Obamacare 2023 Rates for Clayton County

Obamacare > Rates > Georgia > Clayton 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 Clayton County, GA.

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, 180 Plans and 2023 Rates for Clayton County, Georgia

Below, you’ll find a summary of the 180 plans for Clayton County, Georgia and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Cigna HealthCare of Georgia, Inc

Local: | Toll Free:

Toc - Plan #1 Cigna HealthCare of Georgia, Inc

Bronze

(HMO) Cigna Connect 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$275.95
$313.20
$352.66
$492.84
$748.92

$487.05
$524.30
$563.76
$703.94

$698.15
$735.40
$774.86
$915.04

$909.25
$946.50
$985.96
$1,126.14

$211.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$551.90
$626.40
$705.32
$985.68
$1,497.84

$763.00
$837.50
$916.42
$1,196.78

$974.10
$1,048.60
$1,127.52
$1,407.88

$1,185.20
$1,259.70
$1,338.62
$1,618.98

$211.10

Toc - Plan #2 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 7800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,800 $15,600 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

$285.68
$324.25
$365.10
$510.23
$775.35

$504.23
$542.80
$583.65
$728.78

$722.78
$761.35
$802.20
$947.33

$941.33
$979.90
$1,020.75
$1,165.88

$218.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$571.36
$648.50
$730.20
$1,020.46
$1,550.70

$789.91
$867.05
$948.75
$1,239.01

$1,008.46
$1,085.60
$1,167.30
$1,457.56

$1,227.01
$1,304.15
$1,385.85
$1,676.11

$218.55

Toc - Plan #3 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 6500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$286.65
$325.35
$366.34
$511.96
$777.97

$505.94
$544.64
$585.63
$731.25

$725.23
$763.93
$804.92
$950.54

$944.52
$983.22
$1,024.21
$1,169.83

$219.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$573.30
$650.70
$732.68
$1,023.92
$1,555.94

$792.59
$869.99
$951.97
$1,243.21

$1,011.88
$1,089.28
$1,171.26
$1,462.50

$1,231.17
$1,308.57
$1,390.55
$1,681.79

$219.29

Toc - Plan #4 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect HSA 7050

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,050 $14,100 Annual Deductible

$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$289.74
$328.86
$370.29
$517.48
$786.36

$511.39
$550.51
$591.94
$739.13

$733.04
$772.16
$813.59
$960.78

$954.69
$993.81
$1,035.24
$1,182.43

$221.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$579.48
$657.72
$740.58
$1,034.96
$1,572.72

$801.13
$879.37
$962.23
$1,256.61

$1,022.78
$1,101.02
$1,183.88
$1,478.26

$1,244.43
$1,322.67
$1,405.53
$1,699.91

$221.65

Toc - Plan #5 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,800 $13,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$289.47
$328.55
$369.94
$516.99
$785.62

$510.92
$550.00
$591.39
$738.44

$732.37
$771.45
$812.84
$959.89

$953.82
$992.90
$1,034.29
$1,181.34

$221.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.94
$657.10
$739.88
$1,033.98
$1,571.24

$800.39
$878.55
$961.33
$1,255.43

$1,021.84
$1,100.00
$1,182.78
$1,476.88

$1,243.29
$1,321.45
$1,404.23
$1,698.33

$221.45

Toc - Plan #6 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 3700

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,700 $7,400 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

$334.53
$379.69
$427.53
$597.47
$907.91

$590.44
$635.60
$683.44
$853.38

$846.35
$891.51
$939.35
$1,109.29

$1,102.26
$1,147.42
$1,195.26
$1,365.20

$255.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$669.06
$759.38
$855.06
$1,194.94
$1,815.82

$924.97
$1,015.29
$1,110.97
$1,450.85

$1,180.88
$1,271.20
$1,366.88
$1,706.76

$1,436.79
$1,527.11
$1,622.79
$1,962.67

$255.91

Toc - Plan #7 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 5000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$334.57
$379.73
$427.58
$597.54
$908.01

$590.51
$635.67
$683.52
$853.48

$846.45
$891.61
$939.46
$1,109.42

$1,102.39
$1,147.55
$1,195.40
$1,365.36

$255.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$669.14
$759.46
$855.16
$1,195.08
$1,816.02

$925.08
$1,015.40
$1,111.10
$1,451.02

$1,181.02
$1,271.34
$1,367.04
$1,706.96

$1,436.96
$1,527.28
$1,622.98
$1,962.90

$255.94

Toc - Plan #8 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 6000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$335.07
$380.30
$428.22
$598.43
$909.38

$591.40
$636.63
$684.55
$854.76

$847.73
$892.96
$940.88
$1,111.09

$1,104.06
$1,149.29
$1,197.21
$1,367.42

$256.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$670.14
$760.60
$856.44
$1,196.86
$1,818.76

