Obamacare 2024 Rates for Lake County, Illinois

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Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Deerfield, IL.

The health insurance rates listed below are for calendar year 2024.

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, 104 Plans and 2024 Rates for Lake County, Illinois

Below, you’ll find a summary of the 104 plans for Lake County, Illinois and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |



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Oscar Health Plan, Inc.

Local: 1-855-672-2755 | 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
$6,500 $13,000 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
$318.32
$361.28
$406.80
$568.50
$863.88
$561.82
$604.78
$650.30
$812.00
$805.32
$848.28
$893.80
$1,055.50
$1,048.82
$1,091.78
$1,137.30
$1,299.00
$243.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.64
$722.56
$813.60
$1,137.00
$1,727.76
$880.14
$966.06
$1,057.10
$1,380.50
$1,123.64
$1,209.56
$1,300.60
$1,624.00
$1,367.14
$1,453.06
$1,544.10
$1,867.50
$243.50
Toc - Plan #2 Oscar Health Plan, Inc.
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$348.35
$395.36
$445.18
$622.13
$945.39
$614.83
$661.84
$711.66
$888.61
$881.31
$928.32
$978.14
$1,155.09
$1,147.79
$1,194.80
$1,244.62
$1,421.57
$266.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.70
$790.72
$890.36
$1,244.26
$1,890.78
$963.18
$1,057.20
$1,156.84
$1,510.74
$1,229.66
$1,323.68
$1,423.32
$1,777.22
$1,496.14
$1,590.16
$1,689.80
$2,043.70
$266.48
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
$382.67
$434.32
$489.04
$683.43
$1,038.54
$675.40
$727.05
$781.77
$976.16
$968.13
$1,019.78
$1,074.50
$1,268.89
$1,260.86
$1,312.51
$1,367.23
$1,561.62
$292.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.34
$868.64
$978.08
$1,366.86
$2,077.08
$1,058.07
$1,161.37
$1,270.81
$1,659.59
$1,350.80
$1,454.10
$1,563.54
$1,952.32
$1,643.53
$1,746.83
$1,856.27
$2,245.05
$292.73
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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$274.73
$311.81
$351.09
$490.65
$745.60
$484.89
$521.97
$561.25
$700.81
$695.05
$732.13
$771.41
$910.97
$905.21
$942.29
$981.57
$1,121.13
$210.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$549.46
$623.62
$702.18
$981.30
$1,491.20
$759.62
$833.78
$912.34
$1,191.46
$969.78
$1,043.94
$1,122.50
$1,401.62
$1,179.94
$1,254.10
$1,332.66
$1,611.78
$210.16
Toc - Plan #5 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
$317.07
$359.87
$405.21
$566.27
$860.51
$559.62
$602.42
$647.76
$808.82
$802.17
$844.97
$890.31
$1,051.37
$1,044.72
$1,087.52
$1,132.86
$1,293.92
$242.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.14
$719.74
$810.42
$1,132.54
$1,721.02
$876.69
$962.29
$1,052.97
$1,375.09
$1,119.24
$1,204.84
$1,295.52
$1,617.64
$1,361.79
$1,447.39
$1,538.07
$1,860.19
$242.55
Toc - Plan #6 Oscar Health Plan, Inc.
Expanded Bronze

(HMO) Bronze Classic 4700 (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
$321.32
$364.68
$410.63
$573.85
$872.02
$567.12
$610.48
$656.43
$819.65
$812.92
$856.28
$902.23
$1,065.45
$1,058.72
$1,102.08
$1,148.03
$1,311.25
$245.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.64
$729.36
$821.26
$1,147.70
$1,744.04
$888.44
$975.16
$1,067.06
$1,393.50
$1,134.24
$1,220.96
$1,312.86
$1,639.30
$1,380.04
$1,466.76
$1,558.66
$1,885.10
$245.80
Toc - Plan #7 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
$374.62
$425.18
$478.75
$669.06
$1,016.70
$661.20
$711.76
$765.33
$955.64
$947.78
$998.34
$1,051.91
$1,242.22
$1,234.36
$1,284.92
$1,338.49
$1,528.80
$286.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.24
$850.36
$957.50
$1,338.12
$2,033.40
$1,035.82
$1,136.94
$1,244.08
$1,624.70
$1,322.40
$1,423.52
$1,530.66
$1,911.28
$1,608.98
$1,710.10
$1,817.24
$2,197.86
$286.58
Toc - Plan #8 Oscar Health Plan, Inc.
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.57
$443.29
$499.14
$697.54
$1,059.98
$689.35
$742.07
$797.92
$996.32
$988.13
$1,040.85
$1,096.70
$1,295.10
$1,286.91
$1,339.63
$1,395.48
$1,593.88
$298.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.14
$886.58
$998.28
$1,395.08
$2,119.96
$1,079.92
$1,185.36
$1,297.06
$1,693.86
$1,378.70
$1,484.14
$1,595.84
$1,992.64
$1,677.48
$1,782.92
$1,894.62
$2,291.42
$298.78
Toc - Plan #9 Oscar Health Plan, Inc.
Silver

(HMO) Silver Simple Diabetes (Choice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$382.34
$433.95
$488.62
$682.85
$1,037.65
$674.83
$726.44
$781.11
$975.34
$967.32
$1,018.93
$1,073.60
$1,267.83
$1,259.81
$1,311.42
$1,366.09
$1,560.32
$292.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.68
$867.90
$977.24
$1,365.70
$2,075.30
$1,057.17
$1,160.39
$1,269.73
$1,658.19
$1,349.66
$1,452.88
$1,562.22
$1,950.68
$1,642.15
$1,745.37
$1,854.71
$2,243.17
$292.49
Toc - Plan #10 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.75
$356.10
$400.96
$560.34
$851.49
$553.76
$596.11
$640.97
$800.35
$793.77
$836.12
$880.98
$1,040.36
$1,033.78
$1,076.13
$1,120.99
$1,280.37
$240.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.50
$712.20
$801.92
$1,120.68
$1,702.98
$867.51
$952.21
$1,041.93
$1,360.69
$1,107.52
$1,192.22
$1,281.94
$1,600.70
$1,347.53
$1,432.23
$1,521.95
$1,840.71
$240.01
Toc - Plan #11 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$371.97
$422.18
$475.37
$664.33
$1,009.51
$656.52
$706.73
$759.92
$948.88
$941.07
$991.28
$1,044.47
$1,233.43
$1,225.62
$1,275.83
$1,329.02
$1,517.98
$284.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$743.94
$844.36
$950.74
$1,328.66
$2,019.02
$1,028.49
$1,128.91
$1,235.29
$1,613.21
$1,313.04
$1,413.46
$1,519.84
$1,897.76
$1,597.59
$1,698.01
$1,804.39
$2,182.31
$284.55
Toc - Plan #12 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
$1,500 $3,000 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
$402.51
$456.84
$514.39
$718.86
$1,092.38
$710.42
$764.75
$822.30
$1,026.77
$1,018.33
$1,072.66
$1,130.21
$1,334.68
$1,326.24
$1,380.57
$1,438.12
$1,642.59
$307.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.02
$913.68
$1,028.78
$1,437.72
$2,184.76
$1,112.93
$1,221.59
$1,336.69
$1,745.63
$1,420.84
$1,529.50
$1,644.60
$2,053.54
$1,728.75
$1,837.41
$1,952.51
$2,361.45
$307.91

