silver + Vision + Adult Dental

46. Silver Clear Silver + Vision + Adult Dental

47. Bronze Clear Bronze + Vision + Adult Dental

48. Gold Elite Gold + Vision + Adult Dental

49. Expanded Bronze Central Bronze + Vision + Adult Dental

50. Silver Central Silver + Vision + Adult Dental

51. Gold Central Gold + Vision + Adult Dental

Molina Healthcare

Local: 1-833-644-1623 | Toll Free: 1-833-644-1623 | TTY: 1-800-877-8339

52. Gold Confident Care Gold 1

53. Silver Constant Care Silver 1

54. Gold Confident Care Gold 8

55. Silver Constant Care Silver 8

56. Gold Confident Care Gold 1 + Vision

57. Silver Constant Care Silver 1 with RX Copay + Vision

Blue Cross and Blue Shield of Illinois

Local: 1-800-538-8833 | Toll Free: 1-800-538-8833 | TTY: 1-800-526-0844

58. Gold Blue Precision Gold HMO? 207

59. Silver Blue Precision Silver HMO? 206

60. Expanded Bronze Blue Precision Bronze HMO? 205

61. Gold Blue Precision Gold HMO? 703 - Rx Copays

62. Silver Blue Precision Silver HMO 704? - Rx Copays

63. Expanded Bronze Blue Precision Bronze HMO? 701 - Rx Copays

64. Gold Blue Precision Gold HMO? 707

65. Silver Blue Precision Silver HMO? 706

66. Expanded Bronze Blue Precision Bronze HMO? 708

67. Silver BlueCare Direct Silver? 212 with Advocate

68. Gold BlueCare Direct Gold? 409 with Advocate

69. Expanded Bronze BlueCare Direct Bronze? 401 with Advocate

70. Gold Blue Choice Preferred Gold PPO? 204

71. Silver Blue Choice Preferred Silver PPO? 203

72. Expanded Bronze Blue Choice Preferred Bronze PPO? 202

73. Catastrophic Blue Choice Preferred Security PPO? 200

74. Expanded Bronze Blue Choice Preferred Bronze PPO? 201

75. Bronze Blue Choice Preferred Bronze PPO? 601

76. Bronze Blue Choice Preferred Bronze PPO? 701

77. Gold Blue Choice Preferred Gold PPO? 707

78. Silver Blue Choice Preferred Silver PPO? 706

79. Expanded Bronze Blue Choice Preferred Bronze PPO? 708

80. Bronze Blue Choice Preferred Bronze PPO? 705

UnitedHealthcare

Local: 1-888-200-0325 | Toll Free: 1-888-200-0325 | TTY: 1-888-200-0325

81. Expanded Bronze UHC Bronze Virtual First (Unlimited App-based Care, Preferred Rx) (Disponible en espa�ol)

82. Silver UHC Silver Value 1 (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

83. Silver UHC Silver Virtual First (Unlimited App-based Care, Preferred Rx) (Disponible en espa�ol)

84. Gold UHC Gold Value (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

85. Gold UHC Gold Advantage (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

86. Gold UHC Gold Advantage+ (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx, Dental + Vision)

87. Gold UHC Gold Standard (Rx Copay)

88. Silver UHC Silver Advantage 1 (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

89. Silver UHC Silver Advantage+ (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx, Dental + Vision)

90. Silver UHC Silver Value (Unlimited Virtual Urgent Care + Primary Care Visits, Preferred Rx)

91. Silver UHC Silver Advantage (Unlimited Virtual Urgent Care + Primary Care Visits, Rx Copay)

92. Silver UHC Silver Standard

93. Expanded Bronze UHC Bronze Value (Unlimited Virtual Urgent Care + Primary Care Visits, Rx Copay)

94. Bronze UHC Bronze Essential (Preferred Rx)

95. Expanded Bronze UHC Bronze Value HSA

96. Expanded Bronze UHC Bronze Standard 1

97. Bronze UHC Bronze Standard

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

98. Expanded Bronze Cigna Connect 5000 Rx Copay

99. Silver Cigna Connect 3000 Rx Copay

100. Gold Cigna Connect 1000 Rx Copay

101. Expanded Bronze Cigna Connect 0A

102. Silver Cigna Connect 6000

103. Silver Cigna Connect 8000

104. Silver Cigna Connect 3800 Enhanced Diabetes Care

105. Expanded Bronze Cigna Plus with Northwestern Medicine 0A

106. Expanded Bronze Cigna Plus with Northwestern Medicine 5000 Rx Copay

107. Silver Cigna Plus with Northwestern Medicine 6000

108. Silver Cigna Plus with Northwestern Medicine 3000 Rx Copay

109. Silver Cigna Plus with Northwestern Medicine 3800 Enhanced Diabetes Care

110. Gold Cigna Plus with Northwestern Medicine 750 Rx Copay

111. Expanded Bronze Cigna Connect HSA 7050

112. Expanded Bronze Cigna Connect 6800 Enhanced Diabetes Care

113. Silver Cigna Connect 0B

114. Silver Cigna Connect 4200 Enhanced Asthma COPD Care