$926.47
$1,016.93
$1,112.77
$1,453.19

$1,182.80
$1,273.26
$1,369.10
$1,709.52

$1,439.13
$1,529.59
$1,625.43
$1,965.85

$256.33

Toc - Plan #9 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 7200

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,200 $14,400 Annual Deductible

$7,200 $14,400 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

$339.44
$385.26
$433.80
$606.23
$921.23

$599.11
$644.93
$693.47
$865.90

$858.78
$904.60
$953.14
$1,125.57

$1,118.45
$1,164.27
$1,212.81
$1,385.24

$259.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$678.88
$770.52
$867.60
$1,212.46
$1,842.46

$938.55
$1,030.19
$1,127.27
$1,472.13

$1,198.22
$1,289.86
$1,386.94
$1,731.80

$1,457.89
$1,549.53
$1,646.61
$1,991.47

$259.67

Toc - Plan #10 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

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

$337.81
$383.42
$431.72
$603.33
$916.82

$596.24
$641.85
$690.15
$861.76

$854.67
$900.28
$948.58
$1,120.19

$1,113.10
$1,158.71
$1,207.01
$1,378.62

$258.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.62
$766.84
$863.44
$1,206.66
$1,833.64

$934.05
$1,025.27
$1,121.87
$1,465.09

$1,192.48
$1,283.70
$1,380.30
$1,723.52

$1,450.91
$1,542.13
$1,638.73
$1,981.95

$258.43

Toc - Plan #11 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,200 $8,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$336.23
$381.62
$429.70
$600.50
$912.52

$593.44
$638.83
$686.91
$857.71

$850.65
$896.04
$944.12
$1,114.92

$1,107.86
$1,153.25
$1,201.33
$1,372.13

$257.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$672.46
$763.24
$859.40
$1,201.00
$1,825.04

$929.67
$1,020.45
$1,116.61
$1,458.21

$1,186.88
$1,277.66
$1,373.82
$1,715.42

$1,444.09
$1,534.87
$1,631.03
$1,972.63

$257.21

Toc - Plan #12 Cigna HealthCare of Georgia, Inc

Gold

(HMO) Cigna Connect 1600

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,600 $3,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$423.75
$480.96
$541.56
$756.82
$1,150.07

$747.92
$805.13
$865.73
$1,080.99

$1,072.09
$1,129.30
$1,189.90
$1,405.16

$1,396.26
$1,453.47
$1,514.07
$1,729.33

$324.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$847.50
$961.92
$1,083.12
$1,513.64
$2,300.14

$1,171.67
$1,286.09
$1,407.29
$1,837.81

$1,495.84
$1,610.26
$1,731.46
$2,161.98

$1,820.01
$1,934.43
$2,055.63
$2,486.15

$324.17

Toc - Plan #13 Cigna HealthCare of Georgia, Inc

Gold

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$426.46
$484.03
$545.01
$761.65
$1,157.41

$752.70
$810.27
$871.25
$1,087.89

$1,078.94
$1,136.51
$1,197.49
$1,414.13

$1,405.18
$1,462.75
$1,523.73
$1,740.37

$326.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$852.92
$968.06
$1,090.02
$1,523.30
$2,314.82

$1,179.16
$1,294.30
$1,416.26
$1,849.54

$1,505.40
$1,620.54
$1,742.50
$2,175.78

$1,831.64
$1,946.78
$2,068.74
$2,502.02

$326.24

Toc - Plan #14 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,600 $15,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$290.20
$329.38
$370.88
$518.31
$787.62

$512.21
$551.39
$592.89
$740.32

$734.22
$773.40
$814.90
$962.33

$956.23
$995.41
$1,036.91
$1,184.34

$222.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$580.40
$658.76
$741.76
$1,036.62
$1,575.24

$802.41
$880.77
$963.77
$1,258.63

$1,024.42
$1,102.78
$1,185.78
$1,480.64

$1,246.43
$1,324.79
$1,407.79
$1,702.65

$222.01

Toc - Plan #15 Cigna HealthCare of Georgia, Inc

Bronze

(HMO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$275.95
$313.20
$352.66
$492.84
$748.92

$487.05
$524.30
$563.76
$703.94

$698.15
$735.40
$774.86
$915.04

$909.25
$946.50
$985.96
$1,126.14

$211.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$551.90
$626.40
$705.32
$985.68
$1,497.84

$763.00
$837.50
$916.42
$1,196.78

$974.10
$1,048.60
$1,127.52
$1,407.88

$1,185.20
$1,259.70
$1,338.62
$1,618.98

$211.10

Toc - Plan #16 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$287.54
$326.36
$367.47
$513.54
$780.38

