Obamacare 2024 Rates for Saint Clair 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 Summerfield, 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, 64 Plans and 2024 Rates for Saint Clair County, Illinois

Below, you’ll find a summary of the 64 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.

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
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 		$467.28
$530.35
$597.17
$834.55
$1,268.17 		$824.74
$887.81
$954.63
$1,192.01 		$1,182.20
$1,245.27
$1,312.09
$1,549.47 		$1,539.66
$1,602.73
$1,669.55
$1,906.93 		$357.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$934.56
$1,060.70
$1,194.34
$1,669.10
$2,536.34 		$1,292.02
$1,418.16
$1,551.80
$2,026.56 		$1,649.48
$1,775.62
$1,909.26
$2,384.02 		$2,006.94
$2,133.08
$2,266.72
$2,741.48 		$357.46
Toc - Plan #2 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 		$328.40
$372.72
$419.68
$586.50
$891.24 		$579.62
$623.94
$670.90
$837.72 		$830.84
$875.16
$922.12
$1,088.94 		$1,082.06
$1,126.38
$1,173.34
$1,340.16 		$251.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.80
$745.44
$839.36
$1,173.00
$1,782.48 		$908.02
$996.66
$1,090.58
$1,424.22 		$1,159.24
$1,247.88
$1,341.80
$1,675.44 		$1,410.46
$1,499.10
$1,593.02
$1,926.66 		$251.22
Toc - Plan #3 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 		$389.04
$441.55
$497.19
$694.82
$1,055.84 		$686.65
$739.16
$794.80
$992.43 		$984.26
$1,036.77
$1,092.41
$1,290.04 		$1,281.87
$1,334.38
$1,390.02
$1,587.65 		$297.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.08
$883.10
$994.38
$1,389.64
$2,111.68 		$1,075.69
$1,180.71
$1,291.99
$1,687.25 		$1,373.30
$1,478.32
$1,589.60
$1,984.86 		$1,670.91
$1,775.93
$1,887.21
$2,282.47 		$297.61
Toc - Plan #4 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 		$368.31
$418.02
$470.69
$657.78
$999.57 		$650.06
$699.77
$752.44
$939.53 		$931.81
$981.52
$1,034.19
$1,221.28 		$1,213.56
$1,263.27
$1,315.94
$1,503.03 		$281.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.62
$836.04
$941.38
$1,315.56
$1,999.14 		$1,018.37
$1,117.79
$1,223.13
$1,597.31 		$1,300.12
$1,399.54
$1,504.88
$1,879.06 		$1,581.87
$1,681.29
$1,786.63
$2,160.81 		$281.75
Toc - Plan #5 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 		$377.01
$427.90
$481.81
$673.32
$1,023.18 		$665.42
$716.31
$770.22
$961.73 		$953.83
$1,004.72
$1,058.63
$1,250.14 		$1,242.24
$1,293.13
$1,347.04
$1,538.55 		$288.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.02
$855.80
$963.62
$1,346.64
$2,046.36 		$1,042.43
$1,144.21
$1,252.03
$1,635.05 		$1,330.84
$1,432.62
$1,540.44
$1,923.46 		$1,619.25
$1,721.03
$1,828.85
$2,211.87 		$288.41
Toc - Plan #6 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 		$443.21
$503.04
$566.42
$791.56
$1,202.86 		$782.26
$842.09
$905.47
$1,130.61 		$1,121.31
$1,181.14
$1,244.52
$1,469.66 		$1,460.36
$1,520.19
$1,583.57
$1,808.71 		$339.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$886.42
$1,006.08
$1,132.84
$1,583.12
$2,405.72 		$1,225.47
$1,345.13
$1,471.89
$1,922.17 		$1,564.52
$1,684.18
$1,810.94
$2,261.22 		$1,903.57
$2,023.23
$2,149.99
$2,600.27 		$339.05
Toc - Plan #7 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 		$522.56
$593.10
$667.82
$933.28
$1,418.20 		$922.31
$992.85
$1,067.57
$1,333.03 		$1,322.06
$1,392.60
$1,467.32
$1,732.78 		$1,721.81
$1,792.35
$1,867.07
$2,132.53 		$399.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,045.12
$1,186.20
$1,335.64
$1,866.56
$2,836.40 		$1,444.87
$1,585.95
$1,735.39
$2,266.31 		$1,844.62
$1,985.70
$2,135.14
$2,666.06 		$2,244.37
$2,385.45
$2,534.89
$3,065.81 		$399.75
Toc - Plan #8 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 		$325.80
$369.78
$416.36
$581.87
$884.20 		$575.03
$619.01
$665.59
$831.10 		$824.26
$868.24
$914.82
$1,080.33 		$1,073.49
$1,117.47
$1,164.05
$1,329.56 		$249.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$651.60
$739.56
$832.72
$1,163.74
$1,768.40 		$900.83
$988.79
$1,081.95
$1,412.97 		$1,150.06
$1,238.02
$1,331.18
$1,662.20 		$1,399.29
$1,487.25
$1,580.41
$1,911.43 		$249.23
Toc - Plan #9 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 		$398.30
$452.06
$509.02