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Ambetter of Illinois

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

Toc - Plan #13 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
$394.03
$447.21
$503.56
$703.72
$1,069.37
$695.45
$748.63
$804.98
$1,005.14
$996.87
$1,050.05
$1,106.40
$1,306.56
$1,298.29
$1,351.47
$1,407.82
$1,607.98
$301.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.06
$894.42
$1,007.12
$1,407.44
$2,138.74
$1,089.48
$1,195.84
$1,308.54
$1,708.86
$1,390.90
$1,497.26
$1,609.96
$2,010.28
$1,692.32
$1,798.68
$1,911.38
$2,311.70
$301.42
Toc - Plan #14 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$276.92
$314.29
$353.89
$494.55
$751.52
$488.75
$526.12
$565.72
$706.38
$700.58
$737.95
$777.55
$918.21
$912.41
$949.78
$989.38
$1,130.04
$211.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$553.84
$628.58
$707.78
$989.10
$1,503.04
$765.67
$840.41
$919.61
$1,200.93
$977.50
$1,052.24
$1,131.44
$1,412.76
$1,189.33
$1,264.07
$1,343.27
$1,624.59
$211.83
Toc - Plan #15 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
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.06
$372.33
$419.24
$585.89
$890.32
$579.02
$623.29
$670.20
$836.85
$829.98
$874.25
$921.16
$1,087.81
$1,080.94
$1,125.21
$1,172.12
$1,338.77
$250.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.12
$744.66
$838.48
$1,171.78
$1,780.64
$907.08
$995.62
$1,089.44
$1,422.74
$1,158.04
$1,246.58
$1,340.40
$1,673.70
$1,409.00
$1,497.54
$1,591.36
$1,924.66
$250.96
Toc - Plan #16 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
$310.57
$352.49
$396.90
$554.66
$842.87
$548.15
$590.07
$634.48
$792.24
$785.73
$827.65
$872.06
$1,029.82
$1,023.31
$1,065.23
$1,109.64
$1,267.40
$237.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.14
$704.98
$793.80
$1,109.32
$1,685.74
$858.72
$942.56
$1,031.38
$1,346.90
$1,096.30
$1,180.14
$1,268.96
$1,584.48
$1,333.88
$1,417.72
$1,506.54
$1,822.06
$237.58
Toc - Plan #17 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
$6,300 $12,600 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
$317.91
$360.82
$406.28
$567.77
$862.78
$561.10
$604.01
$649.47
$810.96
$804.29
$847.20
$892.66
$1,054.15
$1,047.48
$1,090.39
$1,135.85
$1,297.34
$243.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$635.82
$721.64
$812.56
$1,135.54
$1,725.56
$879.01
$964.83
$1,055.75
$1,378.73
$1,122.20
$1,208.02
$1,298.94
$1,621.92
$1,365.39
$1,451.21
$1,542.13
$1,865.11
$243.19
Toc - Plan #18 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
$373.73
$424.18
$477.62
$667.47
$1,014.29
$659.63
$710.08
$763.52
$953.37
$945.53
$995.98
$1,049.42
$1,239.27
$1,231.43
$1,281.88
$1,335.32
$1,525.17
$285.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.46
$848.36
$955.24
$1,334.94
$2,028.58
$1,033.36
$1,134.26
$1,241.14
$1,620.84
$1,319.26
$1,420.16
$1,527.04
$1,906.74
$1,605.16
$1,706.06
$1,812.94
$2,192.64
$285.90
Toc - Plan #19 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
$5,500 $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
$440.64
$500.12
$563.13
$786.97
$1,195.88
$777.72
$837.20
$900.21
$1,124.05
$1,114.80
$1,174.28
$1,237.29
$1,461.13
$1,451.88
$1,511.36
$1,574.37
$1,798.21
$337.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$881.28
$1,000.24
$1,126.26
$1,573.94
$2,391.76
$1,218.36
$1,337.32
$1,463.34
$1,911.02
$1,555.44
$1,674.40
$1,800.42
$2,248.10
$1,892.52
$2,011.48
$2,137.50
$2,585.18
$337.08
Toc - Plan #20 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
$8,500 $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
$274.73
$311.81
$351.09
$490.65
$745.59
$484.89
$521.97
$561.25
$700.81
$695.05
$732.13
$771.41
$910.97
$905.21
$942.29
$981.57
$1,121.13
$210.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$549.46
$623.62
$702.18
$981.30
$1,491.18
$759.62
$833.78
$912.34
$1,191.46
$969.78
$1,043.94
$1,122.50
$1,401.62
$1,179.94
$1,254.10
$1,332.66
$1,611.78
$210.16
Toc - Plan #21 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
$335.86
$381.19
$429.22
$599.83
$911.50
$592.79
$638.12
$686.15
$856.76
$849.72
$895.05
$943.08
$1,113.69
$1,106.65
$1,151.98
$1,200.01
$1,370.62
$256.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$671.72
$762.38
$858.44
$1,199.66
$1,823.00
$928.65
$1,019.31
$1,115.37
$1,456.59
$1,185.58
$1,276.24
$1,372.30
$1,713.52
$1,442.51
$1,533.17
$1,629.23
$1,970.45
$256.93
Toc - Plan #22 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
$380.70
$432.08
$486.52
$679.91
$1,033.18
$671.93
$723.31
$777.75
$971.14
$963.16
$1,014.54
$1,068.98
$1,262.37
$1,254.39
$1,305.77
$1,360.21
$1,553.60
$291.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.40
$864.16
$973.04
$1,359.82
$2,066.36
$1,052.63
$1,155.39
$1,264.27
$1,651.05
$1,343.86
$1,446.62
$1,555.50
$1,942.28
$1,635.09
$1,737.85
$1,846.73
$2,233.51
$291.23
Toc - Plan #23 Ambetter of Illinois
Expanded Bronze

(HMO) 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
$9,400 $18,800 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
$269.45
$305.82
$344.35
$481.23
$731.27
$475.57
$511.94
$550.47
$687.35
$681.69
$718.06
$756.59
$893.47
$887.81
$924.18
$962.71
$1,099.59
$206.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$538.90
$611.64
$688.70
$962.46
$1,462.54
$745.02
$817.76
$894.82
$1,168.58
$951.14
$1,023.88
$1,100.94
$1,374.70
$1,157.26
$1,230.00
$1,307.06
$1,580.82
$206.12
Toc - Plan #24 Ambetter of Illinois
Silver

(HMO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$312.23
$354.37
$399.01
$557.62
$847.36
$551.08
$593.22
$637.86
$796.47
$789.93
$832.07
$876.71
$1,035.32
$1,028.78
$1,070.92
$1,115.56
$1,274.17
$238.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624.46
$708.74
$798.02
$1,115.24
$1,694.72
$863.31
$947.59
$1,036.87
$1,354.09
$1,102.16
$1,186.44
$1,275.72
$1,592.94
$1,341.01
$1,425.29
$1,514.57
$1,831.79
$238.85
Toc - Plan #25 Ambetter of Illinois
Gold