$507.51
$546.33
$587.44
$733.51

$727.48
$766.30
$807.41
$953.48

$947.45
$986.27
$1,027.38
$1,173.45

$219.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$575.08
$652.72
$734.94
$1,027.08
$1,560.76

$795.05
$872.69
$954.91
$1,247.05

$1,015.02
$1,092.66
$1,174.88
$1,467.02

$1,234.99
$1,312.63
$1,394.85
$1,686.99

$219.97

Toc - Plan #17 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 0

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$308.95
$350.65
$394.83
$551.78
$838.48

$545.29
$586.99
$631.17
$788.12

$781.63
$823.33
$867.51
$1,024.46

$1,017.97
$1,059.67
$1,103.85
$1,260.80

$236.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$617.90
$701.30
$789.66
$1,103.56
$1,676.96

$854.24
$937.64
$1,026.00
$1,339.90

$1,090.58
$1,173.98
$1,262.34
$1,576.24

$1,326.92
$1,410.32
$1,498.68
$1,812.58

$236.34

Toc - Plan #18 Cigna HealthCare of Georgia, Inc

Gold

(HMO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$421.78
$478.72
$539.04
$753.30
$1,144.72

$744.44
$801.38
$861.70
$1,075.96

$1,067.10
$1,124.04
$1,184.36
$1,398.62

$1,389.76
$1,446.70
$1,507.02
$1,721.28

$322.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$843.56
$957.44
$1,078.08
$1,506.60
$2,289.44

$1,166.22
$1,280.10
$1,400.74
$1,829.26

$1,488.88
$1,602.76
$1,723.40
$2,151.92

$1,811.54
$1,925.42
$2,046.06
$2,474.58

$322.66

Toc - Plan #19 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$335.07
$380.30
$428.22
$598.43
$909.38

$591.40
$636.63
$684.55
$854.76

$847.73
$892.96
$940.88
$1,111.09

$1,104.06
$1,149.29
$1,197.21
$1,367.42

$256.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$670.14
$760.60
$856.44
$1,196.86
$1,818.76

$926.47
$1,016.93
$1,112.77
$1,453.19

$1,182.80
$1,273.26
$1,369.10
$1,709.52

$1,439.13
$1,529.59
$1,625.43
$1,965.85

$256.33

UnitedHealthcare

Local: 1-800-609-9754 | Toll Free: 1-800-609-9754 | TTY: 1-800-609-9754

Toc - Plan #20 UnitedHealthcare

Gold

(HMO) UHC Gold Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$1,200 $2,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$550.66
$624.99
$703.74
$983.47
$1,494.48

$971.91
$1,046.24
$1,124.99
$1,404.72

$1,393.16
$1,467.49
$1,546.24
$1,825.97

$1,814.41
$1,888.74
$1,967.49
$2,247.22

$421.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,101.32
$1,249.98
$1,407.48
$1,966.94
$2,988.96

$1,522.57
$1,671.23
$1,828.73
$2,388.19

$1,943.82
$2,092.48
$2,249.98
$2,809.44

$2,365.07
$2,513.73
$2,671.23
$3,230.69

$421.25

Toc - Plan #21 UnitedHealthcare

Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$1,200 $2,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$572.27
$649.53
$731.36
$1,022.08
$1,553.15

$1,010.06
$1,087.32
$1,169.15
$1,459.87

$1,447.85
$1,525.11
$1,606.94
$1,897.66

$1,885.64
$1,962.90
$2,044.73
$2,335.45

$437.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,144.54
$1,299.06
$1,462.72
$2,044.16
$3,106.30

$1,582.33
$1,736.85
$1,900.51
$2,481.95

$2,020.12
$2,174.64
$2,338.30
$2,919.74

$2,457.91
$2,612.43
$2,776.09
$3,357.53

$437.79

Toc - Plan #22 UnitedHealthcare

Gold

(HMO) UHC Gold Value $2,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$525.92
$596.92
$672.12
$939.29
$1,427.34

$928.25
$999.25
$1,074.45
$1,341.62

$1,330.58
$1,401.58
$1,476.78
$1,743.95

$1,732.91
$1,803.91
$1,879.11
$2,146.28

$402.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,051.84
$1,193.84
$1,344.24
$1,878.58
$2,854.68

$1,454.17
$1,596.17
$1,746.57
$2,280.91

$1,856.50
$1,998.50
$2,148.90
$2,683.24

$2,258.83
$2,400.83
$2,551.23
$3,085.57

$402.33

Toc - Plan #23 UnitedHealthcare

Gold

(HMO) UHC Gold Value $2,200 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$2,200 $4,400 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