$711.35
$1,080.96 		$702.99
$756.75
$813.71
$1,016.04 		$1,007.68
$1,061.44
$1,118.40
$1,320.73 		$1,312.37
$1,366.13
$1,423.09
$1,625.42 		$304.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$796.60
$904.12
$1,018.04
$1,422.70
$2,161.92 		$1,101.29
$1,208.81
$1,322.73
$1,727.39 		$1,405.98
$1,513.50
$1,627.42
$2,032.08 		$1,710.67
$1,818.19
$1,932.11
$2,336.77 		$304.69
Toc - Plan #10 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 		$451.47
$512.41
$576.97
$806.31
$1,225.27 		$796.84
$857.78
$922.34
$1,151.68 		$1,142.21
$1,203.15
$1,267.71
$1,497.05 		$1,487.58
$1,548.52
$1,613.08
$1,842.42 		$345.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.94
$1,024.82
$1,153.94
$1,612.62
$2,450.54 		$1,248.31
$1,370.19
$1,499.31
$1,957.99 		$1,593.68
$1,715.56
$1,844.68
$2,303.36 		$1,939.05
$2,060.93
$2,190.05
$2,648.73 		$345.37
Toc - Plan #11 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 		$319.55
$362.67
$408.37
$570.69
$867.22 		$564.00
$607.12
$652.82
$815.14 		$808.45
$851.57
$897.27
$1,059.59 		$1,052.90
$1,096.02
$1,141.72
$1,304.04 		$244.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.10
$725.34
$816.74
$1,141.38
$1,734.44 		$883.55
$969.79
$1,061.19
$1,385.83 		$1,128.00
$1,214.24
$1,305.64
$1,630.28 		$1,372.45
$1,458.69
$1,550.09
$1,874.73 		$244.45
Toc - Plan #12 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 		$370.27
$420.25
$473.20
$661.29
$1,004.89 		$653.52
$703.50
$756.45
$944.54 		$936.77
$986.75
$1,039.70
$1,227.79 		$1,220.02
$1,270.00
$1,322.95
$1,511.04 		$283.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.54
$840.50
$946.40
$1,322.58
$2,009.78 		$1,023.79
$1,123.75
$1,229.65
$1,605.83 		$1,307.04
$1,407.00
$1,512.90
$1,889.08 		$1,590.29
$1,690.25
$1,796.15
$2,172.33 		$283.25
Toc - Plan #13 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 		$440.14
$499.55
$562.49
$786.07
$1,194.52 		$776.84
$836.25
$899.19
$1,122.77 		$1,113.54
$1,172.95
$1,235.89
$1,459.47 		$1,450.24
$1,509.65
$1,572.59
$1,796.17 		$336.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.28
$999.10
$1,124.98
$1,572.14
$2,389.04 		$1,216.98
$1,335.80
$1,461.68
$1,908.84 		$1,553.68
$1,672.50
$1,798.38
$2,245.54 		$1,890.38
$2,009.20
$2,135.08
$2,582.24 		$336.70
Toc - Plan #14 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 		$482.12
$547.19
$616.13
$861.05
$1,308.44 		$850.93
$916.00
$984.94
$1,229.86 		$1,219.74
$1,284.81
$1,353.75
$1,598.67 		$1,588.55
$1,653.62
$1,722.56
$1,967.48 		$368.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.24
$1,094.38
$1,232.26
$1,722.10
$2,616.88 		$1,333.05
$1,463.19
$1,601.07
$2,090.91 		$1,701.86
$1,832.00
$1,969.88
$2,459.72 		$2,070.67
$2,200.81
$2,338.69
$2,828.53 		$368.81
Toc - Plan #15 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 		$338.82
$384.55
$433.00
$605.12
$919.54 		$598.01
$643.74
$692.19
$864.31 		$857.20
$902.93
$951.38
$1,123.50 		$1,116.39
$1,162.12
$1,210.57
$1,382.69 		$259.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$677.64
$769.10
$866.00
$1,210.24
$1,839.08 		$936.83
$1,028.29
$1,125.19
$1,469.43 		$1,196.02
$1,287.48
$1,384.38
$1,728.62 		$1,455.21
$1,546.67
$1,643.57
$1,987.81 		$259.19
Toc - Plan #16 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 		$401.40
$455.57
$512.97
$716.88
$1,089.37 		$708.46
$762.63
$820.03
$1,023.94 		$1,015.52
$1,069.69
$1,127.09
$1,331.00 		$1,322.58
$1,376.75
$1,434.15
$1,638.06 		$307.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.80
$911.14
$1,025.94
$1,433.76
$2,178.74 		$1,109.86
$1,218.20
$1,333.00
$1,740.82 		$1,416.92
$1,525.26
$1,640.06
$2,047.88 		$1,723.98
$1,832.32
$1,947.12
$2,354.94 		$307.06
Toc - Plan #17 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 		$388.98
$441.48
$497.11
$694.70
$1,055.67 		$686.54
$739.04
$794.67
$992.26 		$984.10
$1,036.60
$1,092.23
$1,289.82 		$1,281.66
$1,334.16
$1,389.79
$1,587.38 		$297.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.96
$882.96
$994.22
$1,389.40
$2,111.34 		$1,075.52
$1,180.52
$1,291.78
$1,686.96 		$1,373.08
$1,478.08
$1,589.34
$1,984.52 		$1,670.64
$1,775.64
$1,886.90
$2,282.08 		$297.56
Toc - Plan #18 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 		$457.29
