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You are viewing information for Dallas County, AR

Obamacare 2023 Rates for Dallas County

Obamacare > Rates > Arkansas > Dallas County

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

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, 51 Plans and 2023 Rates for Dallas County, Arkansas

Below, you’ll find a summary of the 51 plans for Dallas County, Arkansas 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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Health Advantage

Local: 1-501-378-2363 | Toll Free: 1-800-800-4298

Toc - Plan #1 Health Advantage
Silver

(POS) HA Silver Plan AH1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$369.17
$419.01
$471.80
$659.34
$1,001.93 		$651.59
$701.43
$754.22
$941.76 		$934.01
$983.85
$1,036.64
$1,224.18 		$1,216.43
$1,266.27
$1,319.06
$1,506.60 		$282.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.34
$838.02
$943.60
$1,318.68
$2,003.86 		$1,020.76
$1,120.44
$1,226.02
$1,601.10 		$1,303.18
$1,402.86
$1,508.44
$1,883.52 		$1,585.60
$1,685.28
$1,790.86
$2,165.94 		$282.42
Toc - Plan #2 Health Advantage
Gold

(POS) HA Gold Plan 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$500.81
$568.42
$640.04
$894.45
$1,359.20 		$883.93
$951.54
$1,023.16
$1,277.57 		$1,267.05
$1,334.66
$1,406.28
$1,660.69 		$1,650.17
$1,717.78
$1,789.40
$2,043.81 		$383.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,001.62
$1,136.84
$1,280.08
$1,788.90
$2,718.40 		$1,384.74
$1,519.96
$1,663.20
$2,172.02 		$1,767.86
$1,903.08
$2,046.32
$2,555.14 		$2,150.98
$2,286.20
$2,429.44
$2,938.26 		$383.12
Toc - Plan #3 Health Advantage
Gold

(POS) HA Gold Plan Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

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 		$445.92
$506.12
$569.89
$796.41
$1,210.23 		$787.05
$847.25
$911.02
$1,137.54 		$1,128.18
$1,188.38
$1,252.15
$1,478.67 		$1,469.31
$1,529.51
$1,593.28
$1,819.80 		$341.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891.84
$1,012.24
$1,139.78
$1,592.82
$2,420.46 		$1,232.97
$1,353.37
$1,480.91
$1,933.95 		$1,574.10
$1,694.50
$1,822.04
$2,275.08 		$1,915.23
$2,035.63
$2,163.17
$2,616.21 		$341.13
Toc - Plan #4 Health Advantage
Silver

(POS) HA Silver Plan Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

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 		$332.91
$377.85
$425.46
$594.58
$903.52 		$587.59
$632.53
$680.14
$849.26 		$842.27
$887.21
$934.82
$1,103.94 		$1,096.95
$1,141.89
$1,189.50
$1,358.62 		$254.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$665.82
$755.70
$850.92
$1,189.16
$1,807.04 		$920.50
$1,010.38
$1,105.60
$1,443.84 		$1,175.18
$1,265.06
$1,360.28
$1,698.52 		$1,429.86
$1,519.74
$1,614.96
$1,953.20 		$254.68

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Ambetter from Arkansas Health & Wellness

Local: 1-877-617-0390 | Toll Free: 1-877-617-0390 | TTY: 1-877-617-0392
Toc - Plan #5 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Connected Silver (QualChoiceLife)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$359.33
$407.83
$459.21
$641.75
$975.19 		$634.21
$682.71
$734.09
$916.63 		$909.09
$957.59
$1,008.97
$1,191.51 		$1,183.97
$1,232.47
$1,283.85
$1,466.39 		$274.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.66
$815.66
$918.42
$1,283.50
$1,950.38 		$993.54
$1,090.54
$1,193.30
$1,558.38 		$1,268.42
$1,365.42
$1,468.18
$1,833.26 		$1,543.30
$1,640.30
$1,743.06
$2,108.14 		$274.88
Toc - Plan #6 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Elite Silver (QualChoiceLife)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$354.01
$401.79
$452.41
$632.25
$960.76 		$624.82
$672.60
$723.22
$903.06 		$895.63
$943.41
$994.03
$1,173.87 		$1,166.44
$1,214.22
$1,264.84
$1,444.68 		$270.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$708.02
$803.58
$904.82
$1,264.50
$1,921.52 		$978.83
$1,074.39
$1,175.63
$1,535.31 		$1,249.64
$1,345.20
$1,446.44
$1,806.12 		$1,520.45
$1,616.01
$1,717.25
$2,076.93 		$270.81
Toc - Plan #7 Ambetter from Arkansas Health & Wellness
Gold