$525.81
$596.79
$671.98
$939.09
$1,427.03

$928.05
$999.03
$1,074.22
$1,341.33

$1,330.29
$1,401.27
$1,476.46
$1,743.57

$1,732.53
$1,803.51
$1,878.70
$2,145.81

$402.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,051.62
$1,193.58
$1,343.96
$1,878.18
$2,854.06

$1,453.86
$1,595.82
$1,746.20
$2,280.42

$1,856.10
$1,998.06
$2,148.44
$2,682.66

$2,258.34
$2,400.30
$2,550.68
$3,084.90

$402.24

Toc - Plan #24 UnitedHealthcare

Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espa�ol)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$486.80
$552.52
$622.13
$869.42
$1,321.17

$859.20
$924.92
$994.53
$1,241.82

$1,231.60
$1,297.32
$1,366.93
$1,614.22

$1,604.00
$1,669.72
$1,739.33
$1,986.62

$372.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$973.60
$1,105.04
$1,244.26
$1,738.84
$2,642.34

$1,346.00
$1,477.44
$1,616.66
$2,111.24

$1,718.40
$1,849.84
$1,989.06
$2,483.64

$2,090.80
$2,222.24
$2,361.46
$2,856.04

$372.40

Toc - Plan #25 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$424.72
$482.05
$542.79
$758.55
$1,152.68

$749.63
$806.96
$867.70
$1,083.46

$1,074.54
$1,131.87
$1,192.61
$1,408.37

$1,399.45
$1,456.78
$1,517.52
$1,733.28

$324.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$849.44
$964.10
$1,085.58
$1,517.10
$2,305.36

$1,174.35
$1,289.01
$1,410.49
$1,842.01

$1,499.26
$1,613.92
$1,735.40
$2,166.92

$1,824.17
$1,938.83
$2,060.31
$2,491.83

$324.91

Toc - Plan #26 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en espa�ol)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$7,250 $14,500 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$409.07
$464.30
$522.80
$730.60
$1,110.22

$722.01
$777.24
$835.74
$1,043.54

$1,034.95
$1,090.18
$1,148.68
$1,356.48

$1,347.89
$1,403.12
$1,461.62
$1,669.42

$312.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$818.14
$928.60
$1,045.60
$1,461.20
$2,220.44

$1,131.08
$1,241.54
$1,358.54
$1,774.14

$1,444.02
$1,554.48
$1,671.48
$2,087.08

$1,756.96
$1,867.42
$1,984.42
$2,400.02

$312.94

Toc - Plan #27 UnitedHealthcare

Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

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

$536.47
$608.89
$685.61
$958.13
$1,455.98

$946.87
$1,019.29
$1,096.01
$1,368.53

$1,357.27
$1,429.69
$1,506.41
$1,778.93

$1,767.67
$1,840.09
$1,916.81
$2,189.33

$410.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,072.94
$1,217.78
$1,371.22
$1,916.26
$2,911.96

$1,483.34
$1,628.18
$1,781.62
$2,326.66

$1,893.74
$2,038.58
$2,192.02
$2,737.06

$2,304.14
$2,448.98
$2,602.42
$3,147.46

$410.40

Toc - Plan #28 UnitedHealthcare

Silver

(HMO) UHC Silver Advantage $0 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$499.71
$567.18
$638.63
$892.49
$1,356.22

$881.99
$949.46
$1,020.91
$1,274.77

$1,264.27
$1,331.74
$1,403.19
$1,657.05

$1,646.55
$1,714.02
$1,785.47
$2,039.33

$382.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$999.42
$1,134.36
$1,277.26
$1,784.98
$2,712.44

$1,381.70
$1,516.64
$1,659.54
$2,167.26

$1,763.98
$1,898.92
$2,041.82
$2,549.54

$2,146.26
$2,281.20
$2,424.10
$2,931.82

$382.28

Toc - Plan #29 UnitedHealthcare

Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$514.31
$583.75
$657.29
$918.57
$1,395.85

$907.76
$977.20
$1,050.74
$1,312.02

$1,301.21
$1,370.65
$1,444.19
$1,705.47

$1,694.66
$1,764.10
$1,837.64
$2,098.92

$393.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,028.62
$1,167.50
$1,314.58
$1,837.14
$2,791.70

$1,422.07
$1,560.95
$1,708.03
$2,230.59

$1,815.52
$1,954.40
$2,101.48
$2,624.04

$2,208.97
$2,347.85
$2,494.93
$3,017.49

$393.45

Toc - Plan #30 UnitedHealthcare

Silver

(HMO) UHC Silver Value $4,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$495.86
$562.80
$633.71
$885.61
$1,345.76