(HMO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$371.14
$421.24
$474.31
$662.84
$1,007.25
$655.06
$705.16
$758.23
$946.76
$938.98
$989.08
$1,042.15
$1,230.68
$1,222.90
$1,273.00
$1,326.07
$1,514.60
$283.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.28
$842.48
$948.62
$1,325.68
$2,014.50
$1,026.20
$1,126.40
$1,232.54
$1,609.60
$1,310.12
$1,410.32
$1,516.46
$1,893.52
$1,594.04
$1,694.24
$1,800.38
$2,177.44
$283.92
Toc - Plan #26 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
$406.54
$461.41
$519.54
$726.06
$1,103.32
$717.53
$772.40
$830.53
$1,037.05
$1,028.52
$1,083.39
$1,141.52
$1,348.04
$1,339.51
$1,394.38
$1,452.51
$1,659.03
$310.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$813.08
$922.82
$1,039.08
$1,452.12
$2,206.64
$1,124.07
$1,233.81
$1,350.07
$1,763.11
$1,435.06
$1,544.80
$1,661.06
$2,074.10
$1,746.05
$1,855.79
$1,972.05
$2,385.09
$310.99
Toc - Plan #27 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.71
$324.27
$365.12
$510.26
$775.38
$504.27
$542.83
$583.68
$728.82
$722.83
$761.39
$802.24
$947.38
$941.39
$979.95
$1,020.80
$1,165.94
$218.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$571.42
$648.54
$730.24
$1,020.52
$1,550.76
$789.98
$867.10
$948.80
$1,239.08
$1,008.54
$1,085.66
$1,167.36
$1,457.64
$1,227.10
$1,304.22
$1,385.92
$1,676.20
$218.56
Toc - Plan #28 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
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$338.47
$384.16
$432.56
$604.49
$918.59
$597.39
$643.08
$691.48
$863.41
$856.31
$902.00
$950.40
$1,122.33
$1,115.23
$1,160.92
$1,209.32
$1,381.25
$258.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$676.94
$768.32
$865.12
$1,208.98
$1,837.18
$935.86
$1,027.24
$1,124.04
$1,467.90
$1,194.78
$1,286.16
$1,382.96
$1,726.82
$1,453.70
$1,545.08
$1,641.88
$1,985.74
$258.92
Toc - Plan #29 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
$6,300 $12,600 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
$328.00
$372.27
$419.18
$585.80
$890.17
$578.92
$623.19
$670.10
$836.72
$829.84
$874.11
$921.02
$1,087.64
$1,080.76
$1,125.03
$1,171.94
$1,338.56
$250.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.00
$744.54
$838.36
$1,171.60
$1,780.34
$906.92
$995.46
$1,089.28
$1,422.52
$1,157.84
$1,246.38
$1,340.20
$1,673.44
$1,408.76
$1,497.30
$1,591.12
$1,924.36
$250.92
Toc - Plan #30 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
$385.60
$437.65
$492.78
$688.66
$1,046.49
$680.58
$732.63
$787.76
$983.64
$975.56
$1,027.61
$1,082.74
$1,278.62
$1,270.54
$1,322.59
$1,377.72
$1,573.60
$294.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.20
$875.30
$985.56
$1,377.32
$2,092.98
$1,066.18
$1,170.28
$1,280.54
$1,672.30
$1,361.16
$1,465.26
$1,575.52
$1,967.28
$1,656.14
$1,760.24
$1,870.50
$2,262.26
$294.98
Toc - Plan #31 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
$320.43
$363.68
$409.50
$572.28
$869.63
$565.55
$608.80
$654.62
$817.40
$810.67
$853.92
$899.74
$1,062.52
$1,055.79
$1,099.04
$1,144.86
$1,307.64
$245.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.86
$727.36
$819.00
$1,144.56
$1,739.26
$885.98
$972.48
$1,064.12
$1,389.68
$1,131.10
$1,217.60
$1,309.24
$1,634.80
$1,376.22
$1,462.72
$1,554.36
$1,879.92
$245.12
Toc - Plan #32 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
$5,500 $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
$454.63
$516.00
$581.01
$811.96
$1,233.85
$802.42
$863.79
$928.80
$1,159.75
$1,150.21
$1,211.58
$1,276.59
$1,507.54
$1,498.00
$1,559.37
$1,624.38
$1,855.33
$347.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.26
$1,032.00
$1,162.02
$1,623.92
$2,467.70
$1,257.05
$1,379.79
$1,509.81
$1,971.71
$1,604.84
$1,727.58
$1,857.60
$2,319.50
$1,952.63
$2,075.37
$2,205.39
$2,667.29
$347.79
Toc - Plan #33 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
$8,500 $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
$283.45
$321.71
$362.24
$506.23
$769.26
$500.28
$538.54
$579.07
$723.06
$717.11
$755.37
$795.90
$939.89
$933.94
$972.20
$1,012.73
$1,156.72
$216.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$566.90
$643.42
$724.48
$1,012.46
$1,538.52
$783.73
$860.25
$941.31
$1,229.29
$1,000.56
$1,077.08
$1,158.14
$1,446.12
$1,217.39
$1,293.91
$1,374.97
$1,662.95
$216.83
Toc - Plan #34 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
$346.53
$393.30
$442.85
$618.88
$940.44
$611.61
$658.38
$707.93
$883.96
$876.69
$923.46
$973.01
$1,149.04
$1,141.77
$1,188.54
$1,238.09
$1,414.12
$265.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.06
$786.60
$885.70
$1,237.76
$1,880.88
$958.14
$1,051.68
$1,150.78
$1,502.84
$1,223.22
$1,316.76
$1,415.86
$1,767.92
$1,488.30
$1,581.84
$1,680.94
$2,033.00
$265.08
Toc - Plan #35 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
$392.78
$445.80
$501.97
$701.49
$1,065.99
$693.25
$746.27
$802.44
$1,001.96
$993.72
$1,046.74
$1,102.91
$1,302.43
$1,294.19
$1,347.21
$1,403.38
$1,602.90
$300.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$785.56
$891.60
$1,003.94
$1,402.98
$2,131.98
$1,086.03
$1,192.07
$1,304.41
$1,703.45
$1,386.50
$1,492.54
$1,604.88
$2,003.92
$1,686.97
$1,793.01
$1,905.35
$2,304.39
$300.47
Toc - Plan #36 Ambetter of Illinois
Expanded Bronze

(HMO) Standard Expanded Bronze + Vision + Adult Dental

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
$9,400 $18,800 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
$278.01
$315.53
$355.28
$496.51
$754.49
$490.68
$528.20
$567.95
$709.18
$703.35
$740.87
$780.62
$921.85
$916.02
$953.54
$993.29
$1,134.52
$212.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$556.02
$631.06
$710.56
$993.02
$1,508.98
$768.69
$843.73
$923.23
$1,205.69
$981.36
$1,056.40
$1,135.90
$1,418.36
$1,194.03
$1,269.07
$1,348.57
$1,631.03
$212.67
Toc - Plan #37 Ambetter of Illinois
Silver

(HMO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.14
$365.62
$411.68
$575.33
$874.26
$568.57
$612.05
$658.11
$821.76
$815.00
$858.48
$904.54
$1,068.19
$1,061.43
$1,104.91
$1,150.97
$1,314.62
$246.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$644.28
$731.24
$823.36
$1,150.66
$1,748.52
$890.71
$977.67
$1,069.79
$1,397.09
$1,137.14
$1,224.10
$1,316.22
$1,643.52
$1,383.57
$1,470.53
$1,562.65
$1,889.95
$246.43
Toc - Plan #38 Ambetter of Illinois
Gold

(HMO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-745-5507

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$382.93
$434.61
$489.37
$683.89
$1,039.24
$675.86
$727.54
$782.30
$976.82
$968.79
$1,020.47
$1,075.23
$1,269.75
$1,261.72
$1,313.40
$1,368.16
$1,562.68
$292.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.86
$869.22
$978.74
$1,367.78
$2,078.48
$1,058.79
$1,162.15
$1,271.67
$1,660.71
$1,351.72
$1,455.08
$1,564.60
$1,953.64
$1,644.65
$1,748.01
$1,857.53
$2,246.57
$292.93

