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Obamacare 2023 Rates for Saint Clair County

Obamacare > Rates > Illinois > Saint Clair County

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

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

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

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

Obamacare Providers, 77 Plans and 2023 Rates for Saint Clair County, Illinois

Below, you’ll find a summary of the 77 plans for Saint Clair County, Illinois and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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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 #1 Ambetter of Illinois
Silver

(HMO) Premier Silver

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

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.95
$425.55
$479.17
$669.64
$1,017.58 		$661.78
$712.38
$766.00
$956.47 		$948.61
$999.21
$1,052.83
$1,243.30 		$1,235.44
$1,286.04
$1,339.66
$1,530.13 		$286.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.90
$851.10
$958.34
$1,339.28
$2,035.16 		$1,036.73
$1,137.93
$1,245.17
$1,626.11 		$1,323.56
$1,424.76
$1,532.00
$1,912.94 		$1,610.39
$1,711.59
$1,818.83
$2,199.77 		$286.83
Toc - Plan #2 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 		$438.05
$497.17
$559.81
$782.34
$1,188.83 		$773.15
$832.27
$894.91
$1,117.44 		$1,108.25
$1,167.37
$1,230.01
$1,452.54 		$1,443.35
$1,502.47
$1,565.11
$1,787.64 		$335.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$876.10
$994.34
$1,119.62
$1,564.68
$2,377.66 		$1,211.20
$1,329.44
$1,454.72
$1,899.78 		$1,546.30
$1,664.54
$1,789.82
$2,234.88 		$1,881.40
$1,999.64
$2,124.92
$2,569.98 		$335.10
Toc - Plan #3 Ambetter of Illinois
Silver

(HMO) Complete Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.42
$424.96
$478.50
$668.70
$1,016.15 		$660.84
$711.38
$764.92
$955.12 		$947.26
$997.80
$1,051.34
$1,241.54 		$1,233.68
$1,284.22
$1,337.76
$1,527.96 		$286.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.84
$849.92
$957.00
$1,337.40
$2,032.30 		$1,035.26
$1,136.34
$1,243.42
$1,623.82 		$1,321.68
$1,422.76
$1,529.84
$1,910.24 		$1,608.10
$1,709.18
$1,816.26
$2,196.66 		$286.42
Toc - Plan #4 Ambetter of Illinois
Expanded Bronze

(HMO) Everyday Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$311.58
$353.63
$398.19
$556.47
$845.61 		$549.93
$591.98
$636.54
$794.82 		$788.28
$830.33
$874.89
$1,033.17 		$1,026.63
$1,068.68
$1,113.24
$1,271.52 		$238.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$623.16
$707.26
$796.38
$1,112.94
$1,691.22 		$861.51
$945.61
$1,034.73
$1,351.29 		$1,099.86
$1,183.96
$1,273.08
$1,589.64 		$1,338.21
$1,422.31
$1,511.43
$1,827.99 		$238.35
Toc - Plan #5 Ambetter of Illinois
Silver

(HMO) Everyday Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$368.61
$418.36
$471.07
$658.32
$1,000.38 		$650.59
$700.34
$753.05
$940.30 		$932.57
$982.32
$1,035.03
$1,222.28 		$1,214.55
$1,264.30
$1,317.01
$1,504.26 		$281.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$737.22
$836.72
$942.14
$1,316.64
$2,000.76 		$1,019.20
$1,118.70
$1,224.12
$1,598.62 		$1,301.18
$1,400.68
$1,506.10
$1,880.60 		$1,583.16
$1,682.66
$1,788.08
$2,162.58 		$281.98
Toc - Plan #6 Ambetter of Illinois
Silver

(HMO) Elite Silver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.97
$448.28
$504.76
$705.39
$1,071.92 		$697.11
$750.42
$806.90
$1,007.53 		$999.25
$1,052.56
$1,109.04
$1,309.67 		$1,301.39
$1,354.70
$1,411.18
$1,611.81 		$302.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.94
$896.56
$1,009.52
$1,410.78
$2,143.84 		$1,092.08
$1,198.70
$1,311.66
$1,712.92 		$1,394.22
$1,500.84
$1,613.80
$2,015.06 		$1,696.36
$1,802.98
$1,915.94
$2,317.20 		$302.14
Toc - Plan #7 Ambetter of Illinois
Expanded Bronze

(HMO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.25
$343.04
$386.26
$539.79
$820.27 		$533.46
$574.25
$617.47
$771.00 		$764.67
$805.46
$848.68
$1,002.21 		$995.88
$1,036.67
$1,079.89
$1,233.42 		$231.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.50
$686.08
$772.52
$1,079.58
$1,640.54 		$835.71
$917.29
$1,003.73
$1,310.79 		$1,066.92
$1,148.50
$1,234.94
$1,542.00 		$1,298.13
$1,379.71
$1,466.15
$1,773.21 		$231.21
Toc - Plan #8 Ambetter of Illinois
Expanded Bronze

(HMO) Elite Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.94
$410.79
$462.54
$646.40
$982.27 		$638.81
$687.66
$739.41
$923.27 		$915.68
$964.53
$1,016.28
$1,200.14 		$1,192.55
$1,241.40
$1,293.15
$1,477.01 		$276.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.88
$821.58
$925.08
$1,292.80
$1,964.54 		$1,000.75
$1,098.45
$1,201.95
$1,569.67 		$1,277.62
$1,375.32
$1,478.82
$1,846.54 		$1,554.49
$1,652.19
$1,755.69
$2,123.41 		$276.87
Toc - Plan #9 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 		$357.44
$405.68
$456.79
$638.36
$970.06 		$630.87
$679.11
$730.22
$911.79 		$904.30
$952.54
$1,003.65
$1,185.22 		$1,177.73
$1,225.97
$1,277.08
$1,458.65 		$273.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.88
$811.36
$913.58
$1,276.72
$1,940.12 		$988.31
$1,084.79
$1,187.01
$1,550.15 		$1,261.74
$1,358.22
$1,460.44
$1,823.58 		$1,535.17
$1,631.65
$1,733.87
$2,097.01 		$273.43
Toc - Plan #10 Ambetter of Illinois
Silver