$519.01
$584.40
$816.70
$1,241.05 		$807.11
$868.83
$934.22
$1,166.52 		$1,156.93
$1,218.65
$1,284.04
$1,516.34 		$1,506.75
$1,568.47
$1,633.86
$1,866.16 		$349.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$914.58
$1,038.02
$1,168.80
$1,633.40
$2,482.10 		$1,264.40
$1,387.84
$1,518.62
$1,983.22 		$1,614.22
$1,737.66
$1,868.44
$2,333.04 		$1,964.04
$2,087.48
$2,218.26
$2,682.86 		$349.82
Toc - Plan #19 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 		$380.00
$431.29
$485.63
$678.67
$1,031.30 		$670.70
$721.99
$776.33
$969.37 		$961.40
$1,012.69
$1,067.03
$1,260.07 		$1,252.10
$1,303.39
$1,357.73
$1,550.77 		$290.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$760.00
$862.58
$971.26
$1,357.34
$2,062.60 		$1,050.70
$1,153.28
$1,261.96
$1,648.04 		$1,341.40
$1,443.98
$1,552.66
$1,938.74 		$1,632.10
$1,734.68
$1,843.36
$2,229.44 		$290.70
Toc - Plan #20 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 		$539.15
$611.93
$689.03
$962.91
$1,463.24 		$951.59
$1,024.37
$1,101.47
$1,375.35 		$1,364.03
$1,436.81
$1,513.91
$1,787.79 		$1,776.47
$1,849.25
$1,926.35
$2,200.23 		$412.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,078.30
$1,223.86
$1,378.06
$1,925.82
$2,926.48 		$1,490.74
$1,636.30
$1,790.50
$2,338.26 		$1,903.18
$2,048.74
$2,202.94
$2,750.70 		$2,315.62
$2,461.18
$2,615.38
$3,163.14 		$412.44
Toc - Plan #21 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 		$336.15
$381.52
$429.59
$600.34
$912.28 		$593.30
$638.67
$686.74
$857.49 		$850.45
$895.82
$943.89
$1,114.64 		$1,107.60
$1,152.97
$1,201.04
$1,371.79 		$257.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.30
$763.04
$859.18
$1,200.68
$1,824.56 		$929.45
$1,020.19
$1,116.33
$1,457.83 		$1,186.60
$1,277.34
$1,373.48
$1,714.98 		$1,443.75
$1,534.49
$1,630.63
$1,972.13 		$257.15
Toc - Plan #22 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 		$410.95
$466.41
$525.18
$733.94
$1,115.29 		$725.32
$780.78
$839.55
$1,048.31 		$1,039.69
$1,095.15
$1,153.92
$1,362.68 		$1,354.06
$1,409.52
$1,468.29
$1,677.05 		$314.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$821.90
$932.82
$1,050.36
$1,467.88
$2,230.58 		$1,136.27
$1,247.19
$1,364.73
$1,782.25 		$1,450.64
$1,561.56
$1,679.10
$2,096.62 		$1,765.01
$1,875.93
$1,993.47
$2,410.99 		$314.37
Toc - Plan #23 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 		$465.81
$528.68
$595.29
$831.91
$1,264.17 		$822.14
$885.01
$951.62
$1,188.24 		$1,178.47
$1,241.34
$1,307.95
$1,544.57 		$1,534.80
$1,597.67
$1,664.28
$1,900.90 		$356.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$931.62
$1,057.36
$1,190.58
$1,663.82
$2,528.34 		$1,287.95
$1,413.69
$1,546.91
$2,020.15 		$1,644.28
$1,770.02
$1,903.24
$2,376.48 		$2,000.61
$2,126.35
$2,259.57
$2,732.81 		$356.33
Toc - Plan #24 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 		$329.69
$374.19
$421.33
$588.81
$894.76 		$581.90
$626.40
$673.54
$841.02 		$834.11
$878.61
$925.75
$1,093.23 		$1,086.32
$1,130.82
$1,177.96
$1,345.44 		$252.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.38
$748.38
$842.66
$1,177.62
$1,789.52 		$911.59
$1,000.59
$1,094.87
$1,429.83 		$1,163.80
$1,252.80
$1,347.08
$1,682.04 		$1,416.01
$1,505.01
$1,599.29
$1,934.25 		$252.21
Toc - Plan #25 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 		$382.03
$433.59
$488.22
$682.29
$1,036.80 		$674.27
$725.83
$780.46
$974.53 		$966.51
$1,018.07
$1,072.70
$1,266.77 		$1,258.75
$1,310.31
$1,364.94
$1,559.01 		$292.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$764.06
$867.18
$976.44
$1,364.58
$2,073.60 		$1,056.30
$1,159.42
$1,268.68
$1,656.82 		$1,348.54
$1,451.66
$1,560.92
$1,949.06 		$1,640.78
$1,743.90
$1,853.16
$2,241.30 		$292.24
Toc - Plan #26 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 		$454.12
$515.41
$580.35
$811.03
$1,232.44 		$801.51
$862.80
$927.74
$1,158.42 		$1,148.90
$1,210.19
$1,275.13
$1,505.81 		$1,496.29
$1,557.58
$1,622.52
$1,853.20 		$347.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$908.24
$1,030.82
$1,160.70
$1,622.06
$2,464.88 		$1,255.63
$1,378.21
$1,508.09
$1,969.45 		$1,603.02
$1,725.60
$1,855.48
$2,316.84 		$1,950.41
$2,072.99
$2,202.87
$2,664.23 		$347.39