ADVERTISEMENT

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 #39 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 $1,500 Annual Deductible
$9,450 $18,900 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
$434.48
$493.14
$555.27
$775.99
$1,179.19
$766.86
$825.52
$887.65
$1,108.37
$1,099.24
$1,157.90
$1,220.03
$1,440.75
$1,431.62
$1,490.28
$1,552.41
$1,773.13
$332.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.96
$986.28
$1,110.54
$1,551.98
$2,358.38
$1,201.34
$1,318.66
$1,442.92
$1,884.36
$1,533.72
$1,651.04
$1,775.30
$2,216.74
$1,866.10
$1,983.42
$2,107.68
$2,549.12
$332.38
Toc - Plan #40 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
$4,400 $8,800 Annual Deductible
$9,450 $18,900 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
$363.92
$413.05
$465.09
$649.96
$987.68
$642.32
$691.45
$743.49
$928.36
$920.72
$969.85
$1,021.89
$1,206.76
$1,199.12
$1,248.25
$1,300.29
$1,485.16
$278.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.84
$826.10
$930.18
$1,299.92
$1,975.36
$1,006.24
$1,104.50
$1,208.58
$1,578.32
$1,284.64
$1,382.90
$1,486.98
$1,856.72
$1,563.04
$1,661.30
$1,765.38
$2,135.12
$278.40
Toc - Plan #41 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 $14,800 Annual Deductible
$9,450 $18,900 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
$314.53
$356.99
$401.96
$561.74
$853.62
$555.14
$597.60
$642.57
$802.35
$795.75
$838.21
$883.18
$1,042.96
$1,036.36
$1,078.82
$1,123.79
$1,283.57
$240.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$629.06
$713.98
$803.92
$1,123.48
$1,707.24
$869.67
$954.59
$1,044.53
$1,364.09
$1,110.28
$1,195.20
$1,285.14
$1,604.70
$1,350.89
$1,435.81
$1,525.75
$1,845.31
$240.61
Toc - Plan #42 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
$2,000 $4,000 Annual Deductible
$9,450 $18,900 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
$444.81
$504.85
$568.46
$794.42
$1,207.20
$785.09
$845.13
$908.74
$1,134.70
$1,125.37
$1,185.41
$1,249.02
$1,474.98
$1,465.65
$1,525.69
$1,589.30
$1,815.26
$340.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.62
$1,009.70
$1,136.92
$1,588.84
$2,414.40
$1,229.90
$1,349.98
$1,477.20
$1,929.12
$1,570.18
$1,690.26
$1,817.48
$2,269.40
$1,910.46
$2,030.54
$2,157.76
$2,609.68
$340.28
Toc - Plan #43 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
$9,450 $18,900 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
$380.32
$431.66
$486.05
$679.25
$1,032.18
$671.26
$722.60
$776.99
$970.19
$962.20
$1,013.54
$1,067.93
$1,261.13
$1,253.14
$1,304.48
$1,358.87
$1,552.07
$290.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.64
$863.32
$972.10
$1,358.50
$2,064.36
$1,051.58
$1,154.26
$1,263.04
$1,649.44
$1,342.52
$1,445.20
$1,553.98
$1,940.38
$1,633.46
$1,736.14
$1,844.92
$2,231.32
$290.94
Toc - Plan #44 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
$0 $0 Annual Deductible
$9,450 $18,900 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
$308.83
$350.53
$394.69
$551.58
$838.18
$545.09
$586.79
$630.95
$787.84
$781.35
$823.05
$867.21
$1,024.10
$1,017.61
$1,059.31
$1,103.47
$1,260.36
$236.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.66
$701.06
$789.38
$1,103.16
$1,676.36
$853.92
$937.32
$1,025.64
$1,339.42
$1,090.18
$1,173.58
$1,261.90
$1,575.68
$1,326.44
$1,409.84
$1,498.16
$1,811.94
$236.26
Toc - Plan #45 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
$1,500 $3,000 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
$438.22
$497.38
$560.05
$782.66
$1,189.33
$773.46
$832.62
$895.29
$1,117.90
$1,108.70
$1,167.86
$1,230.53
$1,453.14
$1,443.94
$1,503.10
$1,565.77
$1,788.38
$335.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$876.44
$994.76
$1,120.10
$1,565.32
$2,378.66
$1,211.68
$1,330.00
$1,455.34
$1,900.56
$1,546.92
$1,665.24
$1,790.58
$2,235.80
$1,882.16
$2,000.48
$2,125.82
$2,571.04
$335.24
Toc - Plan #46 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.26
$442.94
$498.75
$697.00
$1,059.15
$688.81
$741.49
$797.30
$995.55
$987.36
$1,040.04
$1,095.85
$1,294.10
$1,285.91
$1,338.59
$1,394.40
$1,592.65
$298.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$780.52
$885.88
$997.50
$1,394.00
$2,118.30
$1,079.07
$1,184.43
$1,296.05
$1,692.55
$1,377.62
$1,482.98
$1,594.60
$1,991.10
$1,676.17
$1,781.53
$1,893.15
$2,289.65
$298.55
Toc - Plan #47 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
$9,400 $18,800 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
$331.18
$375.88
$423.24
$591.48
$898.81
$584.53
$629.23
$676.59
$844.83
$837.88
$882.58
$929.94
$1,098.18
$1,091.23
$1,135.93
$1,183.29
$1,351.53
$253.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$662.36
$751.76
$846.48
$1,182.96
$1,797.62
$915.71
$1,005.11
$1,099.83
$1,436.31
$1,169.06
$1,258.46
$1,353.18
$1,689.66
$1,422.41
$1,511.81
$1,606.53
$1,943.01
$253.35
Toc - Plan #48 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) BlueCare Direct Bronze? 401 with Advocate - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$326.40
$370.46
$417.14
$582.95
$885.85
$576.09
$620.15
$666.83
$832.64
$825.78
$869.84
$916.52
$1,082.33
$1,075.47
$1,119.53
$1,166.21
$1,332.02
$249.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652.80
$740.92
$834.28
$1,165.90
$1,771.70
$902.49
$990.61
$1,083.97
$1,415.59
$1,152.18
$1,240.30
$1,333.66
$1,665.28
$1,401.87
$1,489.99
$1,583.35
$1,914.97
$249.69
Toc - Plan #49 Blue Cross and Blue Shield of Illinois
Gold

(HMO) BlueCare Direct Gold? 409 with Advocate - Rx Copays

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
$9,450 $18,900 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
$453.30
$514.50
$579.32
$809.60
$1,230.26
$800.08
$861.28
$926.10
$1,156.38
$1,146.86
$1,208.06
$1,272.88
$1,503.16
$1,493.64
$1,554.84
$1,619.66
$1,849.94
$346.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.60
$1,029.00
$1,158.64
$1,619.20
$2,460.52
$1,253.38
$1,375.78
$1,505.42
$1,965.98
$1,600.16
$1,722.56
$1,852.20
$2,312.76
$1,946.94
$2,069.34
$2,198.98
$2,659.54
$346.78
Toc - Plan #50 Blue Cross and Blue Shield of Illinois
Silver

(HMO) BlueCare Direct Silver? 212 with Advocate - 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
$9,450 $18,900 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
$379.64
$430.89
$485.18
$678.04
$1,030.34
$670.06
$721.31
$775.60
$968.46
$960.48
$1,011.73
$1,066.02
$1,258.88
$1,250.90
$1,302.15
$1,356.44
$1,549.30
$290.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$759.28
$861.78
$970.36
$1,356.08
$2,060.68
$1,049.70
$1,152.20
$1,260.78
$1,646.50
$1,340.12
$1,442.62
$1,551.20
$1,936.92
$1,630.54
$1,733.04
$1,841.62
$2,227.34
$290.42
Toc - Plan #51 Blue Cross and Blue Shield of Illinois
Gold

(HMO) BlueCare Direct Gold? 804 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$458.60
$520.51
$586.09
$819.05
$1,244.63
$809.43
$871.34
$936.92
$1,169.88
$1,160.26
$1,222.17
$1,287.75
$1,520.71
$1,511.09
$1,573.00
$1,638.58
$1,871.54
$350.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$917.20
$1,041.02
$1,172.18
$1,638.10
$2,489.26
$1,268.03
$1,391.85
$1,523.01
$1,988.93
$1,618.86
$1,742.68
$1,873.84
$2,339.76
$1,969.69
$2,093.51
$2,224.67
$2,690.59
$350.83
Toc - Plan #52 Blue Cross and Blue Shield of Illinois
Silver

(HMO) BlueCare Direct Silver? 803 with Advocate

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.87
$454.99
$512.32
$715.96
$1,087.97
$707.54
$761.66
$818.99
$1,022.63
$1,014.21
$1,068.33
$1,125.66
$1,329.30
$1,320.88
$1,375.00
$1,432.33
$1,635.97
$306.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$801.74
$909.98
$1,024.64
$1,431.92
$2,175.94
$1,108.41
$1,216.65
$1,331.31
$1,738.59
$1,415.08
$1,523.32
$1,637.98
$2,045.26
$1,721.75
$1,829.99
$1,944.65
$2,351.93
$306.67
Toc - Plan #53 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(HMO) BlueCare Direct Bronze? 802 with Advocate

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
$9,400 $18,800 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
$300.23
$340.76
$383.69
$536.21
$814.82
$529.90
$570.43
$613.36
$765.88
$759.57
$800.10
$843.03
$995.55
$989.24
$1,029.77
$1,072.70
$1,225.22
$229.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$600.46
$681.52
$767.38
$1,072.42
$1,629.64
$830.13
$911.19
$997.05
$1,302.09
$1,059.80
$1,140.86
$1,226.72
$1,531.76
$1,289.47
$1,370.53
$1,456.39
$1,761.43
$229.67
Toc - Plan #54 Blue Cross and Blue Shield of Illinois
Gold