(HMO) Focused Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.89
$413.00
$465.03
$649.88
$987.56 		$642.25
$691.36
$743.39
$928.24 		$920.61
$969.72
$1,021.75
$1,206.60 		$1,198.97
$1,248.08
$1,300.11
$1,484.96 		$278.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$727.78
$826.00
$930.06
$1,299.76
$1,975.12 		$1,006.14
$1,104.36
$1,208.42
$1,578.12 		$1,284.50
$1,382.72
$1,486.78
$1,856.48 		$1,562.86
$1,661.08
$1,765.14
$2,134.84 		$278.36
Toc - Plan #11 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 		$415.25
$471.30
$530.68
$741.62
$1,126.97 		$732.91
$788.96
$848.34
$1,059.28 		$1,050.57
$1,106.62
$1,166.00
$1,376.94 		$1,368.23
$1,424.28
$1,483.66
$1,694.60 		$317.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.50
$942.60
$1,061.36
$1,483.24
$2,253.94 		$1,148.16
$1,260.26
$1,379.02
$1,800.90 		$1,465.82
$1,577.92
$1,696.68
$2,118.56 		$1,783.48
$1,895.58
$2,014.34
$2,436.22 		$317.66
Toc - Plan #12 Ambetter of Illinois
Bronze

(HMO) Clear Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$277.99
$315.50
$355.26
$496.47
$754.43 		$490.64
$528.15
$567.91
$709.12 		$703.29
$740.80
$780.56
$921.77 		$915.94
$953.45
$993.21
$1,134.42 		$212.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$555.98
$631.00
$710.52
$992.94
$1,508.86 		$768.63
$843.65
$923.17
$1,205.59 		$981.28
$1,056.30
$1,135.82
$1,418.24 		$1,193.93
$1,268.95
$1,348.47
$1,630.89 		$212.65
Toc - Plan #13 Ambetter of Illinois
Gold

(HMO) Elite Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$491.48
$557.81
$628.09
$877.76
$1,333.84 		$867.45
$933.78
$1,004.06
$1,253.73 		$1,243.42
$1,309.75
$1,380.03
$1,629.70 		$1,619.39
$1,685.72
$1,756.00
$2,005.67 		$375.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$982.96
$1,115.62
$1,256.18
$1,755.52
$2,667.68 		$1,358.93
$1,491.59
$1,632.15
$2,131.49 		$1,734.90
$1,867.56
$2,008.12
$2,507.46 		$2,110.87
$2,243.53
$2,384.09
$2,883.43 		$375.97
Toc - Plan #14 Ambetter of Illinois
Expanded Bronze

(HMO) Central Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$307.83
$349.38
$393.40
$549.77
$835.43 		$543.31
$584.86
$628.88
$785.25 		$778.79
$820.34
$864.36
$1,020.73 		$1,014.27
$1,055.82
$1,099.84
$1,256.21 		$235.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.66
$698.76
$786.80
$1,099.54
$1,670.86 		$851.14
$934.24
$1,022.28
$1,335.02 		$1,086.62
$1,169.72
$1,257.76
$1,570.50 		$1,322.10
$1,405.20
$1,493.24
$1,805.98 		$235.48
Toc - Plan #15 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 		$384.73
$436.66
$491.67
$687.11
$1,044.14 		$679.04
$730.97
$785.98
$981.42 		$973.35
$1,025.28
$1,080.29
$1,275.73 		$1,267.66
$1,319.59
$1,374.60
$1,570.04 		$294.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.46
$873.32
$983.34
$1,374.22
$2,088.28 		$1,063.77
$1,167.63
$1,277.65
$1,668.53 		$1,358.08
$1,461.94
$1,571.96
$1,962.84 		$1,652.39
$1,756.25
$1,866.27
$2,257.15 		$294.31
Toc - Plan #16 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 		$424.36
$481.64
$542.32
$757.89
$1,151.69 		$748.99
$806.27
$866.95
$1,082.52 		$1,073.62
$1,130.90
$1,191.58
$1,407.15 		$1,398.25
$1,455.53
$1,516.21
$1,731.78 		$324.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$848.72
$963.28
$1,084.64
$1,515.78
$2,303.38 		$1,173.35
$1,287.91
$1,409.27
$1,840.41 		$1,497.98
$1,612.54
$1,733.90
$2,165.04 		$1,822.61
$1,937.17
$2,058.53
$2,489.67 		$324.63
Toc - Plan #17 Ambetter of Illinois
Bronze

(HMO) CMS Standard Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$260.93
$296.14
$333.45
$466.00
$708.13 		$460.53
$495.74
$533.05
$665.60 		$660.13
$695.34
$732.65
$865.20 		$859.73
$894.94
$932.25
$1,064.80 		$199.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$521.86
$592.28
$666.90
$932.00
$1,416.26 		$721.46
$791.88
$866.50
$1,131.60 		$921.06
$991.48
$1,066.10
$1,331.20 		$1,120.66
$1,191.08
$1,265.70
$1,530.80 		$199.60
Toc - Plan #18 Ambetter of Illinois
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$302.51
$343.34
$386.59
$540.26
$820.98 		$533.92
$574.75
$618.00
$771.67 		$765.33
$806.16
$849.41
$1,003.08 		$996.74
$1,037.57
$1,080.82
$1,234.49 		$231.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$605.02
$686.68
$773.18
$1,080.52
$1,641.96 		$836.43
$918.09
$1,004.59
$1,311.93 		$1,067.84
$1,149.50
$1,236.00
$1,543.34 		$1,299.25
$1,380.91
$1,467.41
$1,774.75 		$231.41
Toc - Plan #19 Ambetter of Illinois
Silver

(HMO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.22
$409.98
$461.63
$645.13
$980.33 		$637.55
$686.31
$737.96
$921.46 		$913.88
$962.64
$1,014.29
$1,197.79 		$1,190.21
$1,238.97
$1,290.62
$1,474.12 		$276.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.44
$819.96
$923.26
$1,290.26
$1,960.66 		$998.77
$1,096.29
$1,199.59
$1,566.59 		$1,275.10
$1,372.62
$1,475.92
$1,842.92 		$1,551.43
$1,648.95
$1,752.25
$2,119.25 		$276.33
Toc - Plan #20 Ambetter of Illinois
Gold