(PPO) Elite Gold (QualChoiceLife)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$483.73
$549.02
$618.19
$863.92
$1,312.81 		$853.77
$919.06
$988.23
$1,233.96 		$1,223.81
$1,289.10
$1,358.27
$1,604.00 		$1,593.85
$1,659.14
$1,728.31
$1,974.04 		$370.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$967.46
$1,098.04
$1,236.38
$1,727.84
$2,625.62 		$1,337.50
$1,468.08
$1,606.42
$2,097.88 		$1,707.54
$1,838.12
$1,976.46
$2,467.92 		$2,077.58
$2,208.16
$2,346.50
$2,837.96 		$370.04
Toc - Plan #8 Ambetter from Arkansas Health & Wellness
Silver

(PPO) CMS Standard Silver (QualChoiceLife)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$325.16
$369.04
$415.54
$580.72
$882.45 		$573.90
$617.78
$664.28
$829.46 		$822.64
$866.52
$913.02
$1,078.20 		$1,071.38
$1,115.26
$1,161.76
$1,326.94 		$248.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.32
$738.08
$831.08
$1,161.44
$1,764.90 		$899.06
$986.82
$1,079.82
$1,410.18 		$1,147.80
$1,235.56
$1,328.56
$1,658.92 		$1,396.54
$1,484.30
$1,577.30
$1,907.66 		$248.74
Toc - Plan #9 Ambetter from Arkansas Health & Wellness
Gold

(PPO) CMS Standard Gold (QualChoiceLife)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$406.51
$461.38
$519.51
$726.01
$1,103.24 		$717.48
$772.35
$830.48
$1,036.98 		$1,028.45
$1,083.32
$1,141.45
$1,347.95 		$1,339.42
$1,394.29
$1,452.42
$1,658.92 		$310.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.02
$922.76
$1,039.02
$1,452.02
$2,206.48 		$1,123.99
$1,233.73
$1,349.99
$1,762.99 		$1,434.96
$1,544.70
$1,660.96
$2,073.96 		$1,745.93
$1,855.67
$1,971.93
$2,384.93 		$310.97
Toc - Plan #10 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Connected Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$353.11
$400.77
$451.26
$630.64
$958.31 		$623.23
$670.89
$721.38
$900.76 		$893.35
$941.01
$991.50
$1,170.88 		$1,163.47
$1,211.13
$1,261.62
$1,441.00 		$270.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$706.22
$801.54
$902.52
$1,261.28
$1,916.62 		$976.34
$1,071.66
$1,172.64
$1,531.40 		$1,246.46
$1,341.78
$1,442.76
$1,801.52 		$1,516.58
$1,611.90
$1,712.88
$2,071.64 		$270.12
Toc - Plan #11 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$329.77
$374.28
$421.43
$588.95
$894.97 		$582.04
$626.55
$673.70
$841.22 		$834.31
$878.82
$925.97
$1,093.49 		$1,086.58
$1,131.09
$1,178.24
$1,345.76 		$252.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$659.54
$748.56
$842.86
$1,177.90
$1,789.94 		$911.81
$1,000.83
$1,095.13
$1,430.17 		$1,164.08
$1,253.10
$1,347.40
$1,682.44 		$1,416.35
$1,505.37
$1,599.67
$1,934.71 		$252.27
Toc - Plan #12 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$326.20
$370.23
$416.88
$582.58
$885.29 		$575.74
$619.77
$666.42
$832.12 		$825.28
$869.31
$915.96
$1,081.66 		$1,074.82
$1,118.85
$1,165.50
$1,331.20 		$249.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.40
$740.46
$833.76
$1,165.16
$1,770.58 		$901.94
$990.00
$1,083.30
$1,414.70 		$1,151.48
$1,239.54
$1,332.84
$1,664.24 		$1,401.02
$1,489.08
$1,582.38
$1,913.78 		$249.54
Toc - Plan #13 Ambetter from Arkansas Health & Wellness
Gold

(PPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$408.09
$463.17
$521.52
$728.83
$1,107.52 		$720.27
$775.35
$833.70
$1,041.01 		$1,032.45
$1,087.53
$1,145.88
$1,353.19 		$1,344.63
$1,399.71
$1,458.06
$1,665.37 		$312.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.18
$926.34
$1,043.04
$1,457.66
$2,215.04 		$1,128.36
$1,238.52
$1,355.22
$1,769.84 		$1,440.54
$1,550.70
$1,667.40
$2,082.02 		$1,752.72
$1,862.88
$1,979.58
$2,394.20 		$312.18
Toc - Plan #14 Ambetter from Arkansas Health & Wellness
Expanded Bronze

(PPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$298.41
$338.69
$381.36
$532.95
$809.87 		$526.69
$566.97
$609.64
$761.23 		$754.97
$795.25
$837.92
$989.51 		$983.25
$1,023.53
$1,066.20
$1,217.79 		$228.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$596.82
$677.38
$762.72
$1,065.90
$1,619.74 		$825.10
$905.66
$991.00
$1,294.18 		$1,053.38
$1,133.94
$1,219.28
$1,522.46 		$1,281.66
$1,362.22
$1,447.56
$1,750.74 		$228.28
Toc - Plan #15 Ambetter from Arkansas Health & Wellness
Expanded Bronze

(PPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$340.19
$386.10
$434.75
$607.56
$923.24 		$600.43
$646.34
$694.99
$867.80 		$860.67
$906.58
$955.23
$1,128.04 		$1,120.91
$1,166.82
$1,215.47
$1,388.28 		$260.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.38
$772.20
$869.50
$1,215.12
$1,846.48 		$940.62
$1,032.44
$1,129.74
$1,475.36 		$1,200.86
$1,292.68
$1,389.98
$1,735.60 		$1,461.10
$1,552.92
$1,650.22
$1,995.84 		$260.24
Toc - Plan #16 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$325.32
$369.23
$415.75
$581.01
$882.89 		$574.18
$618.09
$664.61
$829.87 		$823.04
$866.95
$913.47
$1,078.73 		$1,071.90
$1,115.81
$1,162.33
$1,327.59 		$248.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.64
$738.46
$831.50
$1,162.02
$1,765.78 		$899.50
$987.32
$1,080.36
$1,410.88 		$1,148.36
$1,236.18
$1,329.22
$1,659.74 		$1,397.22
$1,485.04
$1,578.08
$1,908.60 		$248.86
Toc - Plan #17 Ambetter from Arkansas Health & Wellness
Gold

(PPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$388.91
$441.41
$497.02
$694.58
$1,055.49 		$686.42
$738.92
$794.53
$992.09 		$983.93
$1,036.43
$1,092.04
$1,289.60 		$1,281.44
$1,333.94
$1,389.55
$1,587.11 		$297.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.82
$882.82
$994.04
$1,389.16
$2,110.98 		$1,075.33
$1,180.33
$1,291.55
$1,686.67 		$1,372.84
$1,477.84
$1,589.06
$1,984.18 		$1,670.35
$1,775.35
$1,886.57
$2,281.69 		$297.51
Toc - Plan #18 Ambetter from Arkansas Health & Wellness
Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$291.99
$331.40
$373.15
$521.47
$792.43 		$515.35
$554.76
$596.51
$744.83 		$738.71
$778.12
$819.87
$968.19 		$962.07
$1,001.48
$1,043.23
$1,191.55 		$223.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$583.98
$662.80
$746.30
$1,042.94
$1,584.86 		$807.34
$886.16
$969.66
$1,266.30 		$1,030.70
$1,109.52
$1,193.02
$1,489.66 		$1,254.06
$1,332.88
$1,416.38
$1,713.02 		$223.36
Toc - Plan #19 Ambetter from Arkansas Health & Wellness
Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.68
$365.10
$411.10
$574.51
$873.02 		$567.76
$611.18
$657.18
$820.59 		$813.84
$857.26
$903.26
$1,066.67 		$1,059.92
$1,103.34
$1,149.34
$1,312.75 		$246.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.36
$730.20
$822.20
$1,149.02
$1,746.04 		$889.44
$976.28
$1,068.28
$1,395.10 		$1,135.52
$1,222.36
$1,314.36
$1,641.18 		$1,381.60
$1,468.44
$1,560.44
$1,887.26 		$246.08
Toc - Plan #20 Ambetter from Arkansas Health & Wellness
Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$383.97
$435.80
$490.70
$685.75
$1,042.07 		$677.70
$729.53
$784.43
$979.48 		$971.43
$1,023.26
$1,078.16
$1,273.21 		$1,265.16
$1,316.99
$1,371.89
$1,566.94 		$293.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$767.94
$871.60
$981.40
$1,371.50
$2,084.14 		$1,061.67
$1,165.33
$1,275.13
$1,665.23 		$1,355.40
$1,459.06
$1,568.86
$1,958.96 		$1,649.13
$1,752.79
$1,862.59
$2,252.69 		$293.73
Toc - Plan #21 Ambetter from Arkansas Health & Wellness
Bronze

(PPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276.63
$313.96
$353.52
$494.04
$750.74 		$488.24
$525.57
$565.13
$705.65 		$699.85
$737.18
$776.74
$917.26 		$911.46
$948.79
$988.35
$1,128.87 		$211.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.26
$627.92
$707.04
$988.08
$1,501.48 		$764.87
$839.53
$918.65
$1,199.69 		$976.48
$1,051.14
$1,130.26
$1,411.30 		$1,188.09
$1,262.75
$1,341.87
$1,622.91 		$211.61
Toc - Plan #22 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$333.80
$378.85
$426.58
$596.14
$905.89 		$589.15
$634.20
$681.93
$851.49 		$844.50
$889.55
$937.28
$1,106.84 		$1,099.85
$1,144.90
$1,192.63
$1,362.19 		$255.35
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.60
$757.70
$853.16
$1,192.28
$1,811.78 		$922.95
$1,013.05
$1,108.51
$1,447.63 		$1,178.30
$1,268.40
$1,363.86
$1,702.98 		$1,433.65
$1,523.75
$1,619.21
$1,958.33 		$255.35
Toc - Plan #23 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Connected Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$369.94
$419.87
$472.77
$660.69
$1,003.99 		$652.94
$702.87
$755.77
$943.69 		$935.94
$985.87
$1,038.77
$1,226.69 		$1,218.94
$1,268.87
$1,321.77
$1,509.69 		$283.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$739.88
$839.74
$945.54
$1,321.38
$2,007.98 		$1,022.88
$1,122.74
$1,228.54
$1,604.38 		$1,305.88
$1,405.74
$1,511.54
$1,887.38 		$1,588.88
$1,688.74
$1,794.54
$2,170.38 		$283.00
Toc - Plan #24 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$345.49
$392.12
$441.52
$617.02
$937.63 		$609.78
$656.41
$705.81
$881.31 		$874.07
$920.70
$970.10
$1,145.60 		$1,138.36
$1,184.99
$1,234.39
$1,409.89 		$264.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.98
$784.24
$883.04
$1,234.04
$1,875.26 		$955.27
$1,048.53
$1,147.33
$1,498.33 		$1,219.56
$1,312.82
$1,411.62
$1,762.62 		$1,483.85
$1,577.11
$1,675.91
$2,026.91 		$264.29
Toc - Plan #25 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$349.70
$396.90
$446.91
$624.55
$949.07 		$617.22
$664.42
$714.43
$892.07 		$884.74
$931.94
$981.95
$1,159.59 		$1,152.26
$1,199.46
$1,249.47
$1,427.11 		$267.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$699.40
$793.80
$893.82
$1,249.10
$1,898.14 		$966.92
$1,061.32
$1,161.34
$1,516.62 		$1,234.44
$1,328.84
$1,428.86
$1,784.14 		$1,501.96
$1,596.36
$1,696.38
$2,051.66 		$267.52
Toc - Plan #26 Ambetter from Arkansas Health & Wellness
Gold

(PPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$427.54
$485.24
$546.38
$763.57
$1,160.31 		$754.60
$812.30
$873.44
$1,090.63 		$1,081.66
$1,139.36
$1,200.50
$1,417.69 		$1,408.72
$1,466.42
$1,527.56
$1,744.75 		$327.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.08
$970.48
$1,092.76
$1,527.14
$2,320.62 		$1,182.14
$1,297.54
$1,419.82
$1,854.20 		$1,509.20
$1,624.60
$1,746.88
$2,181.26 		$1,836.26
$1,951.66
$2,073.94
$2,508.32 		$327.06
Toc - Plan #27 Ambetter from Arkansas Health & Wellness
Expanded Bronze

(PPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$312.64
$354.83
$399.54
$558.35
$848.47 		$551.80
$593.99
$638.70
$797.51 		$790.96
$833.15
$877.86
$1,036.67 		$1,030.12
$1,072.31
$1,117.02
$1,275.83 		$239.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$625.28
$709.66
$799.08
$1,116.70
$1,696.94 		$864.44
$948.82
$1,038.24
$1,355.86 		$1,103.60
$1,187.98
$1,277.40
$1,595.02 		$1,342.76
$1,427.14
$1,516.56
$1,834.18 		$239.16
Toc - Plan #28 Ambetter from Arkansas Health & Wellness
Expanded Bronze

(PPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$356.40
$404.50
$455.47
$636.51
$967.24 		$629.04
$677.14
$728.11
$909.15 		$901.68
$949.78
$1,000.75
$1,181.79 		$1,174.32
$1,222.42
$1,273.39
$1,454.43 		$272.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$712.80
$809.00
$910.94
$1,273.02
$1,934.48 		$985.44
$1,081.64
$1,183.58
$1,545.66 		$1,258.08
$1,354.28
$1,456.22
$1,818.30 		$1,530.72
$1,626.92
$1,728.86
$2,090.94 		$272.64
Toc - Plan #29 Ambetter from Arkansas Health & Wellness
Gold

(PPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$407.45
$462.45
$520.71
$727.69
$1,105.79 		$719.14
$774.14
$832.40
$1,039.38 		$1,030.83
$1,085.83
$1,144.09
$1,351.07 		$1,342.52
$1,397.52
$1,455.78
$1,662.76 		$311.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.90
$924.90
$1,041.42
$1,455.38
$2,211.58 		$1,126.59
$1,236.59
$1,353.11
$1,767.07 		$1,438.28
$1,548.28
$1,664.80
$2,078.76 		$1,749.97
$1,859.97
$1,976.49
$2,390.45 		$311.69
Toc - Plan #30 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$341.75
$387.88
$436.75
$610.35
$927.49 		$603.18
$649.31
$698.18
$871.78 		$864.61
$910.74
$959.61
$1,133.21 		$1,126.04
$1,172.17
$1,221.04
$1,394.64 		$261.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$683.50
$775.76
$873.50
$1,220.70
$1,854.98 		$944.93
$1,037.19
$1,134.93
$1,482.13 		$1,206.36
$1,298.62
$1,396.36
$1,743.56 		$1,467.79
$1,560.05
$1,657.79
$2,004.99 		$261.43
Toc - Plan #31 Ambetter from Arkansas Health & Wellness
Silver

(PPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$340.83
$386.83
$435.56
$608.70
$924.98 		$601.55
$647.55
$696.28
$869.42 		$862.27
$908.27
$957.00
$1,130.14 		$1,122.99
$1,168.99
$1,217.72
$1,390.86 		$260.72
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.66
$773.66
$871.12
$1,217.40
$1,849.96 		$942.38
$1,034.38
$1,131.84
$1,478.12 		$1,203.10
$1,295.10
$1,392.56
$1,738.84 		$1,463.82
$1,555.82
$1,653.28
$1,999.56 		$260.72
Toc - Plan #32 Ambetter from Arkansas Health & Wellness
Bronze

(PPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$289.81
$328.93
$370.37
$517.59
$786.53 		$511.51
$550.63
$592.07
$739.29 		$733.21
$772.33
$813.77
$960.99 		$954.91
$994.03
$1,035.47
$1,182.69 		$221.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.62
$657.86
$740.74
$1,035.18
$1,573.06 		$801.32
$879.56
$962.44
$1,256.88 		$1,023.02
$1,101.26
$1,184.14
$1,478.58 		$1,244.72
$1,322.96
$1,405.84
$1,700.28 		$221.70
Toc - Plan #33 Ambetter from Arkansas Health & Wellness
Silver

(POS) Connected Silver (QualChoice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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 		$366.04
$415.44
$467.79
$653.73
$993.41 		$646.05
$695.45
$747.80
$933.74 		$926.06
$975.46
$1,027.81
$1,213.75 		$1,206.07
$1,255.47
$1,307.82
$1,493.76 		$280.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$732.08
$830.88
$935.58
$1,307.46
$1,986.82 		$1,012.09
$1,110.89
$1,215.59
$1,587.47 		$1,292.10
$1,390.90
$1,495.60
$1,867.48 		$1,572.11
$1,670.91
$1,775.61
$2,147.49 		$280.01
Toc - Plan #34 Ambetter from Arkansas Health & Wellness
Silver