(PPO) Blue Choice Preferred Gold PPO? 204 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$9,450 $18,900 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
$566.28
$642.72
$723.70
$1,011.37
$1,536.87
$999.48
$1,075.92
$1,156.90
$1,444.57
$1,432.68
$1,509.12
$1,590.10
$1,877.77
$1,865.88
$1,942.32
$2,023.30
$2,310.97
$433.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,132.56
$1,285.44
$1,447.40
$2,022.74
$3,073.74
$1,565.76
$1,718.64
$1,880.60
$2,455.94
$1,998.96
$2,151.84
$2,313.80
$2,889.14
$2,432.16
$2,585.04
$2,747.00
$3,322.34
$433.20
Toc - Plan #55 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 $4,500 Annual Deductible
$9,450 $18,900 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
$478.55
$543.15
$611.58
$854.69
$1,298.78
$844.64
$909.24
$977.67
$1,220.78
$1,210.73
$1,275.33
$1,343.76
$1,586.87
$1,576.82
$1,641.42
$1,709.85
$1,952.96
$366.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$957.10
$1,086.30
$1,223.16
$1,709.38
$2,597.56
$1,323.19
$1,452.39
$1,589.25
$2,075.47
$1,689.28
$1,818.48
$1,955.34
$2,441.56
$2,055.37
$2,184.57
$2,321.43
$2,807.65
$366.09
Toc - Plan #56 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 $9,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.23
$472.42
$531.94
$743.38
$1,129.64
$734.64
$790.83
$850.35
$1,061.79
$1,053.05
$1,109.24
$1,168.76
$1,380.20
$1,371.46
$1,427.65
$1,487.17
$1,698.61
$318.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.46
$944.84
$1,063.88
$1,486.76
$2,259.28
$1,150.87
$1,263.25
$1,382.29
$1,805.17
$1,469.28
$1,581.66
$1,700.70
$2,123.58
$1,787.69
$1,900.07
$2,019.11
$2,441.99
$318.41
Toc - Plan #57 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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 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
$342.16
$388.35
$437.28
$611.09
$928.61
$603.91
$650.10
$699.03
$872.84
$865.66
$911.85
$960.78
$1,134.59
$1,127.41
$1,173.60
$1,222.53
$1,396.34
$261.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$684.32
$776.70
$874.56
$1,222.18
$1,857.22
$946.07
$1,038.45
$1,136.31
$1,483.93
$1,207.82
$1,300.20
$1,398.06
$1,745.68
$1,469.57
$1,561.95
$1,659.81
$2,007.43
$261.75
Toc - Plan #58 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 $14,000 Annual Deductible
$9,450 $18,900 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
$374.03
$424.52
$478.01
$668.01
$1,015.11
$660.16
$710.65
$764.14
$954.14
$946.29
$996.78
$1,050.27
$1,240.27
$1,232.42
$1,282.91
$1,336.40
$1,526.40
$286.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748.06
$849.04
$956.02
$1,336.02
$2,030.22
$1,034.19
$1,135.17
$1,242.15
$1,622.15
$1,320.32
$1,421.30
$1,528.28
$1,908.28
$1,606.45
$1,707.43
$1,814.41
$2,194.41
$286.13
Toc - Plan #59 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 601 - 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
$9,450 $18,900 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
$365.93
$415.33
$467.66
$653.56
$993.14
$645.87
$695.27
$747.60
$933.50
$925.81
$975.21
$1,027.54
$1,213.44
$1,205.75
$1,255.15
$1,307.48
$1,493.38
$279.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.86
$830.66
$935.32
$1,307.12
$1,986.28
$1,011.80
$1,110.60
$1,215.26
$1,587.06
$1,291.74
$1,390.54
$1,495.20
$1,867.00
$1,571.68
$1,670.48
$1,775.14
$2,146.94
$279.94
Toc - Plan #60 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 701 - Rx Copays

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$9,000 $18,000 Annual Deductible
$9,450 $18,900 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
$343.89
$390.31
$439.49
$614.18
$933.31
$606.96
$653.38
$702.56
$877.25
$870.03
$916.45
$965.63
$1,140.32
$1,133.10
$1,179.52
$1,228.70
$1,403.39
$263.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.78
$780.62
$878.98
$1,228.36
$1,866.62
$950.85
$1,043.69
$1,142.05
$1,491.43
$1,213.92
$1,306.76
$1,405.12
$1,754.50
$1,476.99
$1,569.83
$1,668.19
$2,017.57
$263.07
Toc - Plan #61 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
$1,500 $3,000 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
$556.19
$631.27
$710.81
$993.35
$1,509.49
$981.67
$1,056.75
$1,136.29
$1,418.83
$1,407.15
$1,482.23
$1,561.77
$1,844.31
$1,832.63
$1,907.71
$1,987.25
$2,269.79
$425.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,112.38
$1,262.54
$1,421.62
$1,986.70
$3,018.98
$1,537.86
$1,688.02
$1,847.10
$2,412.18
$1,963.34
$2,113.50
$2,272.58
$2,837.66
$2,388.82
$2,538.98
$2,698.06
$3,263.14
$425.48
Toc - Plan #62 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.16
$550.66
$620.04
$866.50
$1,316.73
$856.31
$921.81
$991.19
$1,237.65
$1,227.46
$1,292.96
$1,362.34
$1,608.80
$1,598.61
$1,664.11
$1,733.49
$1,979.95
$371.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$970.32
$1,101.32
$1,240.08
$1,733.00
$2,633.46
$1,341.47
$1,472.47
$1,611.23
$2,104.15
$1,712.62
$1,843.62
$1,982.38
$2,475.30
$2,083.77
$2,214.77
$2,353.53
$2,846.45
$371.15
Toc - Plan #63 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
$9,400 $18,800 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
$416.41
$472.62
$532.17
$743.70
$1,130.13
$734.96
$791.17
$850.72
$1,062.25
$1,053.51
$1,109.72
$1,169.27
$1,380.80
$1,372.06
$1,428.27
$1,487.82
$1,699.35
$318.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$832.82
$945.24
$1,064.34
$1,487.40
$2,260.26
$1,151.37
$1,263.79
$1,382.89
$1,805.95
$1,469.92
$1,582.34
$1,701.44
$2,124.50
$1,788.47
$1,900.89
$2,019.99
$2,443.05
$318.55
Toc - Plan #64 Blue Cross and Blue Shield of Illinois
Silver

(PPO) Blue Choice Preferred Silver PPO? 801 - Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-538-8833

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$9,450 $18,900 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
$471.66
$535.33
$602.78
$842.38
$1,280.08
$832.48
$896.15
$963.60
$1,203.20
$1,193.30
$1,256.97
$1,324.42
$1,564.02
$1,554.12
$1,617.79
$1,685.24
$1,924.84
$360.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$943.32
$1,070.66
$1,205.56
$1,684.76
$2,560.16
$1,304.14
$1,431.48
$1,566.38
$2,045.58
$1,664.96
$1,792.30
$1,927.20
$2,406.40
$2,025.78
$2,153.12
$2,288.02
$2,767.22
$360.82

ADVERTISEMENT

UnitedHealthcare

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

Toc - Plan #65 UnitedHealthcare
Silver

(HMO) UHC Silver Value (Virtual Urgent Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 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
$353.56
$401.29
$451.84
$631.45
$959.55
$624.03
$671.76
$722.31
$901.92
$894.50
$942.23
$992.78
$1,172.39
$1,164.97
$1,212.70
$1,263.25
$1,442.86
$270.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.12
$802.58
$903.68
$1,262.90
$1,919.10
$977.59
$1,073.05
$1,174.15
$1,533.37
$1,248.06
$1,343.52
$1,444.62
$1,803.84
$1,518.53
$1,613.99
$1,715.09
$2,074.31
$270.47
Toc - Plan #66 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited App-based Care) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