(HMO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$405.09
$459.77
$517.69
$723.47
$1,099.39 		$714.98
$769.66
$827.58
$1,033.36 		$1,024.87
$1,079.55
$1,137.47
$1,343.25 		$1,334.76
$1,389.44
$1,447.36
$1,653.14 		$309.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.18
$919.54
$1,035.38
$1,446.94
$2,198.78 		$1,120.07
$1,229.43
$1,345.27
$1,756.83 		$1,429.96
$1,539.32
$1,655.16
$2,066.72 		$1,739.85
$1,849.21
$1,965.05
$2,376.61 		$309.89
Toc - Plan #21 Ambetter of Illinois
Silver

(HMO) Premier Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,550 $15,100 Annual Deductible
$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.37
$441.92
$497.60
$695.40
$1,056.73 		$687.23
$739.78
$795.46
$993.26 		$985.09
$1,037.64
$1,093.32
$1,291.12 		$1,282.95
$1,335.50
$1,391.18
$1,588.98 		$297.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.74
$883.84
$995.20
$1,390.80
$2,113.46 		$1,076.60
$1,181.70
$1,293.06
$1,688.66 		$1,374.46
$1,479.56
$1,590.92
$1,986.52 		$1,672.32
$1,777.42
$1,888.78
$2,284.38 		$297.86
Toc - Plan #22 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 		$454.90
$516.30
$581.35
$812.43
$1,234.57 		$802.89
$864.29
$929.34
$1,160.42 		$1,150.88
$1,212.28
$1,277.33
$1,508.41 		$1,498.87
$1,560.27
$1,625.32
$1,856.40 		$347.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.80
$1,032.60
$1,162.70
$1,624.86
$2,469.14 		$1,257.79
$1,380.59
$1,510.69
$1,972.85 		$1,605.78
$1,728.58
$1,858.68
$2,320.84 		$1,953.77
$2,076.57
$2,206.67
$2,668.83 		$347.99
Toc - Plan #23 Ambetter of Illinois
Silver

(HMO) Complete Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$388.83
$441.31
$496.91
$694.42
$1,055.25 		$686.27
$738.75
$794.35
$991.86 		$983.71
$1,036.19
$1,091.79
$1,289.30 		$1,281.15
$1,333.63
$1,389.23
$1,586.74 		$297.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.66
$882.62
$993.82
$1,388.84
$2,110.50 		$1,075.10
$1,180.06
$1,291.26
$1,686.28 		$1,372.54
$1,477.50
$1,588.70
$1,983.72 		$1,669.98
$1,774.94
$1,886.14
$2,281.16 		$297.44
Toc - Plan #24 Ambetter of Illinois
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323.57
$367.24
$413.51
$577.88
$878.14 		$571.09
$614.76
$661.03
$825.40 		$818.61
$862.28
$908.55
$1,072.92 		$1,066.13
$1,109.80
$1,156.07
$1,320.44 		$247.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.14
$734.48
$827.02
$1,155.76
$1,756.28 		$894.66
$982.00
$1,074.54
$1,403.28 		$1,142.18
$1,229.52
$1,322.06
$1,650.80 		$1,389.70
$1,477.04
$1,569.58
$1,898.32 		$247.52
Toc - Plan #25 Ambetter of Illinois
Silver

(HMO) Elite Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,200 $16,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$410.16
$465.52
$524.18
$732.53
$1,113.15 		$723.93
$779.29
$837.95
$1,046.30 		$1,037.70
$1,093.06
$1,151.72
$1,360.07 		$1,351.47
$1,406.83
$1,465.49
$1,673.84 		$313.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$820.32
$931.04
$1,048.36
$1,465.06
$2,226.30 		$1,134.09
$1,244.81
$1,362.13
$1,778.83 		$1,447.86
$1,558.58
$1,675.90
$2,092.60 		$1,761.63
$1,872.35
$1,989.67
$2,406.37 		$313.77
Toc - Plan #26 Ambetter of Illinois
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$313.87
$356.24
$401.12
$560.56
$851.83 		$553.98
$596.35
$641.23
$800.67 		$794.09
$836.46
$881.34
$1,040.78 		$1,034.20
$1,076.57
$1,121.45
$1,280.89 		$240.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$627.74
$712.48
$802.24
$1,121.12
$1,703.66 		$867.85
$952.59
$1,042.35
$1,361.23 		$1,107.96
$1,192.70
$1,282.46
$1,601.34 		$1,348.07
$1,432.81
$1,522.57
$1,841.45 		$240.11
Toc - Plan #27 Ambetter of Illinois
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.86
$426.59
$480.34
$671.27
$1,020.06 		$663.39
$714.12
$767.87
$958.80 		$950.92
$1,001.65
$1,055.40
$1,246.33 		$1,238.45
$1,289.18
$1,342.93
$1,533.86 		$287.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.72
$853.18
$960.68
$1,342.54
$2,040.12 		$1,039.25
$1,140.71
$1,248.21
$1,630.07 		$1,326.78
$1,428.24
$1,535.74
$1,917.60 		$1,614.31
$1,715.77
$1,823.27
$2,205.13 		$287.53
Toc - Plan #28 Ambetter of Illinois
Silver

(HMO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$377.88
$428.89
$482.92
$674.88
$1,025.55 		$666.95
$717.96
$771.99
$963.95 		$956.02
$1,007.03
$1,061.06
$1,253.02 		$1,245.09
$1,296.10
$1,350.13
$1,542.09 		$289.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$755.76
$857.78
$965.84
$1,349.76
$2,051.10 		$1,044.83
$1,146.85
$1,254.91
$1,638.83 		$1,333.90
$1,435.92
$1,543.98
$1,927.90 		$1,622.97
$1,724.99
$1,833.05
$2,216.97 		$289.07
Toc - Plan #29 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 		$431.23
$489.43
$551.10
$770.15
$1,170.32 		$761.11
$819.31
$880.98
$1,100.03 		$1,090.99
$1,149.19
$1,210.86
$1,429.91 		$1,420.87
$1,479.07
$1,540.74
$1,759.79 		$329.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.46
$978.86
$1,102.20
$1,540.30
$2,340.64 		$1,192.34
$1,308.74
$1,432.08
$1,870.18 		$1,522.22
$1,638.62
$1,761.96
$2,200.06 		$1,852.10
$1,968.50
$2,091.84
$2,529.94 		$329.88
Toc - Plan #30 Ambetter of Illinois
Silver