(POS) Elite Silver (QualChoice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$360.62
$409.30
$460.86
$644.05
$978.70 		$636.49
$685.17
$736.73
$919.92 		$912.36
$961.04
$1,012.60
$1,195.79 		$1,188.23
$1,236.91
$1,288.47
$1,471.66 		$275.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$721.24
$818.60
$921.72
$1,288.10
$1,957.40 		$997.11
$1,094.47
$1,197.59
$1,563.97 		$1,272.98
$1,370.34
$1,473.46
$1,839.84 		$1,548.85
$1,646.21
$1,749.33
$2,115.71 		$275.87
Toc - Plan #35 Ambetter from Arkansas Health & Wellness
Gold

(POS) Elite Gold (QualChoice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$492.76
$559.27
$629.73
$880.05
$1,337.32 		$869.71
$936.22
$1,006.68
$1,257.00 		$1,246.66
$1,313.17
$1,383.63
$1,633.95 		$1,623.61
$1,690.12
$1,760.58
$2,010.90 		$376.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.52
$1,118.54
$1,259.46
$1,760.10
$2,674.64 		$1,362.47
$1,495.49
$1,636.41
$2,137.05 		$1,739.42
$1,872.44
$2,013.36
$2,514.00 		$2,116.37
$2,249.39
$2,390.31
$2,890.95 		$376.95
Toc - Plan #36 Ambetter from Arkansas Health & Wellness
Expanded Bronze

(POS) Choice Bronze HSA (QualChoice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$321.79
$365.22
$411.23
$574.69
$873.30 		$567.95
$611.38
$657.39
$820.85 		$814.11
$857.54
$903.55
$1,067.01 		$1,060.27
$1,103.70
$1,149.71
$1,313.17 		$246.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.58
$730.44
$822.46
$1,149.38
$1,746.60 		$889.74
$976.60
$1,068.62
$1,395.54 		$1,135.90
$1,222.76
$1,314.78
$1,641.70 		$1,382.06
$1,468.92
$1,560.94
$1,887.86 		$246.16
Toc - Plan #37 Ambetter from Arkansas Health & Wellness
Expanded Bronze

(POS) CMS Standard Expanded Bronze (QualChoice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$309.34
$351.09
$395.33
$552.47
$839.53 		$545.98
$587.73
$631.97
$789.11 		$782.62
$824.37
$868.61
$1,025.75 		$1,019.26
$1,061.01
$1,105.25
$1,262.39 		$236.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$618.68
$702.18
$790.66
$1,104.94
$1,679.06 		$855.32
$938.82
$1,027.30
$1,341.58 		$1,091.96
$1,175.46
$1,263.94
$1,578.22 		$1,328.60
$1,412.10
$1,500.58
$1,814.86 		$236.64
Toc - Plan #38 Ambetter from Arkansas Health & Wellness
Silver

(POS) CMS Standard Silver (QualChoice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$331.23
$375.94
$423.30
$591.56
$898.93 		$584.61
$629.32
$676.68
$844.94 		$837.99
$882.70
$930.06
$1,098.32 		$1,091.37
$1,136.08
$1,183.44
$1,351.70 		$253.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$662.46
$751.88
$846.60
$1,183.12
$1,797.86 		$915.84
$1,005.26
$1,099.98
$1,436.50 		$1,169.22
$1,258.64
$1,353.36
$1,689.88 		$1,422.60
$1,512.02
$1,606.74
$1,943.26 		$253.38
Toc - Plan #39 Ambetter from Arkansas Health & Wellness
Gold

(POS) CMS Standard Gold (QualChoice)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-617-0390

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 		$414.06
$469.95
$529.16
$739.50
$1,123.74 		$730.81
$786.70
$845.91
$1,056.25 		$1,047.56
$1,103.45
$1,162.66
$1,373.00 		$1,364.31
$1,420.20
$1,479.41
$1,689.75 		$316.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$828.12
$939.90
$1,058.32
$1,479.00
$2,247.48 		$1,144.87
$1,256.65
$1,375.07
$1,795.75 		$1,461.62
$1,573.40
$1,691.82
$2,112.50 		$1,778.37
$1,890.15
$2,008.57
$2,429.25 		$316.75

ADVERTISEMENT

Arkansas Blue Cross and Blue Shield

Local: 1-800-800-4298 | Toll Free: 1-800-800-4298 | TTY: 1-800-800-4298
Toc - Plan #40 Arkansas Blue Cross and Blue Shield
Silver