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
$348.38
$395.41
$445.23
$622.21
$945.51
$614.89
$661.92
$711.74
$888.72
$881.40
$928.43
$978.25
$1,155.23
$1,147.91
$1,194.94
$1,244.76
$1,421.74
$266.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.76
$790.82
$890.46
$1,244.42
$1,891.02
$963.27
$1,057.33
$1,156.97
$1,510.93
$1,229.78
$1,323.84
$1,423.48
$1,777.44
$1,496.29
$1,590.35
$1,689.99
$2,043.95
$266.51
Toc - Plan #67 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
$1,500 $3,000 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
$413.36
$469.16
$528.27
$738.26
$1,121.85
$729.58
$785.38
$844.49
$1,054.48
$1,045.80
$1,101.60
$1,160.71
$1,370.70
$1,362.02
$1,417.82
$1,476.93
$1,686.92
$316.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.72
$938.32
$1,056.54
$1,476.52
$2,243.70
$1,142.94
$1,254.54
$1,372.76
$1,792.74
$1,459.16
$1,570.76
$1,688.98
$2,108.96
$1,775.38
$1,886.98
$2,005.20
$2,425.18
$316.22
Toc - Plan #68 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus (Virtual Urgent Care + PCP Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$362.94
$411.94
$463.84
$648.21
$985.02
$640.59
$689.59
$741.49
$925.86
$918.24
$967.24
$1,019.14
$1,203.51
$1,195.89
$1,244.89
$1,296.79
$1,481.16
$277.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$725.88
$823.88
$927.68
$1,296.42
$1,970.04
$1,003.53
$1,101.53
$1,205.33
$1,574.07
$1,281.18
$1,379.18
$1,482.98
$1,851.72
$1,558.83
$1,656.83
$1,760.63
$2,129.37
$277.65
Toc - Plan #69 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
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.99
$402.92
$453.68
$634.02
$963.45
$626.56
$674.49
$725.25
$905.59
$898.13
$946.06
$996.82
$1,177.16
$1,169.70
$1,217.63
$1,268.39
$1,448.73
$271.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.98
$805.84
$907.36
$1,268.04
$1,926.90
$981.55
$1,077.41
$1,178.93
$1,539.61
$1,253.12
$1,348.98
$1,450.50
$1,811.18
$1,524.69
$1,620.55
$1,722.07
$2,082.75
$271.57
Toc - Plan #70 UnitedHealthcare
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$7,850 $15,700 Annual Deductible
$9,450 $18,900 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
$292.19
$331.64
$373.42
$521.86
$793.02
$515.72
$555.17
$596.95
$745.39
$739.25
$778.70
$820.48
$968.92
$962.78
$1,002.23
$1,044.01
$1,192.45
$223.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$584.38
$663.28
$746.84
$1,043.72
$1,586.04
$807.91
$886.81
$970.37
$1,267.25
$1,031.44
$1,110.34
$1,193.90
$1,490.78
$1,254.97
$1,333.87
$1,417.43
$1,714.31
$223.53
Toc - Plan #71 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
$8,050 $16,100 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
$281.69
$319.72
$360.00
$503.10
$764.52
$497.19
$535.22
$575.50
$718.60
$712.69
$750.72
$791.00
$934.10
$928.19
$966.22
$1,006.50
$1,149.60
$215.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$563.38
$639.44
$720.00
$1,006.20
$1,529.04
$778.88
$854.94
$935.50
$1,221.70
$994.38
$1,070.44
$1,151.00
$1,437.20
$1,209.88
$1,285.94
$1,366.50
$1,652.70
$215.50
Toc - Plan #72 UnitedHealthcare
Expanded 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
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$294.00
$333.69
$375.73
$525.08
$797.91
$518.91
$558.60
$600.64
$749.99
$743.82
$783.51
$825.55
$974.90
$968.73
$1,008.42
$1,050.46
$1,199.81
$224.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$588.00
$667.38
$751.46
$1,050.16
$1,595.82
$812.91
$892.29
$976.37
$1,275.07
$1,037.82
$1,117.20
$1,201.28
$1,499.98
$1,262.73
$1,342.11
$1,426.19
$1,724.89
$224.91
Toc - Plan #73 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus (Virtual Urgent Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 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
$311.30
$353.32
$397.84
$555.98
$844.86
$549.44
$591.46
$635.98
$794.12
$787.58
$829.60
$874.12
$1,032.26
$1,025.72
$1,067.74
$1,112.26
$1,270.40
$238.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$622.60
$706.64
$795.68
$1,111.96
$1,689.72
$860.74
$944.78
$1,033.82
$1,350.10
$1,098.88
$1,182.92
$1,271.96
$1,588.24
$1,337.02
$1,421.06
$1,510.10
$1,826.38
$238.14
Toc - Plan #74 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited App-based Care, Rx Copay) (Disponible en espanol)

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
$9,450 $18,900 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
$288.33
$327.25
$368.49
$514.96
$782.53
$508.90
$547.82
$589.06
$735.53
$729.47
$768.39
$809.63
$956.10
$950.04
$988.96
$1,030.20
$1,176.67
$220.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.66
$654.50
$736.98
$1,029.92
$1,565.06
$797.23
$875.07
$957.55
$1,250.49
$1,017.80
$1,095.64
$1,178.12
$1,471.06
$1,238.37
$1,316.21
$1,398.69
$1,691.63
$220.57
Toc - Plan #75 UnitedHealthcare
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 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
$354.58
$402.45
$453.15
$633.28
$962.33
$625.83
$673.70
$724.40
$904.53
$897.08
$944.95
$995.65
$1,175.78
$1,168.33
$1,216.20
$1,266.90
$1,447.03
$271.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.16
$804.90
$906.30
$1,266.56
$1,924.66
$980.41
$1,076.15
$1,177.55
$1,537.81
$1,251.66
$1,347.40
$1,448.80
$1,809.06
$1,522.91
$1,618.65
$1,720.05
$2,080.31
$271.25
Toc - Plan #76 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage (Virtual Urgent Care + PCP Visits, Rx Copay)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.81
$475.35
$535.24
$748.00
$1,136.66
$739.20
$795.74
$855.63
$1,068.39
$1,059.59
$1,116.13
$1,176.02
$1,388.78
$1,379.98
$1,436.52
$1,496.41
$1,709.17
$320.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$837.62
$950.70
$1,070.48
$1,496.00
$2,273.32
$1,158.01
$1,271.09
$1,390.87
$1,816.39
$1,478.40
$1,591.48
$1,711.26
$2,136.78
$1,798.79
$1,911.87
$2,031.65
$2,457.17
$320.39
Toc - Plan #77 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus (Virtual Urgent Care + PCP Visits)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$419.95
$476.65
$536.70
$750.04
$1,139.76
$741.22
$797.92
$857.97
$1,071.31
$1,062.49
$1,119.19
$1,179.24
$1,392.58
$1,383.76
$1,440.46
$1,500.51
$1,713.85
$321.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.90
$953.30
$1,073.40
$1,500.08
$2,279.52
$1,161.17
$1,274.57
$1,394.67
$1,821.35
$1,482.44
$1,595.84
$1,715.94
$2,142.62
$1,803.71
$1,917.11
$2,037.21
$2,463.89
$321.27
Toc - Plan #78 UnitedHealthcare
Gold

(HMO) UHC Gold Virtual First (Unlimited App-based Care) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 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
$393.78
$446.94
$503.25
$703.29
$1,068.72
$695.02
$748.18
$804.49
$1,004.53
$996.26
$1,049.42
$1,105.73
$1,305.77
$1,297.50
$1,350.66
$1,406.97
$1,607.01
$301.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.56
$893.88
$1,006.50
$1,406.58
$2,137.44
$1,088.80
$1,195.12
$1,307.74
$1,707.82
$1,390.04
$1,496.36
$1,608.98
$2,009.06
$1,691.28
$1,797.60
$1,910.22
$2,310.30
$301.24
Toc - Plan #79 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Virtual Urgent Care + PCP Visits, Rx Copay, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 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
$371.08
$421.17
$474.24
$662.75
$1,007.11
$654.96
$705.05
$758.12
$946.63
$938.84
$988.93
$1,042.00
$1,230.51
$1,222.72
$1,272.81
$1,325.88
$1,514.39
$283.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.16
$842.34
$948.48
$1,325.50
$2,014.22
$1,026.04
$1,126.22
$1,232.36
$1,609.38
$1,309.92
$1,410.10
$1,516.24
$1,893.26
$1,593.80
$1,693.98
$1,800.12
$2,177.14
$283.88
Toc - Plan #80 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Virtual Urgent Care + PCP Visits, Rx Copay, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-200-0325