(HMO) Everyday Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$382.79
$434.46
$489.19
$683.65
$1,038.87 		$675.62
$727.29
$782.02
$976.48 		$968.45
$1,020.12
$1,074.85
$1,269.31 		$1,261.28
$1,312.95
$1,367.68
$1,562.14 		$292.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.58
$868.92
$978.38
$1,367.30
$2,077.74 		$1,058.41
$1,161.75
$1,271.21
$1,660.13 		$1,351.24
$1,454.58
$1,564.04
$1,952.96 		$1,644.07
$1,747.41
$1,856.87
$2,245.79 		$292.83
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 		$371.19
$421.29
$474.37
$662.92
$1,007.38 		$655.14
$705.24
$758.32
$946.87 		$939.09
$989.19
$1,042.27
$1,230.82 		$1,223.04
$1,273.14
$1,326.22
$1,514.77 		$283.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.38
$842.58
$948.74
$1,325.84
$2,014.76 		$1,026.33
$1,126.53
$1,232.69
$1,609.79 		$1,310.28
$1,410.48
$1,516.64
$1,893.74 		$1,594.23
$1,694.43
$1,800.59
$2,177.69 		$283.95
Toc - Plan #32 Ambetter of Illinois
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$288.68
$327.64
$368.92
$515.57
$783.46 		$509.51
$548.47
$589.75
$736.40 		$730.34
$769.30
$810.58
$957.23 		$951.17
$990.13
$1,031.41
$1,178.06 		$220.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$577.36
$655.28
$737.84
$1,031.14
$1,566.92 		$798.19
$876.11
$958.67
$1,251.97 		$1,019.02
$1,096.94
$1,179.50
$1,472.80 		$1,239.85
$1,317.77
$1,400.33
$1,693.63 		$220.83
Toc - Plan #33 Ambetter of Illinois
Gold

(HMO) Elite Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$510.38
$579.27
$652.26
$911.53
$1,385.16 		$900.82
$969.71
$1,042.70
$1,301.97 		$1,291.26
$1,360.15
$1,433.14
$1,692.41 		$1,681.70
$1,750.59
$1,823.58
$2,082.85 		$390.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,020.76
$1,158.54
$1,304.52
$1,823.06
$2,770.32 		$1,411.20
$1,548.98
$1,694.96
$2,213.50 		$1,801.64
$1,939.42
$2,085.40
$2,603.94 		$2,192.08
$2,329.86
$2,475.84
$2,994.38 		$390.44
Toc - Plan #34 Ambetter of Illinois
Expanded Bronze

(HMO) Central Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.68
$362.82
$408.53
$570.92
$867.57 		$564.22
$607.36
$653.07
$815.46 		$808.76
$851.90
$897.61
$1,060.00 		$1,053.30
$1,096.44
$1,142.15
$1,304.54 		$244.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.36
$725.64
$817.06
$1,141.84
$1,735.14 		$883.90
$970.18
$1,061.60
$1,386.38 		$1,128.44
$1,214.72
$1,306.14
$1,630.92 		$1,372.98
$1,459.26
$1,550.68
$1,875.46 		$244.54
Toc - Plan #35 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 		$399.53
$453.46
$510.59
$713.55
$1,084.31 		$705.17
$759.10
$816.23
$1,019.19 		$1,010.81
$1,064.74
$1,121.87
$1,324.83 		$1,316.45
$1,370.38
$1,427.51
$1,630.47 		$305.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$799.06
$906.92
$1,021.18
$1,427.10
$2,168.62 		$1,104.70
$1,212.56
$1,326.82
$1,732.74 		$1,410.34
$1,518.20
$1,632.46
$2,038.38 		$1,715.98
$1,823.84
$1,938.10
$2,344.02 		$305.64
Toc - Plan #36 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 		$440.69
$500.17
$563.19
$787.05
$1,196.00 		$777.81
$837.29
$900.31
$1,124.17 		$1,114.93
$1,174.41
$1,237.43
$1,461.29 		$1,452.05
$1,511.53
$1,574.55
$1,798.41 		$337.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.38
$1,000.34
$1,126.38
$1,574.10
$2,392.00 		$1,218.50
$1,337.46
$1,463.50
$1,911.22 		$1,555.62
$1,674.58
$1,800.62
$2,248.34 		$1,892.74
$2,011.70
$2,137.74
$2,585.46 		$337.12

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 #37 Blue Cross and Blue Shield of Illinois
Gold

(PPO) Blue Choice Preferred Gold PPO? 204

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

Annual Out of Pocket Expenses:

Individual Family
$750 $2,250 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$533.49
$605.51
$681.80
$952.81
$1,447.89 		$941.61
$1,013.63
$1,089.92
$1,360.93 		$1,349.73
$1,421.75
$1,498.04
$1,769.05 		$1,757.85
$1,829.87
$1,906.16
$2,177.17 		$408.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,066.98
$1,211.02
$1,363.60
$1,905.62
$2,895.78 		$1,475.10
$1,619.14
$1,771.72
$2,313.74 		$1,883.22
$2,027.26
$2,179.84
$2,721.86 		$2,291.34
$2,435.38
$2,587.96
$3,129.98 		$408.12
Toc - Plan #38 Blue Cross and Blue Shield of Illinois
Silver

(PPO) Blue Choice Preferred Silver PPO? 203

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

Annual Out of Pocket Expenses:

Individual Family
$2,250 $6,750 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$447.01
$507.35
$571.28
$798.36
$1,213.18 		$788.97
$849.31
$913.24
$1,140.32 		$1,130.93
$1,191.27
$1,255.20
$1,482.28 		$1,472.89
$1,533.23
$1,597.16
$1,824.24 		$341.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$894.02
$1,014.70
$1,142.56
$1,596.72
$2,426.36 		$1,235.98
$1,356.66
$1,484.52
$1,938.68 		$1,577.94
$1,698.62
$1,826.48
$2,280.64 		$1,919.90
$2,040.58
$2,168.44
$2,622.60 		$341.96
Toc - Plan #39 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 202

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $13,500 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$392.72
$445.74
$501.89
$701.40
$1,065.84 		$693.15
$746.17
$802.32
$1,001.83 		$993.58
$1,046.60
$1,102.75
$1,302.26 		$1,294.01
$1,347.03
$1,403.18
$1,602.69 		$300.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.44
$891.48
$1,003.78
$1,402.80
$2,131.68 		$1,085.87
$1,191.91
$1,304.21
$1,703.23 		$1,386.30
$1,492.34
$1,604.64
$2,003.66 		$1,686.73
$1,792.77
$1,905.07
$2,304.09 		$300.43
Toc - Plan #40 Blue Cross and Blue Shield of Illinois
Catastrophic