$875.19
$942.13
$1,013.04
$1,264.94

$1,254.52
$1,321.46
$1,392.37
$1,644.27

$1,633.85
$1,700.79
$1,771.70
$2,023.60

$379.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$991.72
$1,125.60
$1,267.42
$1,771.22
$2,691.52

$1,371.05
$1,504.93
$1,646.75
$2,150.55

$1,750.38
$1,884.26
$2,026.08
$2,529.88

$2,129.71
$2,263.59
$2,405.41
$2,909.21

$379.33

Toc - Plan #31 UnitedHealthcare

Silver

(HMO) UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$497.16
$564.28
$635.37
$887.93
$1,349.30

$877.49
$944.61
$1,015.70
$1,268.26

$1,257.82
$1,324.94
$1,396.03
$1,648.59

$1,638.15
$1,705.27
$1,776.36
$2,028.92

$380.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$994.32
$1,128.56
$1,270.74
$1,775.86
$2,698.60

$1,374.65
$1,508.89
$1,651.07
$2,156.19

$1,754.98
$1,889.22
$2,031.40
$2,536.52

$2,135.31
$2,269.55
$2,411.73
$2,916.85

$380.33

Toc - Plan #32 UnitedHealthcare

Silver

(HMO) UHC Silver Value $3,350 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$3,350 $6,700 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

$495.12
$561.96
$632.76
$884.28
$1,343.74

$873.88
$940.72
$1,011.52
$1,263.04

$1,252.64
$1,319.48
$1,390.28
$1,641.80

$1,631.40
$1,698.24
$1,769.04
$2,020.56

$378.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$990.24
$1,123.92
$1,265.52
$1,768.56
$2,687.48

$1,369.00
$1,502.68
$1,644.28
$2,147.32

$1,747.76
$1,881.44
$2,023.04
$2,526.08

$2,126.52
$2,260.20
$2,401.80
$2,904.84

$378.76

Toc - Plan #33 UnitedHealthcare

Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

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

$497.38
$564.53
$635.65
$888.32
$1,349.89

$877.87
$945.02
$1,016.14
$1,268.81

$1,258.36
$1,325.51
$1,396.63
$1,649.30

$1,638.85
$1,706.00
$1,777.12
$2,029.79

$380.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$994.76
$1,129.06
$1,271.30
$1,776.64
$2,699.78

$1,375.25
$1,509.55
$1,651.79
$2,157.13

$1,755.74
$1,890.04
$2,032.28
$2,537.62

$2,136.23
$2,270.53
$2,412.77
$2,918.11

$380.49

Toc - Plan #34 UnitedHealthcare

Bronze

(HMO) UHC Bronze Essential $9,100 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

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

$411.16
$466.67
$525.46
$734.33
$1,115.89

$725.70
$781.21
$840.00
$1,048.87

$1,040.24
$1,095.75
$1,154.54
$1,363.41

$1,354.78
$1,410.29
$1,469.08
$1,677.95

$314.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$822.32
$933.34
$1,050.92
$1,468.66
$2,231.78

$1,136.86
$1,247.88
$1,365.46
$1,783.20

$1,451.40
$1,562.42
$1,680.00
$2,097.74

$1,765.94
$1,876.96
$1,994.54
$2,412.28

$314.54

Toc - Plan #35 UnitedHealthcare

Bronze

(HMO) UHC Bronze Essential $6,350 Deductible ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$6,350 $12,700 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

$409.50
$464.78
$523.34
$731.36
$1,111.37

$722.77
$778.05
$836.61
$1,044.63

$1,036.04
$1,091.32
$1,149.88
$1,357.90

$1,349.31
$1,404.59
$1,463.15
$1,671.17

$313.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$819.00
$929.56
$1,046.68
$1,462.72
$2,222.74

$1,132.27
$1,242.83
$1,359.95
$1,775.99

$1,445.54
$1,556.10
$1,673.22
$2,089.26

$1,758.81
$1,869.37
$1,986.49
$2,402.53

$313.27

Toc - Plan #36 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

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

$422.36
$479.38
$539.78
$754.34
$1,146.29

$745.47
$802.49
$862.89
$1,077.45

$1,068.58
$1,125.60
$1,186.00
$1,400.56

$1,391.69
$1,448.71
$1,509.11
$1,723.67

$323.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$844.72
$958.76
$1,079.56
$1,508.68
$2,292.58

$1,167.83
$1,281.87
$1,402.67
$1,831.79

$1,490.94
$1,604.98
$1,725.78
$2,154.90

$1,814.05
$1,928.09
$2,048.89
$2,478.01

$323.11

Toc - Plan #37 UnitedHealthcare

Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

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

$400.99
$455.13
$512.47
$716.17
$1,088.29

$707.75
$761.89
$819.23
$1,022.93

$1,014.51
$1,068.65
$1,125.99
$1,329.69

$1,321.27
$1,375.41
$1,432.75
$1,636.45

$306.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$801.98
$910.26
$1,024.94
$1,432.34
$2,176.58