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 #27 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 		$567.99
$644.67
$725.89
$1,014.43
$1,541.53 		$1,002.50
$1,079.18
$1,160.40
$1,448.94 		$1,437.01
$1,513.69
$1,594.91
$1,883.45 		$1,871.52
$1,948.20
$2,029.42
$2,317.96 		$434.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,135.98
$1,289.34
$1,451.78
$2,028.86
$3,083.06 		$1,570.49
$1,723.85
$1,886.29
$2,463.37 		$2,005.00
$2,158.36
$2,320.80
$2,897.88 		$2,439.51
$2,592.87
$2,755.31
$3,332.39 		$434.51
Toc - Plan #28 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 		$479.71
$544.47
$613.06
$856.75
$1,301.92 		$846.69
$911.45
$980.04
$1,223.73 		$1,213.67
$1,278.43
$1,347.02
$1,590.71 		$1,580.65
$1,645.41
$1,714.00
$1,957.69 		$366.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$959.42
$1,088.94
$1,226.12
$1,713.50
$2,603.84 		$1,326.40
$1,455.92
$1,593.10
$2,080.48 		$1,693.38
$1,822.90
$1,960.08
$2,447.46 		$2,060.36
$2,189.88
$2,327.06
$2,814.44 		$366.98
Toc - Plan #29 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 		$418.79
$475.33
$535.21
$747.96
$1,136.59 		$739.16
$795.70
$855.58
$1,068.33 		$1,059.53
$1,116.07
$1,175.95
$1,388.70 		$1,379.90
$1,436.44
$1,496.32
$1,709.07 		$320.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$837.58
$950.66
$1,070.42
$1,495.92
$2,273.18 		$1,157.95
$1,271.03
$1,390.79
$1,816.29 		$1,478.32
$1,591.40
$1,711.16
$2,136.66 		$1,798.69
$1,911.77
$2,031.53
$2,457.03 		$320.37
Toc - Plan #30 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 		$345.15
$391.74
$441.10
$616.43
$936.73 		$609.19
$655.78
$705.14
$880.47 		$873.23
$919.82
$969.18
$1,144.51 		$1,137.27
$1,183.86
$1,233.22
$1,408.55 		$264.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.30
$783.48
$882.20
$1,232.86
$1,873.46 		$954.34
$1,047.52
$1,146.24
$1,496.90 		$1,218.38
$1,311.56
$1,410.28
$1,760.94 		$1,482.42
$1,575.60
$1,674.32
$2,024.98 		$264.04
Toc - Plan #31 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 		$377.01
$427.91
$481.82
$673.35
$1,023.21 		$665.43
$716.33
$770.24
$961.77 		$953.85
$1,004.75
$1,058.66
$1,250.19 		$1,242.27
$1,293.17
$1,347.08
$1,538.61 		$288.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.02
$855.82
$963.64
$1,346.70
$2,046.42 		$1,042.44
$1,144.24
$1,252.06
$1,635.12 		$1,330.86
$1,432.66
$1,540.48
$1,923.54 		$1,619.28
$1,721.08
$1,828.90
$2,211.96 		$288.42
Toc - Plan #32 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 		$368.15
$417.85
$470.50
$657.51
$999.16 		$649.78
$699.48
$752.13
$939.14 		$931.41
$981.11
$1,033.76
$1,220.77 		$1,213.04
$1,262.74
$1,315.39
$1,502.40 		$281.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.30
$835.70
$941.00
$1,315.02
$1,998.32 		$1,017.93
$1,117.33
$1,222.63
$1,596.65 		$1,299.56
$1,398.96
$1,504.26
$1,878.28 		$1,581.19
$1,680.59
$1,785.89
$2,159.91 		$281.63
Toc - Plan #33 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 		$347.66
$394.60
$444.32
$620.93
$943.56 		$613.62
$660.56
$710.28
$886.89 		$879.58
$926.52
$976.24
$1,152.85 		$1,145.54
$1,192.48
$1,242.20
$1,418.81 		$265.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.32
$789.20
$888.64
$1,241.86
$1,887.12 		$961.28
$1,055.16
$1,154.60
$1,507.82 		$1,227.24
$1,321.12
$1,420.56
$1,773.78 		$1,493.20
$1,587.08
$1,686.52
$2,039.74 		$265.96
Toc - Plan #34 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 		$554.42
$629.26
$708.54
$990.19
$1,504.68 		$978.55
$1,053.39
$1,132.67
$1,414.32 		$1,402.68
$1,477.52
$1,556.80
$1,838.45 		$1,826.81
$1,901.65
$1,980.93
$2,262.58 		$424.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,108.84
$1,258.52
$1,417.08
$1,980.38
$3,009.36 		$1,532.97
$1,682.65
$1,841.21
$2,404.51 		$1,957.10
$2,106.78
$2,265.34
$2,828.64 		$2,381.23
$2,530.91
$2,689.47
$3,252.77 		$424.13
Toc - Plan #35 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 		$423.53
$480.70
$541.27
$756.42
$1,149.45 		$747.53
$804.70
$865.27
$1,080.42 		$1,071.53
$1,128.70
$1,189.27
$1,404.42 		$1,395.53
$1,452.70
$1,513.27
$1,728.42 		$324.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$847.06
$961.40
$1,082.54
$1,512.84
$2,298.90 		$1,171.06
$1,285.40
$1,406.54
$1,836.84 		$1,495.06
$1,609.40
$1,730.54
$2,160.84 		$1,819.06
$1,933.40
$2,054.54
$2,484.84 		$324.00
Toc - Plan #36 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 		$485.48
$551.02
$620.44
$867.07
$1,317.60 		$856.87
$922.41
$991.83
$1,238.46 		$1,228.26
$1,293.80
$1,363.22
$1,609.85 		$1,599.65
$1,665.19
$1,734.61
$1,981.24 		$371.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$970.96
$1,102.04
$1,240.88
$1,734.14
$2,635.20 		$1,342.35
$1,473.43
$1,612.27
$2,105.53 		$1,713.74
$1,844.82
$1,983.66
$2,476.92 		$2,085.13
$2,216.21
$2,355.05
$2,848.31 		$371.39
Toc - Plan #37 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 		$473.86
$537.83
$605.60
$846.32
$1,286.06 		$836.36
$900.33
$968.10
$1,208.82 		$1,198.86
$1,262.83
$1,330.60
$1,571.32 		$1,561.36
$1,625.33
$1,693.10
$1,933.82 		$362.50
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.72
$1,075.66
$1,211.20
$1,692.64
$2,572.12 		$1,310.22
$1,438.16
$1,573.70
$2,055.14 		$1,672.72
$1,800.66
$1,936.20
$2,417.64 		$2,035.22
$2,163.16
$2,298.70
$2,780.14 		$362.50