(PPO) Blue Choice Preferred Security PPO? 200

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$323.55
$367.23
$413.49
$577.86
$878.11 		$571.06
$614.74
$661.00
$825.37 		$818.57
$862.25
$908.51
$1,072.88 		$1,066.08
$1,109.76
$1,156.02
$1,320.39 		$247.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$647.10
$734.46
$826.98
$1,155.72
$1,756.22 		$894.61
$981.97
$1,074.49
$1,403.23 		$1,142.12
$1,229.48
$1,322.00
$1,650.74 		$1,389.63
$1,476.99
$1,569.51
$1,898.25 		$247.51
Toc - Plan #41 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 201

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$353.36
$401.06
$451.59
$631.10
$959.02 		$623.68
$671.38
$721.91
$901.42 		$894.00
$941.70
$992.23
$1,171.74 		$1,164.32
$1,212.02
$1,262.55
$1,442.06 		$270.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.72
$802.12
$903.18
$1,262.20
$1,918.04 		$977.04
$1,072.44
$1,173.50
$1,532.52 		$1,247.36
$1,342.76
$1,443.82
$1,802.84 		$1,517.68
$1,613.08
$1,714.14
$2,073.16 		$270.32
Toc - Plan #42 Blue Cross and Blue Shield of Illinois
Bronze

(PPO) Blue Choice Preferred Bronze PPO? 601

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $17,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$345.02
$391.60
$440.94
$616.21
$936.39 		$608.96
$655.54
$704.88
$880.15 		$872.90
$919.48
$968.82
$1,144.09 		$1,136.84
$1,183.42
$1,232.76
$1,408.03 		$263.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.04
$783.20
$881.88
$1,232.42
$1,872.78 		$953.98
$1,047.14
$1,145.82
$1,496.36 		$1,217.92
$1,311.08
$1,409.76
$1,760.30 		$1,481.86
$1,575.02
$1,673.70
$2,024.24 		$263.94
Toc - Plan #43 Blue Cross and Blue Shield of Illinois
Bronze

(PPO) Blue Choice Preferred Bronze PPO? 701

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

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$325.71
$369.68
$416.26
$581.72
$883.99 		$574.88
$618.85
$665.43
$830.89 		$824.05
$868.02
$914.60
$1,080.06 		$1,073.22
$1,117.19
$1,163.77
$1,329.23 		$249.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.42
$739.36
$832.52
$1,163.44
$1,767.98 		$900.59
$988.53
$1,081.69
$1,412.61 		$1,149.76
$1,237.70
$1,330.86
$1,661.78 		$1,398.93
$1,486.87
$1,580.03
$1,910.95 		$249.17
Toc - Plan #44 Blue Cross and Blue Shield of Illinois
Gold

(PPO) Blue Choice Preferred Gold PPO? 707

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$520.46
$590.72
$665.15
$929.55
$1,412.53 		$918.61
$988.87
$1,063.30
$1,327.70 		$1,316.76
$1,387.02
$1,461.45
$1,725.85 		$1,714.91
$1,785.17
$1,859.60
$2,124.00 		$398.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,040.92
$1,181.44
$1,330.30
$1,859.10
$2,825.06 		$1,439.07
$1,579.59
$1,728.45
$2,257.25 		$1,837.22
$1,977.74
$2,126.60
$2,655.40 		$2,235.37
$2,375.89
$2,524.75
$3,053.55 		$398.15
Toc - Plan #45 Blue Cross and Blue Shield of Illinois
Expanded Bronze

(PPO) Blue Choice Preferred Bronze PPO? 708

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.91
$451.63
$508.53
$710.68
$1,079.94 		$702.31
$756.03
$812.93
$1,015.08 		$1,006.71
$1,060.43
$1,117.33
$1,319.48 		$1,311.11
$1,364.83
$1,421.73
$1,623.88 		$304.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.82
$903.26
$1,017.06
$1,421.36
$2,159.88 		$1,100.22
$1,207.66
$1,321.46
$1,725.76 		$1,404.62
$1,512.06
$1,625.86
$2,030.16 		$1,709.02
$1,816.46
$1,930.26
$2,334.56 		$304.40
Toc - Plan #46 Blue Cross and Blue Shield of Illinois
Silver

(PPO) Blue Choice Preferred Silver PPO? 706

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$452.45
$513.53
$578.23
$808.07
$1,227.94 		$798.57
$859.65
$924.35
$1,154.19 		$1,144.69
$1,205.77
$1,270.47
$1,500.31 		$1,490.81
$1,551.89
$1,616.59
$1,846.43 		$346.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.90
$1,027.06
$1,156.46
$1,616.14
$2,455.88 		$1,251.02
$1,373.18
$1,502.58
$1,962.26 		$1,597.14
$1,719.30
$1,848.70
$2,308.38 		$1,943.26
$2,065.42
$2,194.82
$2,654.50 		$346.12
Toc - Plan #47 Blue Cross and Blue Shield of Illinois
Bronze

(PPO) Blue Choice Preferred Bronze PPO? 705

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$338.98
$384.74
$433.21
$605.41
$919.98 		$598.30
$644.06
$692.53
$864.73 		$857.62
$903.38
$951.85
$1,124.05 		$1,116.94
$1,162.70
$1,211.17
$1,383.37 		$259.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.96
$769.48
$866.42
$1,210.82
$1,839.96 		$937.28
$1,028.80
$1,125.74
$1,470.14 		$1,196.60
$1,288.12
$1,385.06
$1,729.46 		$1,455.92
$1,547.44
$1,644.38
$1,988.78 		$259.32