(PPO) Silver Plan 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 Annual Deductible
$8,950 $17,900 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 		$375.20
$425.85
$479.51
$670.11
$1,018.29 		$662.23
$712.88
$766.54
$957.14 		$949.26
$999.91
$1,053.57
$1,244.17 		$1,236.29
$1,286.94
$1,340.60
$1,531.20 		$287.03
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.40
$851.70
$959.02
$1,340.22
$2,036.58 		$1,037.43
$1,138.73
$1,246.05
$1,627.25 		$1,324.46
$1,425.76
$1,533.08
$1,914.28 		$1,611.49
$1,712.79
$1,820.11
$2,201.31 		$287.03
Toc - Plan #41 Arkansas Blue Cross and Blue Shield
Silver

(PPO) Silver Plan AH1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 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 		$350.02
$397.27
$447.33
$625.14
$949.95 		$617.79
$665.04
$715.10
$892.91 		$885.56
$932.81
$982.87
$1,160.68 		$1,153.33
$1,200.58
$1,250.64
$1,428.45 		$267.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$700.04
$794.54
$894.66
$1,250.28
$1,899.90 		$967.81
$1,062.31
$1,162.43
$1,518.05 		$1,235.58
$1,330.08
$1,430.20
$1,785.82 		$1,503.35
$1,597.85
$1,697.97
$2,053.59 		$267.77
Toc - Plan #42 Arkansas Blue Cross and Blue Shield
Silver

(PPO) Silver Plan HSA1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$3,975 $7,950 Annual Deductible
$6,380 $12,760 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$385.81
$437.89
$493.07
$689.06
$1,047.09 		$680.95
$733.03
$788.21
$984.20 		$976.09
$1,028.17
$1,083.35
$1,279.34 		$1,271.23
$1,323.31
$1,378.49
$1,574.48 		$295.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.62
$875.78
$986.14
$1,378.12
$2,094.18 		$1,066.76
$1,170.92
$1,281.28
$1,673.26 		$1,361.90
$1,466.06
$1,576.42
$1,968.40 		$1,657.04
$1,761.20
$1,871.56
$2,263.54 		$295.14
Toc - Plan #43 Arkansas Blue Cross and Blue Shield
Expanded Bronze

(PPO) Bronze Plan 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$8,550 $17,100 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$309.96
$351.80
$396.13
$553.59
$841.23 		$547.08
$588.92
$633.25
$790.71 		$784.20
$826.04
$870.37
$1,027.83 		$1,021.32
$1,063.16
$1,107.49
$1,264.95 		$237.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.92
$703.60
$792.26
$1,107.18
$1,682.46 		$857.04
$940.72
$1,029.38
$1,344.30 		$1,094.16
$1,177.84
$1,266.50
$1,581.42 		$1,331.28
$1,414.96
$1,503.62
$1,818.54 		$237.12
Toc - Plan #44 Arkansas Blue Cross and Blue Shield
Expanded Bronze

(PPO) Bronze Plan HSA1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

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 		$328.32
$372.64
$419.59
$586.38
$891.06 		$579.48
$623.80
$670.75
$837.54 		$830.64
$874.96
$921.91
$1,088.70 		$1,081.80
$1,126.12
$1,173.07
$1,339.86 		$251.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$656.64
$745.28
$839.18
$1,172.76
$1,782.12 		$907.80
$996.44
$1,090.34
$1,423.92 		$1,158.96
$1,247.60
$1,341.50
$1,675.08 		$1,410.12
$1,498.76
$1,592.66
$1,926.24 		$251.16
Toc - Plan #45 Arkansas Blue Cross and Blue Shield
Silver

(PPO) Silver Plan 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$6,750 $13,500 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$356.63
$404.78
$455.77
$636.94
$967.89 		$629.45
$677.60
$728.59
$909.76 		$902.27
$950.42
$1,001.41
$1,182.58 		$1,175.09
$1,223.24
$1,274.23
$1,455.40 		$272.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$713.26
$809.56
$911.54
$1,273.88
$1,935.78 		$986.08
$1,082.38
$1,184.36
$1,546.70 		$1,258.90
$1,355.20
$1,457.18
$1,819.52 		$1,531.72
$1,628.02
$1,730.00
$2,092.34 		$272.82
Toc - Plan #46 Arkansas Blue Cross and Blue Shield
Gold