ADVERTISEMENT

UnitedHealthcare

Local: 1-888-200-0325 | Toll Free: 1-888-200-0325 | TTY: 1-888-200-0325
Toc - Plan #38 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 		$360.43
$409.09
$460.63
$643.73
$978.21 		$636.16
$684.82
$736.36
$919.46 		$911.89
$960.55
$1,012.09
$1,195.19 		$1,187.62
$1,236.28
$1,287.82
$1,470.92 		$275.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$720.86
$818.18
$921.26
$1,287.46
$1,956.42 		$996.59
$1,093.91
$1,196.99
$1,563.19 		$1,272.32
$1,369.64
$1,472.72
$1,838.92 		$1,548.05
$1,645.37
$1,748.45
$2,114.65 		$275.73
Toc - Plan #39 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 		$355.16
$403.10
$453.89
$634.31
$963.90 		$626.86
$674.80
$725.59
$906.01 		$898.56
$946.50
$997.29
$1,177.71 		$1,170.26
$1,218.20
$1,268.99
$1,449.41 		$271.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$710.32
$806.20
$907.78
$1,268.62
$1,927.80 		$982.02
$1,077.90
$1,179.48
$1,540.32 		$1,253.72
$1,349.60
$1,451.18
$1,812.02 		$1,525.42
$1,621.30
$1,722.88
$2,083.72 		$271.70
Toc - Plan #40 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 		$421.40
$478.29
$538.55
$752.62
$1,143.67 		$743.77
$800.66
$860.92
$1,074.99 		$1,066.14
$1,123.03
$1,183.29
$1,397.36 		$1,388.51
$1,445.40
$1,505.66
$1,719.73 		$322.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$842.80
$956.58
$1,077.10
$1,505.24
$2,287.34 		$1,165.17
$1,278.95
$1,399.47
$1,827.61 		$1,487.54
$1,601.32
$1,721.84
$2,149.98 		$1,809.91
$1,923.69
$2,044.21
$2,472.35 		$322.37
Toc - Plan #41 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 		$370.00
$419.95
$472.86
$660.82
$1,004.18 		$653.05
$703.00
$755.91
$943.87 		$936.10
$986.05
$1,038.96
$1,226.92 		$1,219.15
$1,269.10
$1,322.01
$1,509.97 		$283.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.00
$839.90
$945.72
$1,321.64
$2,008.36 		$1,023.05
$1,122.95
$1,228.77
$1,604.69 		$1,306.10
$1,406.00
$1,511.82
$1,887.74 		$1,589.15
$1,689.05
$1,794.87
$2,170.79 		$283.05
Toc - Plan #42 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 		$361.90
$410.76
$462.51
$646.35
$982.19 		$638.75
$687.61
$739.36
$923.20 		$915.60
$964.46
$1,016.21
$1,200.05 		$1,192.45
$1,241.31
$1,293.06
$1,476.90 		$276.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.80
$821.52
$925.02
$1,292.70
$1,964.38 		$1,000.65
$1,098.37
$1,201.87
$1,569.55 		$1,277.50
$1,375.22
$1,478.72
$1,846.40 		$1,554.35
$1,652.07
$1,755.57
$2,123.25 		$276.85
Toc - Plan #43 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 		$297.88
$338.09
$380.69
$532.01
$808.44 		$525.76
$565.97
$608.57
$759.89 		$753.64
$793.85
$836.45
$987.77 		$981.52
$1,021.73
$1,064.33
$1,215.65 		$227.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$595.76
$676.18
$761.38
$1,064.02
$1,616.88 		$823.64
$904.06
$989.26
$1,291.90 		$1,051.52
$1,131.94
$1,217.14
$1,519.78 		$1,279.40
$1,359.82
$1,445.02
$1,747.66 		$227.88
Toc - Plan #44 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 		$287.17
$325.94
$367.01
$512.89
$779.39 		$506.86
$545.63
$586.70
$732.58 		$726.55
$765.32
$806.39
$952.27 		$946.24
$985.01
$1,026.08
$1,171.96 		$219.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$574.34
$651.88
$734.02
$1,025.78
$1,558.78 		$794.03
$871.57
$953.71
$1,245.47 		$1,013.72
$1,091.26
$1,173.40
$1,465.16 		$1,233.41
$1,310.95
$1,393.09
$1,684.85 		$219.69
Toc - Plan #45 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 		$299.72
$340.18
$383.04
$535.29
$813.43 		$529.00
$569.46
$612.32
$764.57 		$758.28
$798.74
$841.60
$993.85 		$987.56
$1,028.02
$1,070.88
$1,223.13 		$229.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$599.44
$680.36
$766.08
$1,070.58
$1,626.86 		$828.72
$909.64
$995.36
$1,299.86 		$1,058.00
$1,138.92
$1,224.64
$1,529.14 		$1,287.28
$1,368.20