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0325 | Toll Free: 1-888-200-0325 | TTY: 1-888-200-0325
Toc - Plan #48 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$301.54
$342.25
$385.37
$538.56
$818.39 		$532.22
$572.93
$616.05
$769.24 		$762.90
$803.61
$846.73
$999.92 		$993.58
$1,034.29
$1,077.41
$1,230.60 		$230.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.08
$684.50
$770.74
$1,077.12
$1,636.78 		$833.76
$915.18
$1,001.42
$1,307.80 		$1,064.44
$1,145.86
$1,232.10
$1,538.48 		$1,295.12
$1,376.54
$1,462.78
$1,769.16 		$230.68
Toc - Plan #49 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,450 $6,900 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$364.87
$414.13
$466.31
$651.66
$990.26 		$644.00
$693.26
$745.44
$930.79 		$923.13
$972.39
$1,024.57
$1,209.92 		$1,202.26
$1,251.52
$1,303.70
$1,489.05 		$279.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$729.74
$828.26
$932.62
$1,303.32
$1,980.52 		$1,008.87
$1,107.39
$1,211.75
$1,582.45 		$1,288.00
$1,386.52
$1,490.88
$1,861.58 		$1,567.13
$1,665.65
$1,770.01
$2,140.71 		$279.13
Toc - Plan #50 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$359.48
$408.01
$459.42
$642.03
$975.63 		$634.48
$683.01
$734.42
$917.03 		$909.48
$958.01
$1,009.42
$1,192.03 		$1,184.48
$1,233.01
$1,284.42
$1,467.03 		$275.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.96
$816.02
$918.84
$1,284.06
$1,951.26 		$993.96
$1,091.02
$1,193.84
$1,559.06 		$1,268.96
$1,366.02
$1,468.84
$1,834.06 		$1,543.96
$1,641.02
$1,743.84
$2,109.06 		$275.00
Toc - Plan #51 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$426.47
$484.05
$545.03
$761.68
$1,157.44 		$752.72
$810.30
$871.28
$1,087.93 		$1,078.97
$1,136.55
$1,197.53
$1,414.18 		$1,405.22
$1,462.80
$1,523.78
$1,740.43 		$326.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$852.94
$968.10
$1,090.06
$1,523.36
$2,314.88 		$1,179.19
$1,294.35
$1,416.31
$1,849.61 		$1,505.44
$1,620.60
$1,742.56
$2,175.86 		$1,831.69
$1,946.85
$2,068.81
$2,502.11 		$326.25
Toc - Plan #52 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$446.32
$506.57
$570.39
$797.12
$1,211.30 		$787.75
$848.00
$911.82
$1,138.55 		$1,129.18
$1,189.43
$1,253.25
$1,479.98 		$1,470.61
$1,530.86
$1,594.68
$1,821.41 		$341.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$892.64
$1,013.14
$1,140.78
$1,594.24
$2,422.60 		$1,234.07
$1,354.57
$1,482.21
$1,935.67 		$1,575.50
$1,696.00
$1,823.64
$2,277.10 		$1,916.93
$2,037.43
$2,165.07
$2,618.53 		$341.43
Toc - Plan #53 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 Annual Deductible
$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$466.28
$529.23
$595.91
$832.78
$1,265.49 		$822.99
$885.94
$952.62
$1,189.49 		$1,179.70
$1,242.65
$1,309.33
$1,546.20 		$1,536.41
$1,599.36
$1,666.04
$1,902.91 		$356.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$932.56
$1,058.46
$1,191.82
$1,665.56
$2,530.98 		$1,289.27
$1,415.17
$1,548.53
$2,022.27 		$1,645.98
$1,771.88
$1,905.24
$2,378.98 		$2,002.69
$2,128.59
$2,261.95
$2,735.69 		$356.71
Toc - Plan #54 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (Rx Copay)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433.84
$492.40
$554.44
$774.83
$1,177.43 		$765.72
$824.28
$886.32
$1,106.71 		$1,097.60
$1,156.16
$1,218.20
$1,438.59 		$1,429.48
$1,488.04
$1,550.08
$1,770.47 		$331.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.68
$984.80
$1,108.88
$1,549.66
$2,354.86 		$1,199.56
$1,316.68
$1,440.76
$1,881.54 		$1,531.44
$1,648.56
$1,772.64
$2,213.42 		$1,863.32
$1,980.44
$2,104.52
$2,545.30 		$331.88
Toc - Plan #55 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$371.63
$421.80
$474.94
$663.72
$1,008.59 		$655.92
$706.09
$759.23
$948.01 		$940.21
$990.38
$1,043.52
$1,232.30 		$1,224.50
$1,274.67
$1,327.81
$1,516.59 		$284.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$743.26
$843.60
$949.88
$1,327.44
$2,017.18 		$1,027.55
$1,127.89
$1,234.17
$1,611.73 		$1,311.84
$1,412.18
$1,518.46
$1,896.02 		$1,596.13
$1,696.47
$1,802.75
$2,180.31 		$284.29
Toc - Plan #56 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$381.15
$432.61
$487.11
$680.73
$1,034.44 		$672.73
$724.19
$778.69
$972.31 		$964.31
$1,015.77
$1,070.27
$1,263.89 		$1,255.89
$1,307.35
$1,361.85
$1,555.47 		$291.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.30
$865.22
$974.22
$1,361.46
$2,068.88 		$1,053.88
$1,156.80
$1,265.80
$1,653.04 		$1,345.46
$1,448.38
$1,557.38
$1,944.62 		$1,637.04
$1,739.96
$1,848.96
$2,236.20 		$291.58
Toc - Plan #57 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$363.02
$412.03
$463.94
$648.36
$985.25 		$640.73
$689.74
$741.65
$926.07 		$918.44
$967.45
$1,019.36
$1,203.78 		$1,196.15
$1,245.16
$1,297.07
$1,481.49 		$277.71
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$726.04
$824.06
$927.88
$1,296.72
$1,970.50 		$1,003.75
$1,101.77
$1,205.59
$1,574.43 		$1,281.46
$1,379.48
$1,483.30
$1,852.14 		$1,559.17
$1,657.19
$1,761.01
$2,129.85 		$277.71
Toc - Plan #58 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$366.78
$416.29
$468.74
$655.06
$995.43 		$647.36
$696.87
$749.32
$935.64 		$927.94
$977.45
$1,029.90
$1,216.22 		$1,208.52
$1,258.03
$1,310.48
$1,496.80 		$280.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$733.56
$832.58
$937.48
$1,310.12
$1,990.86 		$1,014.14
$1,113.16
$1,218.06
$1,590.70 		$1,294.72
$1,393.74
$1,498.64
$1,871.28 		$1,575.30
$1,674.32
$1,779.22
$2,151.86 		$280.58
Toc - Plan #59 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.34
$416.93
$469.46
$656.06
$996.95 		$648.35
$697.94
$750.47
$937.07 		$929.36
$978.95
$1,031.48
$1,218.08 		$1,210.37
$1,259.96
$1,312.49
$1,499.09 		$281.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.68
$833.86
$938.92
$1,312.12
$1,993.90 		$1,015.69
$1,114.87
$1,219.93
$1,593.13 		$1,296.70
$1,395.88
$1,500.94
$1,874.14 		$1,577.71
$1,676.89
$1,781.95
$2,155.15 		$281.01
Toc - Plan #60 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$312.99
$355.24
$400.00
$558.99
$849.45 		$552.42
$594.67
$639.43
$798.42 		$791.85
$834.10
$878.86
$1,037.85 		$1,031.28
$1,073.53
$1,118.29
$1,277.28 		$239.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.98
$710.48
$800.00
$1,117.98
$1,698.90 		$865.41
$949.91
$1,039.43
$1,357.41 		$1,104.84
$1,189.34
$1,278.86
$1,596.84 		$1,344.27
$1,428.77
$1,518.29
$1,836.27 		$239.43
Toc - Plan #61 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential (Preferred Rx)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$300.24
$340.77
$383.71
$536.23
$814.85 		$529.92
$570.45
$613.39
$765.91 		$759.60
$800.13
$843.07
$995.59 		$989.28
$1,029.81
$1,072.75
$1,225.27 		$229.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$600.48
$681.54
$767.42
$1,072.46
$1,629.70 		$830.16
$911.22
$997.10
$1,302.14 		$1,059.84
$1,140.90
$1,226.78
$1,531.82 		$1,289.52
$1,370.58
$1,456.46
$1,761.50 		$229.68
Toc - Plan #62 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.75
$351.57
$395.86
$553.21
$840.66 		$546.71
$588.53
$632.82
$790.17 		$783.67
$825.49
$869.78
$1,027.13 		$1,020.63
$1,062.45
$1,106.74
$1,264.09 		$236.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.50
$703.14
$791.72
$1,106.42
$1,681.32 		$856.46
$940.10
$1,028.68
$1,343.38 		$1,093.42
$1,177.06
$1,265.64
$1,580.34 		$1,330.38
$1,414.02
$1,502.60
$1,817.30 		$236.96
Toc - Plan #63 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard 1