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.31
$494.08
$556.33
$777.47
$1,181.44
$768.32
$827.09
$889.34
$1,110.48
$1,101.33
$1,160.10
$1,222.35
$1,443.49
$1,434.34
$1,493.11
$1,555.36
$1,776.50
$333.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$870.62
$988.16
$1,112.66
$1,554.94
$2,362.88
$1,203.63
$1,321.17
$1,445.67
$1,887.95
$1,536.64
$1,654.18
$1,778.68
$2,220.96
$1,869.65
$1,987.19
$2,111.69
$2,553.97
$333.01

ADVERTISEMENT

Cigna Healthcare

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

Toc - Plan #81 Cigna Healthcare
Expanded Bronze

(HMO) Plus with Northwestern Medicine Bronze 5000 Indiv Med Ded - 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
$9,450 $18,900 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
$365.89
$415.29
$467.61
$653.48
$993.03
$645.80
$695.20
$747.52
$933.39
$925.71
$975.11
$1,027.43
$1,213.30
$1,205.62
$1,255.02
$1,307.34
$1,493.21
$279.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.78
$830.58
$935.22
$1,306.96
$1,986.06
$1,011.69
$1,110.49
$1,215.13
$1,586.87
$1,291.60
$1,390.40
$1,495.04
$1,866.78
$1,571.51
$1,670.31
$1,774.95
$2,146.69
$279.91
Toc - Plan #82 Cigna Healthcare
Silver

(HMO) Plus with Northwestern Medicine Silver 5000 Indiv Med Deductible

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
$9,450 $18,900 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
$406.92
$461.86
$520.05
$726.77
$1,104.39
$718.22
$773.16
$831.35
$1,038.07
$1,029.52
$1,084.46
$1,142.65
$1,349.37
$1,340.82
$1,395.76
$1,453.95
$1,660.67
$311.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$813.84
$923.72
$1,040.10
$1,453.54
$2,208.78
$1,125.14
$1,235.02
$1,351.40
$1,764.84
$1,436.44
$1,546.32
$1,662.70
$2,076.14
$1,747.74
$1,857.62
$1,974.00
$2,387.44
$311.30
Toc - Plan #83 Cigna Healthcare
Silver

(HMO) Plus with Northwestern Medicine Silver 3000 Indiv Med Ded - 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
$408.37
$463.50
$521.90
$729.36
$1,108.33
$720.78
$775.91
$834.31
$1,041.77
$1,033.19
$1,088.32
$1,146.72
$1,354.18
$1,345.60
$1,400.73
$1,459.13
$1,666.59
$312.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$816.74
$927.00
$1,043.80
$1,458.72
$2,216.66
$1,129.15
$1,239.41
$1,356.21
$1,771.13
$1,441.56
$1,551.82
$1,668.62
$2,083.54
$1,753.97
$1,864.23
$1,981.03
$2,395.95
$312.41
Toc - Plan #84 Cigna Healthcare
Expanded Bronze

(HMO) Plus Bronze CMS Standard

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
$9,400 $18,800 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
$357.20
$405.42
$456.50
$637.95
$969.43
$630.46
$678.68
$729.76
$911.21
$903.72
$951.94
$1,003.02
$1,184.47
$1,176.98
$1,225.20
$1,276.28
$1,457.73
$273.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$714.40
$810.84
$913.00
$1,275.90
$1,938.86
$987.66
$1,084.10
$1,186.26
$1,549.16
$1,260.92
$1,357.36
$1,459.52
$1,822.42
$1,534.18
$1,630.62
$1,732.78
$2,095.68
$273.26
Toc - Plan #85 Cigna Healthcare
Silver

(HMO) Plus Silver CMS Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$402.58
$456.92
$514.49
$719.00
$1,092.59
$710.55
$764.89
$822.46
$1,026.97
$1,018.52
$1,072.86
$1,130.43
$1,334.94
$1,326.49
$1,380.83
$1,438.40
$1,642.91
$307.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.16
$913.84
$1,028.98
$1,438.00
$2,185.18
$1,113.13
$1,221.81
$1,336.95
$1,745.97
$1,421.10
$1,529.78
$1,644.92
$2,053.94
$1,729.07
$1,837.75
$1,952.89
$2,361.91
$307.97
Toc - Plan #86 Cigna Healthcare
Gold

(HMO) Plus Gold CMS Standard - Rx Copay

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$474.00
$537.99
$605.77
$846.56
$1,286.42
$836.61
$900.60
$968.38
$1,209.17
$1,199.22
$1,263.21
$1,330.99
$1,571.78
$1,561.83
$1,625.82
$1,693.60
$1,934.39
$362.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$948.00
$1,075.98
$1,211.54
$1,693.12
$2,572.84
$1,310.61
$1,438.59
$1,574.15
$2,055.73
$1,673.22
$1,801.20
$1,936.76
$2,418.34
$2,035.83
$2,163.81
$2,299.37
$2,780.95
$362.61

ADVERTISEMENT

Aetna CVS Health

Local: 1-855-586-6962 | Toll Free: 1-855-586-6962 | TTY: 1-855-586-6962

Toc - Plan #87 Aetna CVS Health
Expanded Bronze

(PPO) Bronze 1 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$8,995 $17,990 Annual Deductible
$9,395 $18,790 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.84
$437.92
$493.10
$689.10
$1,047.15
$681.01
$733.09
$788.27
$984.27
$976.18
$1,028.26
$1,083.44
$1,279.44
$1,271.35
$1,323.43
$1,378.61
$1,574.61
$295.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.68
$875.84
$986.20
$1,378.20
$2,094.30
$1,066.85
$1,171.01
$1,281.37
$1,673.37
$1,362.02
$1,466.18
$1,576.54
$1,968.54
$1,657.19
$1,761.35
$1,871.71
$2,263.71
$295.17
Toc - Plan #88 Aetna CVS Health
Expanded Bronze

(PPO) Bronze 4 PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 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
$420.02
$476.73
$536.79
$750.16
$1,139.94
$741.34
$798.05
$858.11
$1,071.48
$1,062.66
$1,119.37
$1,179.43
$1,392.80
$1,383.98
$1,440.69
$1,500.75
$1,714.12
$321.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$840.04
$953.46
$1,073.58
$1,500.32
$2,279.88
$1,161.36
$1,274.78
$1,394.90
$1,821.64
$1,482.68
$1,596.10
$1,716.22
$2,142.96
$1,804.00
$1,917.42
$2,037.54
$2,464.28
$321.32
Toc - Plan #89 Aetna CVS Health
Expanded Bronze

(PPO) Bronze S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.37
$431.71
$486.11
$679.33
$1,032.30
$671.35
$722.69
$777.09
$970.31
$962.33
$1,013.67
$1,068.07
$1,261.29
$1,253.31
$1,304.65
$1,359.05
$1,552.27
$290.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.74
$863.42
$972.22
$1,358.66
$2,064.60
$1,051.72
$1,154.40
$1,263.20
$1,649.64
$1,342.70
$1,445.38
$1,554.18
$1,940.62
$1,633.68
$1,736.36
$1,845.16
$2,231.60
$290.98
Toc - Plan #90 Aetna CVS Health
Gold

(PPO) Gold 3 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$585.41
$664.44
$748.15
$1,045.54
$1,588.80
$1,033.25
$1,112.28
$1,195.99
$1,493.38
$1,481.09
$1,560.12
$1,643.83
$1,941.22
$1,928.93
$2,007.96
$2,091.67
$2,389.06
$447.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,170.82
$1,328.88
$1,496.30
$2,091.08
$3,177.60
$1,618.66
$1,776.72
$1,944.14
$2,538.92
$2,066.50
$2,224.56
$2,391.98
$2,986.76
$2,514.34
$2,672.40
$2,839.82
$3,434.60
$447.84
Toc - Plan #91 Aetna CVS Health
Gold

(PPO) Gold S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 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
$580.70
$659.09
$742.13
$1,037.12
$1,576.01
$1,024.94
$1,103.33
$1,186.37
$1,481.36
$1,469.18
$1,547.57
$1,630.61
$1,925.60
$1,913.42
$1,991.81
$2,074.85
$2,369.84
$444.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,161.40
$1,318.18
$1,484.26
$2,074.24
$3,152.02
$1,605.64
$1,762.42
$1,928.50
$2,518.48
$2,049.88
$2,206.66
$2,372.74
$2,962.72
$2,494.12
$2,650.90
$2,816.98
$3,406.96
$444.24
Toc - Plan #92 Aetna CVS Health
Silver