$1,453.92
$1,758.42 		$229.28
Toc - Plan #46 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 		$317.35
$360.19
$405.57
$566.79
$861.29 		$560.12
$602.96
$648.34
$809.56 		$802.89
$845.73
$891.11
$1,052.33 		$1,045.66
$1,088.50
$1,133.88
$1,295.10 		$242.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.70
$720.38
$811.14
$1,133.58
$1,722.58 		$877.47
$963.15
$1,053.91
$1,376.35 		$1,120.24
$1,205.92
$1,296.68
$1,619.12 		$1,363.01
$1,448.69
$1,539.45
$1,861.89 		$242.77
Toc - Plan #47 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 		$293.94
$333.62
$375.65
$524.97
$797.75 		$518.80
$558.48
$600.51
$749.83 		$743.66
$783.34
$825.37
$974.69 		$968.52
$1,008.20
$1,050.23
$1,199.55 		$224.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$587.88
$667.24
$751.30
$1,049.94
$1,595.50 		$812.74
$892.10
$976.16
$1,274.80 		$1,037.60
$1,116.96
$1,201.02
$1,499.66 		$1,262.46
$1,341.82
$1,425.88
$1,724.52 		$224.86
Toc - Plan #48 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 		$361.48
$410.28
$461.97
$645.60
$981.05 		$638.01
$686.81
$738.50
$922.13 		$914.54
$963.34
$1,015.03
$1,198.66 		$1,191.07
$1,239.87
$1,291.56
$1,475.19 		$276.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.96
$820.56
$923.94
$1,291.20
$1,962.10 		$999.49
$1,097.09
$1,200.47
$1,567.73 		$1,276.02
$1,373.62
$1,477.00
$1,844.26 		$1,552.55
$1,650.15
$1,753.53
$2,120.79 		$276.53
Toc - Plan #49 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 		$426.96
$484.60
$545.65
$762.55
$1,158.77 		$753.58
$811.22
$872.27
$1,089.17 		$1,080.20
$1,137.84
$1,198.89
$1,415.79 		$1,406.82
$1,464.46
$1,525.51
$1,742.41 		$326.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.92
$969.20
$1,091.30
$1,525.10
$2,317.54 		$1,180.54
$1,295.82
$1,417.92
$1,851.72 		$1,507.16
$1,622.44
$1,744.54
$2,178.34 		$1,833.78
$1,949.06
$2,071.16
$2,504.96 		$326.62
Toc - Plan #50 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 		$428.12
$485.92
$547.14
$764.63
$1,161.93 		$755.63
$813.43
$874.65
$1,092.14 		$1,083.14
$1,140.94
$1,202.16
$1,419.65 		$1,410.65
$1,468.45
$1,529.67
$1,747.16 		$327.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$856.24
$971.84
$1,094.28
$1,529.26
$2,323.86 		$1,183.75
$1,299.35
$1,421.79
$1,856.77 		$1,511.26
$1,626.86
$1,749.30
$2,184.28 		$1,838.77
$1,954.37
$2,076.81
$2,511.79 		$327.51
Toc - Plan #51 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 		$401.44
$455.63
$513.04
$716.97
$1,089.51 		$708.54
$762.73
$820.14
$1,024.07 		$1,015.64
$1,069.83
$1,127.24
$1,331.17 		$1,322.74
$1,376.93
$1,434.34
$1,638.27 		$307.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.88
$911.26
$1,026.08
$1,433.94
$2,179.02 		$1,109.98
$1,218.36
$1,333.18
$1,741.04 		$1,417.08
$1,525.46
$1,640.28
$2,048.14 		$1,724.18
$1,832.56
$1,947.38
$2,355.24 		$307.10
Toc - Plan #52 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 		$378.30
$429.37
$483.46
$675.64
$1,026.70 		$667.70
$718.77
$772.86
$965.04 		$957.10
$1,008.17
$1,062.26
$1,254.44 		$1,246.50
$1,297.57
$1,351.66
$1,543.84 		$289.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$756.60
$858.74
$966.92
$1,351.28
$2,053.40 		$1,046.00
$1,148.14
$1,256.32
$1,640.68 		$1,335.40
$1,437.54
$1,545.72
$1,930.08 		$1,624.80
$1,726.94
$1,835.12
$2,219.48 		$289.40
Toc - Plan #53 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 		$443.78
$503.69
$567.15
$792.59
$1,204.42 		$783.27
$843.18
$906.64
$1,132.08 		$1,122.76
$1,182.67
$1,246.13
$1,471.57 		$1,462.25
$1,522.16
$1,585.62
$1,811.06 		$339.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.56
$1,007.38
$1,134.30
$1,585.18
$2,408.84 		$1,227.05
$1,346.87
$1,473.79
$1,924.67 		$1,566.54
$1,686.36
$1,813.28
$2,264.16 		$1,906.03
$2,025.85
$2,152.77
$2,603.65 		$339.49