$1,108.74
$1,217.02
$1,331.70
$1,739.10

$1,415.50
$1,523.78
$1,638.46
$2,045.86

$1,722.26
$1,830.54
$1,945.22
$2,352.62

$306.76

Toc - Plan #38 UnitedHealthcare

Gold

(HMO) UHC Gold Value $2,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family

$2,100 $4,200 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

$525.17
$596.07
$671.17
$937.96
$1,425.32

$926.93
$997.83
$1,072.93
$1,339.72

$1,328.69
$1,399.59
$1,474.69
$1,741.48

$1,730.45
$1,801.35
$1,876.45
$2,143.24

$401.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,050.34
$1,192.14
$1,342.34
$1,875.92
$2,850.64

$1,452.10
$1,593.90
$1,744.10
$2,277.68

$1,853.86
$1,995.66
$2,145.86
$2,679.44

$2,255.62
$2,397.42
$2,547.62
$3,081.20

$401.76

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Local: 1-855-738-6652 | Toll Free: 1-855-738-6652

Toc - Plan #39 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$354.57
$402.44
$453.14
$633.26
$962.30

$625.82
$673.69
$724.39
$904.51

$897.07
$944.94
$995.64
$1,175.76

$1,168.32
$1,216.19
$1,266.89
$1,447.01

$271.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$709.14
$804.88
$906.28
$1,266.52
$1,924.60

$980.39
$1,076.13
$1,177.53
$1,537.77

$1,251.64
$1,347.38
$1,448.78
$1,809.02

$1,522.89
$1,618.63
$1,720.03
$2,080.27

$271.25

Toc - Plan #40 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 3000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$423.73
$480.93
$541.53
$756.78
$1,150.00

$747.88
$805.08
$865.68
$1,080.93

$1,072.03
$1,129.23
$1,189.83
$1,405.08

$1,396.18
$1,453.38
$1,513.98
$1,729.23

$324.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$847.46
$961.86
$1,083.06
$1,513.56
$2,300.00

$1,171.61
$1,286.01
$1,407.21
$1,837.71

$1,495.76
$1,610.16
$1,731.36
$2,161.86

$1,819.91
$1,934.31
$2,055.51
$2,486.01

$324.15

Toc - Plan #41 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 5500($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$426.97
$484.61
$545.67
$762.57
$1,158.80

$753.60
$811.24
$872.30
$1,089.20

$1,080.23
$1,137.87
$1,198.93
$1,415.83

$1,406.86
$1,464.50
$1,525.56
$1,742.46

$326.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$853.94
$969.22
$1,091.34
$1,525.14
$2,317.60

$1,180.57
$1,295.85
$1,417.97
$1,851.77

$1,507.20
$1,622.48
$1,744.60
$2,178.40

$1,833.83
$1,949.11
$2,071.23
$2,505.03

$326.63

Toc - Plan #42 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5600($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,600 $11,200 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

$343.48
$389.85
$438.97
$613.46
$932.20

$606.24
$652.61
$701.73
$876.22

$869.00
$915.37
$964.49
$1,138.98

$1,131.76
$1,178.13
$1,227.25
$1,401.74

$262.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$686.96
$779.70
$877.94
$1,226.92
$1,864.40

$949.72
$1,042.46
$1,140.70
$1,489.68

$1,212.48
$1,305.22
$1,403.46
$1,752.44

$1,475.24
$1,567.98
$1,666.22
$2,015.20

$262.76

Toc - Plan #43 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 6000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$337.55
$383.12
$431.39
$602.86
$916.11

$595.78
$641.35
$689.62
$861.09

$854.01
$899.58
$947.85
$1,119.32

$1,112.24
$1,157.81
$1,206.08
$1,377.55

$258.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.10
$766.24
$862.78
$1,205.72
$1,832.22

$933.33
$1,024.47
$1,121.01
$1,463.95

$1,191.56
$1,282.70
$1,379.24
$1,722.18

$1,449.79
$1,540.93
$1,637.47
$1,980.41

$258.23

Toc - Plan #44 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Catastrophic

(HMO) Anthem Catastrophic Pathway X Guided Access HMO 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$243.95
$276.88
$311.77
$435.69
$662.08

$430.57
$463.50
$498.39
$622.31

$617.19
$650.12
$685.01
$808.93

$803.81
$836.74
$871.63
$995.55

$186.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$487.90
$553.76
$623.54
$871.38
$1,324.16