(PPO) Gold Plan HSA 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$3,525 $7,050 Annual Deductible
$3,525 $7,050 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$474.11
$538.11
$605.91
$846.76
$1,286.73 		$836.80
$900.80
$968.60
$1,209.45 		$1,199.49
$1,263.49
$1,331.29
$1,572.14 		$1,562.18
$1,626.18
$1,693.98
$1,934.83 		$362.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$948.22
$1,076.22
$1,211.82
$1,693.52
$2,573.46 		$1,310.91
$1,438.91
$1,574.51
$2,056.21 		$1,673.60
$1,801.60
$1,937.20
$2,418.90 		$2,036.29
$2,164.29
$2,299.89
$2,781.59 		$362.69
Toc - Plan #47 Arkansas Blue Cross and Blue Shield
Silver

(PPO) Silver Plan 6

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

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 		$432.46
$490.84
$552.68
$772.37
$1,173.70 		$763.29
$821.67
$883.51
$1,103.20 		$1,094.12
$1,152.50
$1,214.34
$1,434.03 		$1,424.95
$1,483.33
$1,545.17
$1,764.86 		$330.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$864.92
$981.68
$1,105.36
$1,544.74
$2,347.40 		$1,195.75
$1,312.51
$1,436.19
$1,875.57 		$1,526.58
$1,643.34
$1,767.02
$2,206.40 		$1,857.41
$1,974.17
$2,097.85
$2,537.23 		$330.83
Toc - Plan #48 Arkansas Blue Cross and Blue Shield
Expanded Bronze

(PPO) Bronze Plan 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,800 $17,600 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 		$307.91
$349.48
$393.51
$549.93
$835.67 		$543.46
$585.03
$629.06
$785.48 		$779.01
$820.58
$864.61
$1,021.03 		$1,014.56
$1,056.13
$1,100.16
$1,256.58 		$235.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.82
$698.96
$787.02
$1,099.86
$1,671.34 		$851.37
$934.51
$1,022.57
$1,335.41 		$1,086.92
$1,170.06
$1,258.12
$1,570.96 		$1,322.47
$1,405.61
$1,493.67
$1,806.51 		$235.55
Toc - Plan #49 Arkansas Blue Cross and Blue Shield
Gold

(PPO) Gold Plan Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

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 		$435.19
$493.94
$556.17
$777.25
$1,181.11 		$768.11
$826.86
$889.09
$1,110.17 		$1,101.03
$1,159.78
$1,222.01
$1,443.09 		$1,433.95
$1,492.70
$1,554.93
$1,776.01 		$332.92
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$870.38
$987.88
$1,112.34
$1,554.50
$2,362.22 		$1,203.30
$1,320.80
$1,445.26
$1,887.42 		$1,536.22
$1,653.72
$1,778.18
$2,220.34 		$1,869.14
$1,986.64
$2,111.10
$2,553.26 		$332.92
Toc - Plan #50 Arkansas Blue Cross and Blue Shield
Silver

(PPO) Silver Plan Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

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 		$331.86
$376.66
$424.12
$592.70
$900.67 		$585.73
$630.53
$677.99
$846.57 		$839.60
$884.40
$931.86
$1,100.44 		$1,093.47
$1,138.27
$1,185.73
$1,354.31 		$253.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$663.72
$753.32
$848.24
$1,185.40
$1,801.34 		$917.59
$1,007.19
$1,102.11
$1,439.27 		$1,171.46
$1,261.06
$1,355.98
$1,693.14 		$1,425.33
$1,514.93
$1,609.85
$1,947.01 		$253.87
Toc - Plan #51 Arkansas Blue Cross and Blue Shield
Bronze

(PPO) Bronze Plan Standardized

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-800-4298

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 		$291.28
$330.60
$372.26
$520.23
$790.53 		$514.11
$553.43
$595.09
$743.06 		$736.94
$776.26
$817.92
$965.89 		$959.77
$999.09
$1,040.75
$1,188.72 		$222.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$582.56
$661.20
$744.52
$1,040.46
$1,581.06 		$805.39
$884.03
$967.35
$1,263.29 		$1,028.22
$1,106.86
$1,190.18
$1,486.12 		$1,251.05
$1,329.69
$1,413.01
$1,708.95 		$222.83

‡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 Dallas County here.

Dallas County is in “Rating Area 6” of Arkansas.

Currently, there are 51 plans offered in Rating Area 6.

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