ADVERTISEMENT

Medica

Local: 1-866-514-4194 | Toll Free: 1-866-514-4194 | TTY: 1-866-514-4194
Toc - Plan #54 Medica
Gold

(HMO) WellFirst by Medica Gold Copay Plus 1500X (Free Virtual Visits)

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 		$533.11
$605.08
$681.32
$952.14
$1,446.87 		$940.94
$1,012.91
$1,089.15
$1,359.97 		$1,348.77
$1,420.74
$1,496.98
$1,767.80 		$1,756.60
$1,828.57
$1,904.81
$2,175.63 		$407.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,066.22
$1,210.16
$1,362.64
$1,904.28
$2,893.74 		$1,474.05
$1,617.99
$1,770.47
$2,312.11 		$1,881.88
$2,025.82
$2,178.30
$2,719.94 		$2,289.71
$2,433.65
$2,586.13
$3,127.77 		$407.83
Toc - Plan #55 Medica
Silver

(HMO) WellFirst by Medica Silver Copay Plus 4800X (Free Virtual Visits)

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
$9,450 $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 		$468.69
$531.96
$598.98
$837.07
$1,272.01 		$827.23
$890.50
$957.52
$1,195.61 		$1,185.77
$1,249.04
$1,316.06
$1,554.15 		$1,544.31
$1,607.58
$1,674.60
$1,912.69 		$358.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$937.38
$1,063.92
$1,197.96
$1,674.14
$2,544.02 		$1,295.92
$1,422.46
$1,556.50
$2,032.68 		$1,654.46
$1,781.00
$1,915.04
$2,391.22 		$2,013.00
$2,139.54
$2,273.58
$2,749.76 		$358.54
Toc - Plan #56 Medica
Expanded Bronze

(HMO) WellFirst by Medica Bronze Copay Plus 9400X (Free Virtual Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$9,400 $18,800 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 		$376.57
$427.41
$481.26
$672.56
$1,022.01 		$664.65
$715.49
$769.34
$960.64 		$952.73
$1,003.57
$1,057.42
$1,248.72 		$1,240.81
$1,291.65
$1,345.50
$1,536.80 		$288.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.14
$854.82
$962.52
$1,345.12
$2,044.02 		$1,041.22
$1,142.90
$1,250.60
$1,633.20 		$1,329.30
$1,430.98
$1,538.68
$1,921.28 		$1,617.38
$1,719.06
$1,826.76
$2,209.36 		$288.08
Toc - Plan #57 Medica
Silver

(HMO) WellFirst by Medica Silver HSA-E HDHP 3550X

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
$7,500 $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 		$483.64
$548.93
$618.09
$863.79
$1,312.61 		$853.63
$918.92
$988.08
$1,233.78 		$1,223.62
$1,288.91
$1,358.07
$1,603.77 		$1,593.61
$1,658.90
$1,728.06
$1,973.76 		$369.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$967.28
$1,097.86
$1,236.18
$1,727.58
$2,625.22 		$1,337.27
$1,467.85
$1,606.17
$2,097.57 		$1,707.26
$1,837.84
$1,976.16
$2,467.56 		$2,077.25
$2,207.83
$2,346.15
$2,837.55 		$369.99
Toc - Plan #58 Medica
Expanded Bronze