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.94
$352.92
$397.38
$555.34
$843.89 		$548.81
$590.79
$635.25
$793.21 		$786.68
$828.66
$873.12
$1,031.08 		$1,024.55
$1,066.53
$1,110.99
$1,268.95 		$237.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$621.88
$705.84
$794.76
$1,110.68
$1,687.78 		$859.75
$943.71
$1,032.63
$1,348.55 		$1,097.62
$1,181.58
$1,270.50
$1,586.42 		$1,335.49
$1,419.45
$1,508.37
$1,824.29 		$237.87
Toc - Plan #64 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$291.52
$330.88
$372.56
$520.66
$791.19 		$514.53
$553.89
$595.57
$743.67 		$737.54
$776.90
$818.58
$966.68 		$960.55
$999.91
$1,041.59
$1,189.69 		$223.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.04
$661.76
$745.12
$1,041.32
$1,582.38 		$806.05
$884.77
$968.13
$1,264.33 		$1,029.06
$1,107.78
$1,191.14
$1,487.34 		$1,252.07
$1,330.79
$1,414.15
$1,710.35 		$223.01

ADVERTISEMENT

WellFirst Health

Local: 1-866-514-4194 | Toll Free: 1-866-514-4194 | TTY: 1-866-514-4194
Toc - Plan #65 WellFirst Health
Gold

(HMO) WellFirst Gold Copay Plus 1500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$5,700 $11,400 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 		$452.22
$513.27
$577.94
$807.66
$1,227.32 		$798.17
$859.22
$923.89
$1,153.61 		$1,144.12
$1,205.17
$1,269.84
$1,499.56 		$1,490.07
$1,551.12
$1,615.79
$1,845.51 		$345.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$904.44
$1,026.54
$1,155.88
$1,615.32
$2,454.64 		$1,250.39
$1,372.49
$1,501.83
$1,961.27 		$1,596.34
$1,718.44
$1,847.78
$2,307.22 		$1,942.29
$2,064.39
$2,193.73
$2,653.17 		$345.95
Toc - Plan #66 WellFirst Health
Silver

(HMO) WellFirst Silver Copay Plus 4800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,800 $9,600 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 		$400.72
$454.82
$512.12
$715.68
$1,087.55 		$707.27
$761.37
$818.67
$1,022.23 		$1,013.82
$1,067.92
$1,125.22
$1,328.78 		$1,320.37
$1,374.47
$1,431.77
$1,635.33 		$306.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.44
$909.64
$1,024.24
$1,431.36
$2,175.10 		$1,107.99
$1,216.19
$1,330.79
$1,737.91 		$1,414.54
$1,522.74
$1,637.34
$2,044.46 		$1,721.09
$1,829.29
$1,943.89
$2,351.01 		$306.55
Toc - Plan #67 WellFirst Health
Expanded Bronze

(HMO) WellFirst Bronze Copay Plus 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$307.11
$348.57
$392.49
$548.50
$833.50 		$542.05
$583.51
$627.43
$783.44 		$776.99
$818.45
$862.37
$1,018.38 		$1,011.93
$1,053.39
$1,097.31
$1,253.32 		$234.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$614.22
$697.14
$784.98
$1,097.00
$1,667.00 		$849.16
$932.08
$1,019.92
$1,331.94 		$1,084.10
$1,167.02
$1,254.86
$1,566.88 		$1,319.04
$1,401.96
$1,489.80
$1,801.82 		$234.94
Toc - Plan #68 WellFirst Health
Gold

(HMO) WellFirst Gold Value Copay 4000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$4,000 $8,000 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 		$431.51
$489.76
$551.46
$770.67
$1,171.11 		$761.61
$819.86
$881.56
$1,100.77 		$1,091.71
$1,149.96
$1,211.66
$1,430.87 		$1,421.81
$1,480.06
$1,541.76
$1,760.97 		$330.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$863.02
$979.52
$1,102.92
$1,541.34
$2,342.22 		$1,193.12
$1,309.62
$1,433.02
$1,871.44 		$1,523.22
$1,639.72
$1,763.12
$2,201.54 		$1,853.32
$1,969.82
$2,093.22
$2,531.64 		$330.10
Toc - Plan #69 WellFirst Health
Silver