$674.52
$740.38
$810.16
$1,058.00

$861.14
$927.00
$996.78
$1,244.62

$1,047.76
$1,113.62
$1,183.40
$1,431.24

$186.62

Toc - Plan #45 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 8000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$324.24
$368.01
$414.38
$579.09
$879.99

$572.28
$616.05
$662.42
$827.13

$820.32
$864.09
$910.46
$1,075.17

$1,068.36
$1,112.13
$1,158.50
$1,323.21

$248.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$648.48
$736.02
$828.76
$1,158.18
$1,759.98

$896.52
$984.06
$1,076.80
$1,406.22

$1,144.56
$1,232.10
$1,324.84
$1,654.26

$1,392.60
$1,480.14
$1,572.88
$1,902.30

$248.04

Toc - Plan #46 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 4950($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$4,950 $9,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$429.62
$487.62
$549.05
$767.30
$1,165.99

$758.28
$816.28
$877.71
$1,095.96

$1,086.94
$1,144.94
$1,206.37
$1,424.62

$1,415.60
$1,473.60
$1,535.03
$1,753.28

$328.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.24
$975.24
$1,098.10
$1,534.60
$2,331.98

$1,187.90
$1,303.90
$1,426.76
$1,863.26

$1,516.56
$1,632.56
$1,755.42
$2,191.92

$1,845.22
$1,961.22
$2,084.08
$2,520.58

$328.66

Toc - Plan #47 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Gold

(HMO) Anthem Gold Pathway X Guided Access HMO 1600($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$1,600 $3,200 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

$471.51
$535.16
$602.59
$842.12
$1,279.68

$832.22
$895.87
$963.30
$1,202.83

$1,192.93
$1,256.58
$1,324.01
$1,563.54

$1,553.64
$1,617.29
$1,684.72
$1,924.25

$360.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$943.02
$1,070.32
$1,205.18
$1,684.24
$2,559.36

$1,303.73
$1,431.03
$1,565.89
$2,044.95

$1,664.44
$1,791.74
$1,926.60
$2,405.66

$2,025.15
$2,152.45
$2,287.31
$2,766.37

$360.71

Toc - Plan #48 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 5000($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$357.99
$406.32
$457.51
$639.37
$971.58

$631.85
$680.18
$731.37
$913.23

$905.71
$954.04
$1,005.23
$1,187.09

$1,179.57
$1,227.90
$1,279.09
$1,460.95

$273.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.98
$812.64
$915.02
$1,278.74
$1,943.16

$989.84
$1,086.50
$1,188.88
$1,552.60

$1,263.70
$1,360.36
$1,462.74
$1,826.46

$1,537.56
$1,634.22
$1,736.60
$2,100.32

$273.86

Toc - Plan #49 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 2600($0 PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$2,600 $5,200 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

$450.06
$510.82
$575.18
$803.81
$1,221.46

$794.36
$855.12
$919.48
$1,148.11

$1,138.66
$1,199.42
$1,263.78
$1,492.41

$1,482.96
$1,543.72
$1,608.08
$1,836.71

$344.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$900.12
$1,021.64
$1,150.36
$1,607.62
$2,442.92

$1,244.42
$1,365.94
$1,494.66
$1,951.92

$1,588.72
$1,710.24
$1,838.96
$2,296.22

$1,933.02
$2,054.54
$2,183.26
$2,640.52

$344.30

Toc - Plan #50 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 6500($0 Virtual PCP+$0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$421.94
$478.90
$539.24
$753.58
$1,145.15

$744.72
$801.68
$862.02
$1,076.36

$1,067.50
$1,124.46
$1,184.80
$1,399.14

$1,390.28
$1,447.24
$1,507.58
$1,721.92

$322.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$843.88
$957.80
$1,078.48
$1,507.16
$2,290.30

$1,166.66
$1,280.58
$1,401.26
$1,829.94

$1,489.44
$1,603.36
$1,724.04
$2,152.72

$1,812.22
$1,926.14
$2,046.82
$2,475.50

$322.78

Toc - Plan #51 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$333.93
$379.01
$426.76
$596.40
$906.29

$589.39
$634.47
$682.22
$851.86

$844.85
$889.93
$937.68
$1,107.32

$1,100.31
$1,145.39
$1,193.14
$1,362.78

$255.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$667.86
$758.02
$853.52
$1,192.80
$1,812.58

$923.32
$1,013.48
$1,108.98
$1,448.26

$1,178.78
$1,268.94
$1,364.44
$1,703.72

$1,434.24
$1,524.40
$1,619.90
$1,959.18

$255.46

Toc - Plan #52 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X Guided Access HMO 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$365.28
$414.59
$466.83
$652.39
$991.37