(HMO) WellFirst by Medica Bronze HSA-E HDHP 7450X

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

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$374.20
$424.72
$478.23
$668.33
$1,015.59 		$660.47
$710.99
$764.50
$954.60 		$946.74
$997.26
$1,050.77
$1,240.87 		$1,233.01
$1,283.53
$1,337.04
$1,527.14 		$286.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$748.40
$849.44
$956.46
$1,336.66
$2,031.18 		$1,034.67
$1,135.71
$1,242.73
$1,622.93 		$1,320.94
$1,421.98
$1,529.00
$1,909.20 		$1,607.21
$1,708.25
$1,815.27
$2,195.47 		$286.27
Toc - Plan #59 Medica
Catastrophic

(HMO) WellFirst by Medica Catastrophic Safety Net

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

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 		$258.61
$293.52
$330.51
$461.88
$701.87 		$456.45
$491.36
$528.35
$659.72 		$654.29
$689.20
$726.19
$857.56 		$852.13
$887.04
$924.03
$1,055.40 		$197.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$517.22
$587.04
$661.02
$923.76
$1,403.74 		$715.06
$784.88
$858.86
$1,121.60 		$912.90
$982.72
$1,056.70
$1,319.44 		$1,110.74
$1,180.56
$1,254.54
$1,517.28 		$197.84
Toc - Plan #60 Medica
Gold

(HMO) WellFirst by Medica Gold Standard 1500X (Free Virtual Visits)

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
$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 		$502.61
$570.46
$642.33
$897.66
$1,364.07 		$887.10
$954.95
$1,026.82
$1,282.15 		$1,271.59
$1,339.44
$1,411.31
$1,666.64 		$1,656.08
$1,723.93
$1,795.80
$2,051.13 		$384.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,005.22
$1,140.92
$1,284.66
$1,795.32
$2,728.14 		$1,389.71
$1,525.41
$1,669.15
$2,179.81 		$1,774.20
$1,909.90
$2,053.64
$2,564.30 		$2,158.69
$2,294.39
$2,438.13
$2,948.79 		$384.49
Toc - Plan #61 Medica
Silver

(HMO) WellFirst by Medica Silver Standard 5900X (Free Virtual Visits)

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

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 		$461.66
$523.99
$590.01
$824.53
$1,252.96 		$814.83
$877.16
$943.18
$1,177.70 		$1,168.00
$1,230.33
$1,296.35
$1,530.87 		$1,521.17
$1,583.50
$1,649.52
$1,884.04 		$353.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$923.32
$1,047.98
$1,180.02
$1,649.06
$2,505.92 		$1,276.49
$1,401.15
$1,533.19
$2,002.23 		$1,629.66
$1,754.32
$1,886.36
$2,355.40 		$1,982.83
$2,107.49
$2,239.53
$2,708.57 		$353.17
Toc - Plan #62 Medica
Expanded Bronze

(HMO) WellFirst by Medica Bronze Standard 7500X (Free Virtual Visits)

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
$9,400 $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 		$359.58
$408.12
$459.54
$642.20
$975.89 		$634.66
$683.20
$734.62
$917.28 		$909.74
$958.28
$1,009.70
$1,192.36 		$1,184.82
$1,233.36
$1,284.78
$1,467.44 		$275.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$719.16
$816.24
$919.08
$1,284.40
$1,951.78 		$994.24
$1,091.32
$1,194.16
$1,559.48 		$1,269.32
$1,366.40
$1,469.24
$1,834.56 		$1,544.40
$1,641.48
$1,744.32
$2,109.64 		$275.08
Toc - Plan #63 Medica
Gold

(HMO) WellFirst by Medica Gold Copay PCP 3000X (Free Virtual Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$4,900 $9,800 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 		$495.69
$562.61
$633.49
$885.30
$1,345.30 		$874.89
$941.81
$1,012.69
$1,264.50 		$1,254.09
$1,321.01
$1,391.89
$1,643.70 		$1,633.29
$1,700.21
$1,771.09
$2,022.90 		$379.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.38
$1,125.22
$1,266.98
$1,770.60
$2,690.60 		$1,370.58
$1,504.42
$1,646.18
$2,149.80 		$1,749.78
$1,883.62
$2,025.38
$2,529.00 		$2,128.98
$2,262.82
$2,404.58
$2,908.20 		$379.20
Toc - Plan #64 Medica
Silver

(HMO) WellFirst by Medica Silver Copay PCP 4500X (Free Virtual Visits)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.44
$521.46
$587.16
$820.56
$1,246.92 		$810.91
$872.93
$938.63
$1,172.03 		$1,162.38
$1,224.40
$1,290.10
$1,523.50 		$1,513.85
$1,575.87
$1,641.57
$1,874.97 		$351.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.88
$1,042.92
$1,174.32
$1,641.12
$2,493.84 		$1,270.35
$1,394.39
$1,525.79
$1,992.59 		$1,621.82
$1,745.86
$1,877.26
$2,344.06 		$1,973.29
$2,097.33
$2,228.73
$2,695.53 		$351.47

‡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 64 plans offered in Rating Area 12.

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2024 Obamacare Plans for Saint Clair County, IL

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