115. Expanded Bronze Cigna Plus with Northwestern Medicine HSA 7050

116. Expanded Bronze Cigna Plus with Northwestern Medicine 6800 Enhanced Diabetes Care

117. Silver Cigna Plus with Northwestern Medicine 8000

118. Silver Cigna Plus with Northwestern Medicine 0B

119. Silver Cigna Plus with Northwestern Medicine 4200 Enhanced Asthma COPD Care

120. Gold Cigna Plus with Northwestern Medicine 1900 Enhanced Diabetes Care

121. Bronze Cigna Simple Choice 9100

122. Bronze Cigna Simple Choice 9100

123. Expanded Bronze Cigna Simple Choice 7500

124. Expanded Bronze Cigna Simple Choice 7500

125. Silver Cigna Simple Choice 5800

126. Silver Cigna Simple Choice 5800

127. Gold Cigna Simple Choice 2000

128. Gold Cigna Simple Choice 2000

129. Expanded Bronze Cigna Connect 7600 Enhanced Asthma COPD Care

130. Expanded Bronze Cigna Plus with Northwestern Medicine 7600 Enhanced Asthma COPD Care

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More Information

Oscar Health Plan, Inc.

(HMO) Bronze Classic (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Bronze Elite- Deductible+PCP Saver Plus (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Silver Classic (Choice)

Annual Out of Pocket Expenses:

Individual Family $5,400 $10,800 Annual Deductible $8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Secure (Choice)

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:

(HMO) Bronze Simple- $5200 Ded (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Silver Simple- Specialist Saver (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Bronze Classic- PCP Saver Plus Rx Copay (Choice)

Annual Out of Pocket Expenses:

Individual Family $8,500 $17,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Bronze Classic- Deductible Saver (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Silver Simple- PCP Saver (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Silver Elite- Deductible Saver Plus Rx Copay (Choice)

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Silver Simple- For Diabetes (Choice)

Annual Out of Pocket Expenses:

Individual Family $6,450 $12,900 Annual Deductible $8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Bronze Classic- Standard (Choice)

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:

(HMO) Bronze Simple- Standard (Choice)

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:

(HMO) Silver Classic- Standard (Choice)

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:

(HMO) Gold Classic- Standard (Choice)

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:

Ambetter of Illinois

(HMO) Premier Silver

Annual Out of Pocket Expenses:

Individual Family $7,550 $15,100 Annual Deductible $7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Complete Gold

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,400 $10,800 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,200 $10,400 Annual Deductible

$7,450 $14,900 Maximum Out of Pocket Per Year

Individual Family

$6,500 $13,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$8,500 $17,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$4,700 $9,400 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,500 $11,000 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$6,450 $12,900 Annual Deductible

$8,550 $17,100 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$7,550 $15,100 Annual Deductible

$7,550 $15,100 Maximum Out of Pocket Per Year

Individual Family

$1,450 $2,900 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$8,500 $17,000 Maximum Out of Pocket Per Year

Individual Family

$8,300 $16,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$8,200 $16,400 Maximum Out of Pocket Per Year

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,400 $10,800 Annual Deductible

$5,400 $10,800 Maximum Out of Pocket Per Year

Individual Family

$6,100 $12,200 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$750 $1,500 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Individual Family

$0 $0 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Individual Family

$5,000 $10,000 Annual Deductible

$8,300 $16,600 Maximum Out of Pocket Per Year

Individual Family

$6,100 $12,200 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year