(HMO) WellFirst Silver Value Copay 4100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$4,100 $8,200 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.59
$455.80
$513.23
$717.24
$1,089.92 		$708.81
$763.02
$820.45
$1,024.46 		$1,016.03
$1,070.24
$1,127.67
$1,331.68 		$1,323.25
$1,377.46
$1,434.89
$1,638.90 		$307.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$803.18
$911.60
$1,026.46
$1,434.48
$2,179.84 		$1,110.40
$1,218.82
$1,333.68
$1,741.70 		$1,417.62
$1,526.04
$1,640.90
$2,048.92 		$1,724.84
$1,833.26
$1,948.12
$2,356.14 		$307.22
Toc - Plan #70 WellFirst Health
Bronze

(HMO) WellFirst Bronze Value Copay 9050X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$9,050 $18,100 Annual Deductible
$9,050 $18,100 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 		$281.28
$319.26
$359.48
$502.37
$763.40 		$496.46
$534.44
$574.66
$717.55 		$711.64
$749.62
$789.84
$932.73 		$926.82
$964.80
$1,005.02
$1,147.91 		$215.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.56
$638.52
$718.96
$1,004.74
$1,526.80 		$777.74
$853.70
$934.14
$1,219.92 		$992.92
$1,068.88
$1,149.32
$1,435.10 		$1,208.10
$1,284.06
$1,364.50
$1,650.28 		$215.18
Toc - Plan #71 WellFirst Health
Silver

(HMO) WellFirst Silver HSA-E HDHP 3550X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

Individual Family
$3,550 $7,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.32
$447.55
$503.94
$704.25
$1,070.18 		$695.97
$749.20
$805.59
$1,005.90 		$997.62
$1,050.85
$1,107.24
$1,307.55 		$1,299.27
$1,352.50
$1,408.89
$1,609.20 		$301.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.64
$895.10
$1,007.88
$1,408.50
$2,140.36 		$1,090.29
$1,196.75
$1,309.53
$1,710.15 		$1,391.94
$1,498.40
$1,611.18
$2,011.80 		$1,693.59
$1,800.05
$1,912.83
$2,313.45 		$301.65
Toc - Plan #72 WellFirst Health
Expanded Bronze

(HMO) WellFirst Bronze HSA-E HDHP 7000X (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$310.03
$351.88
$396.21
$553.71
$841.41 		$547.20
$589.05
$633.38
$790.88 		$784.37
$826.22
$870.55
$1,028.05 		$1,021.54
$1,063.39
$1,107.72
$1,265.22 		$237.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620.06
$703.76
$792.42
$1,107.42
$1,682.82 		$857.23
$940.93
$1,029.59
$1,344.59 		$1,094.40
$1,178.10
$1,266.76
$1,581.76 		$1,331.57
$1,415.27
$1,503.93
$1,818.93 		$237.17
Toc - Plan #73 WellFirst Health
Catastrophic

(HMO) WellFirst Catastrophic Safety Net (Free Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$223.19
$253.33
$285.24
$398.62
$605.75 		$393.93
$424.07
$455.98
$569.36 		$564.67
$594.81
$626.72
$740.10 		$735.41
$765.55
$797.46
$910.84 		$170.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$446.38
$506.66
$570.48
$797.24
$1,211.50 		$617.12
$677.40
$741.22
$967.98 		$787.86
$848.14
$911.96
$1,138.72 		$958.60
$1,018.88
$1,082.70
$1,309.46 		$170.74
Toc - Plan #74 WellFirst Health
Gold

(HMO) WellFirst Gold Standard 2000X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$432.72
$491.13
$553.01
$772.83
$1,174.40 		$763.75
$822.16
$884.04
$1,103.86 		$1,094.78
$1,153.19
$1,215.07
$1,434.89 		$1,425.81
$1,484.22
$1,546.10
$1,765.92 		$331.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$865.44
$982.26
$1,106.02
$1,545.66
$2,348.80 		$1,196.47
$1,313.29
$1,437.05
$1,876.69 		$1,527.50
$1,644.32
$1,768.08
$2,207.72 		$1,858.53
$1,975.35
$2,099.11
$2,538.75 		$331.03
Toc - Plan #75 WellFirst Health
Silver

(HMO) WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$379.48
$430.70
$484.97
$677.74
$1,029.90 		$669.78
$721.00
$775.27
$968.04 		$960.08
$1,011.30
$1,065.57
$1,258.34 		$1,250.38
$1,301.60
$1,355.87
$1,548.64 		$290.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.96
$861.40
$969.94
$1,355.48
$2,059.80 		$1,049.26
$1,151.70
$1,260.24
$1,645.78 		$1,339.56
$1,442.00
$1,550.54
$1,936.08 		$1,629.86
$1,732.30
$1,840.84
$2,226.38 		$290.30
Toc - Plan #76 WellFirst Health
Expanded Bronze

(HMO) WellFirst Bronze Standard 7500X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$284.65
$323.08
$363.79
$508.39
$772.55 		$502.41
$540.84
$581.55
$726.15 		$720.17
$758.60
$799.31
$943.91 		$937.93
$976.36
$1,017.07
$1,161.67 		$217.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$569.30
$646.16
$727.58
$1,016.78
$1,545.10 		$787.06
$863.92
$945.34
$1,234.54 		$1,004.82
$1,081.68
$1,163.10
$1,452.30 		$1,222.58
$1,299.44
$1,380.86
$1,670.06 		$217.76
Toc - Plan #77 WellFirst Health
Bronze

(HMO) WellFirst Bronze Standard 9100X (Free Virtual Visits & Transportation)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-514-4194

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$263.33
$298.88
$336.54
$470.31
$714.69 		$464.78
$500.33
$537.99
$671.76 		$666.23
$701.78
$739.44
$873.21 		$867.68
$903.23
$940.89
$1,074.66 		$201.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$526.66
$597.76
$673.08
$940.62
$1,429.38 		$728.11
$799.21
$874.53
$1,142.07 		$929.56
$1,000.66
$1,075.98
$1,343.52 		$1,131.01
$1,202.11
$1,277.43
$1,544.97 		$201.45

‡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 Saint Clair County here.

Saint Clair County is in “Rating Area 12” of Illinois.

Currently, there are 77 plans offered in Rating Area 12.

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2023 Obamacare Plans for Saint Clair County, IL

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