(PPO) Silver 5 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$8,200 $16,400 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$502.94
$570.84
$642.76
$898.25
$1,364.98
$887.69
$955.59
$1,027.51
$1,283.00
$1,272.44
$1,340.34
$1,412.26
$1,667.75
$1,657.19
$1,725.09
$1,797.01
$2,052.50
$384.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,005.88
$1,141.68
$1,285.52
$1,796.50
$2,729.96
$1,390.63
$1,526.43
$1,670.27
$2,181.25
$1,775.38
$1,911.18
$2,055.02
$2,566.00
$2,160.13
$2,295.93
$2,439.77
$2,950.75
$384.75
Toc - Plan #93 Aetna CVS Health
Silver

(PPO) Silver 7 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$503.92
$571.94
$644.00
$899.99
$1,367.62
$889.42
$957.44
$1,029.50
$1,285.49
$1,274.92
$1,342.94
$1,415.00
$1,670.99
$1,660.42
$1,728.44
$1,800.50
$2,056.49
$385.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,007.84
$1,143.88
$1,288.00
$1,799.98
$2,735.24
$1,393.34
$1,529.38
$1,673.50
$2,185.48
$1,778.84
$1,914.88
$2,059.00
$2,570.98
$2,164.34
$2,300.38
$2,444.50
$2,956.48
$385.50
Toc - Plan #94 Aetna CVS Health
Silver

(PPO) Silver S PPO: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$491.17
$557.48
$627.72
$877.23
$1,333.03
$866.92
$933.23
$1,003.47
$1,252.98
$1,242.67
$1,308.98
$1,379.22
$1,628.73
$1,618.42
$1,684.73
$1,754.97
$2,004.48
$375.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$982.34
$1,114.96
$1,255.44
$1,754.46
$2,666.06
$1,358.09
$1,490.71
$1,631.19
$2,130.21
$1,733.84
$1,866.46
$2,006.94
$2,505.96
$2,109.59
$2,242.21
$2,382.69
$2,881.71
$375.75
Toc - Plan #95 Aetna CVS Health
Silver

(PPO) Silver 6 PPO: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-586-6962

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$503.32
$571.27
$643.24
$898.93
$1,366.00
$888.36
$956.31
$1,028.28
$1,283.97
$1,273.40
$1,341.35
$1,413.32
$1,669.01
$1,658.44
$1,726.39
$1,798.36
$2,054.05
$385.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,006.64
$1,142.54
$1,286.48
$1,797.86
$2,732.00
$1,391.68
$1,527.58
$1,671.52
$2,182.90
$1,776.72
$1,912.62
$2,056.56
$2,567.94
$2,161.76
$2,297.66
$2,441.60
$2,952.98
$385.04
Toc - Plan #96 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 1: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$8,995 $17,990 Annual Deductible
$9,395 $18,790 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$267.19
$303.25
$341.46
$477.19
$725.13
$471.59
$507.65
$545.86
$681.59
$675.99
$712.05
$750.26
$885.99
$880.39
$916.45
$954.66
$1,090.39
$204.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$534.38
$606.50
$682.92
$954.38
$1,450.26
$738.78
$810.90
$887.32
$1,158.78
$943.18
$1,015.30
$1,091.72
$1,363.18
$1,147.58
$1,219.70
$1,296.12
$1,567.58
$204.40
Toc - Plan #97 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$263.92
$299.55
$337.29
$471.36
$716.27
$465.82
$501.45
$539.19
$673.26
$667.72
$703.35
$741.09
$875.16
$869.62
$905.25
$942.99
$1,077.06
$201.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$527.84
$599.10
$674.58
$942.72
$1,432.54
$729.74
$801.00
$876.48
$1,144.62
$931.64
$1,002.90
$1,078.38
$1,346.52
$1,133.54
$1,204.80
$1,280.28
$1,548.42
$201.90
Toc - Plan #98 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.07
$389.38
$438.44
$612.71
$931.07
$605.52
$651.83
$700.89
$875.16
$867.97
$914.28
$963.34
$1,137.61
$1,130.42
$1,176.73
$1,225.79
$1,400.06
$262.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.14
$778.76
$876.88
$1,225.42
$1,862.14
$948.59
$1,041.21
$1,139.33
$1,487.87
$1,211.04
$1,303.66
$1,401.78
$1,750.32
$1,473.49
$1,566.11
$1,664.23
$2,012.77
$262.45
Toc - Plan #99 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$8,395 $16,790 Annual Deductible
$8,885 $17,770 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.85
$358.49
$403.65
$564.10
$857.21
$557.48
$600.12
$645.28
$805.73
$799.11
$841.75
$886.91
$1,047.36
$1,040.74
$1,083.38
$1,128.54
$1,288.99
$241.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.70
$716.98
$807.30
$1,128.20
$1,714.42
$873.33
$958.61
$1,048.93
$1,369.83
$1,114.96
$1,200.24
$1,290.56
$1,611.46
$1,356.59
$1,441.87
$1,532.19
$1,853.09
$241.63
Toc - Plan #100 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.45
$358.03
$403.14
$563.39
$856.12
$556.77
$599.35
$644.46
$804.71
$798.09
$840.67
$885.78
$1,046.03
$1,039.41
$1,081.99
$1,127.10
$1,287.35
$241.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.90
$716.06
$806.28
$1,126.78
$1,712.24
$872.22
$957.38
$1,047.60
$1,368.10
$1,113.54
$1,198.70
$1,288.92
$1,609.42
$1,354.86
$1,440.02
$1,530.24
$1,850.74
$241.32
Toc - Plan #101 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 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
$291.01
$330.30
$371.91
$519.74
$789.80
$513.63
$552.92
$594.53
$742.36
$736.25
$775.54
$817.15
$964.98
$958.87
$998.16
$1,039.77
$1,187.60
$222.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.02
$660.60
$743.82
$1,039.48
$1,579.60
$804.64
$883.22
$966.44
$1,262.10
$1,027.26
$1,105.84
$1,189.06
$1,484.72
$1,249.88
$1,328.46
$1,411.68
$1,707.34
$222.62
Toc - Plan #102 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$344.16
$390.62
$439.83
$614.66
$934.03
$607.44
$653.90
$703.11
$877.94
$870.72
$917.18
$966.39
$1,141.22
$1,134.00
$1,180.46
$1,229.67
$1,404.50
$263.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.32
$781.24
$879.66
$1,229.32
$1,868.06
$951.60
$1,044.52
$1,142.94
$1,492.60
$1,214.88
$1,307.80
$1,406.22
$1,755.88
$1,478.16
$1,571.08
$1,669.50
$2,019.16
$263.28
Toc - Plan #103 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.15
$366.77
$412.98
$577.14
$877.01
$570.36
$613.98
$660.19
$824.35
$817.57
$861.19
$907.40
$1,071.56
$1,064.78
$1,108.40
$1,154.61
$1,318.77
$247.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.30
$733.54
$825.96
$1,154.28
$1,754.02
$893.51
$980.75
$1,073.17
$1,401.49
$1,140.72
$1,227.96
$1,320.38
$1,648.70
$1,387.93
$1,475.17
$1,567.59
$1,895.91
$247.21
Toc - Plan #104 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7 + Rx Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-365-7373

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.41
$367.08
$413.32
$577.61
$877.74
$570.82
$614.49
$660.73
$825.02
$818.23
$861.90
$908.14
$1,072.43
$1,065.64
$1,109.31
$1,155.55
$1,319.84
$247.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.82
$734.16
$826.64
$1,155.22
$1,755.48
$894.23
$981.57
$1,074.05
$1,402.63
$1,141.64
$1,228.98
$1,321.46
$1,650.04
$1,389.05
$1,476.39
$1,568.87
$1,897.45
$247.41

‡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 Lake County here.

Lake County is in “Rating Area 1” of Illinois.

Currently, there are 104 plans offered in Rating Area 1.

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2024 Obamacare Plans for Lake County, IL

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