$644.72
$694.03
$746.27
$931.83

$924.16
$973.47
$1,025.71
$1,211.27

$1,203.60
$1,252.91
$1,305.15
$1,490.71

$279.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$730.56
$829.18
$933.66
$1,304.78
$1,982.74

$1,010.00
$1,108.62
$1,213.10
$1,584.22

$1,289.44
$1,388.06
$1,492.54
$1,863.66

$1,568.88
$1,667.50
$1,771.98
$2,143.10

$279.44

Toc - Plan #53 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X Guided Access HMO 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$428.51
$486.36
$547.64
$765.32
$1,162.98

$756.32
$814.17
$875.45
$1,093.13

$1,084.13
$1,141.98
$1,203.26
$1,420.94

$1,411.94
$1,469.79
$1,531.07
$1,748.75

$327.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$857.02
$972.72
$1,095.28
$1,530.64
$2,325.96

$1,184.83
$1,300.53
$1,423.09
$1,858.45

$1,512.64
$1,628.34
$1,750.90
$2,186.26

$1,840.45
$1,956.15
$2,078.71
$2,514.07

$327.81

Toc - Plan #54 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Gold

(HMO) Anthem Gold Pathway X Guided Access HMO 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

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

$484.53
$549.94
$619.23
$865.37
$1,315.01

$855.20
$920.61
$989.90
$1,236.04

$1,225.87
$1,291.28
$1,360.57
$1,606.71

$1,596.54
$1,661.95
$1,731.24
$1,977.38

$370.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$969.06
$1,099.88
$1,238.46
$1,730.74
$2,630.02

$1,339.73
$1,470.55
$1,609.13
$2,101.41

$1,710.40
$1,841.22
$1,979.80
$2,472.08

$2,081.07
$2,211.89
$2,350.47
$2,842.75

$370.67

Oscar Health Plan of Georgia

Local: 1-855-672-2755 | Toll Free:

Toc - Plan #55 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$278.71
$316.32
$356.18
$497.76
$756.39

$491.92
$529.53
$569.39
$710.97

$705.13
$742.74
$782.60
$924.18

$918.34
$955.95
$995.81
$1,137.39

$213.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$557.42
$632.64
$712.36
$995.52
$1,512.78

$770.63
$845.85
$925.57
$1,208.73

$983.84
$1,059.06
$1,138.78
$1,421.94

$1,197.05
$1,272.27
$1,351.99
$1,635.15

$213.21

Toc - Plan #56 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$273.45
$310.35
$349.46
$488.36
$742.12

$482.63
$519.53
$558.64
$697.54

$691.81
$728.71
$767.82
$906.72

$900.99
$937.89
$977.00
$1,115.90

$209.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$546.90
$620.70
$698.92
$976.72
$1,484.24

$756.08
$829.88
$908.10
$1,185.90

$965.26
$1,039.06
$1,117.28
$1,395.08

$1,174.44
$1,248.24
$1,326.46
$1,604.26

$209.18

Toc - Plan #57 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Elite- $0 Ded+PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$326.55
$370.62
$417.31
$583.20
$886.22

$576.35
$620.42
$667.11
$833.00

$826.15
$870.22
$916.91
$1,082.80

$1,075.95
$1,120.02
$1,166.71
$1,332.60

$249.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$653.10
$741.24
$834.62
$1,166.40
$1,772.44

$902.90
$991.04
$1,084.42
$1,416.20

$1,152.70
$1,240.84
$1,334.22
$1,666.00

$1,402.50
$1,490.64
$1,584.02
$1,915.80

$249.80

Toc - Plan #58 Oscar Health Plan of Georgia

Silver

(HMO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,400 $10,800 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

$352.36
$399.91
$450.30
$629.29
$956.27

$621.91
$669.46
$719.85
$898.84

$891.46
$939.01
$989.40
$1,168.39

$1,161.01
$1,208.56
$1,258.95
$1,437.94

$269.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$704.72
$799.82
$900.60
$1,258.58
$1,912.54

$974.27
$1,069.37
$1,170.15
$1,528.13

$1,243.82
$1,338.92
$1,439.70
$1,797.68

$1,513.37
$1,608.47
$1,709.25
$2,067.23

$269.55

Toc - Plan #59 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$348.08
$395.06
$444.83
$621.65
$944.66

$614.35
$661.33
$711.10
$887.92

$880.62
$927.60
$977.37
$1,154.19

$1,146.89
$1,193.87
$1,243.64
$1,420.46

$266.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$696.16
$790.12
$889.66
$1,243.30
$1,889.32

$962.43
$1,056.39
$1,155.93
$1,509.57

$1,228.70
$1,322.66
$1,422.20
$1,775.84

$1,494.97
$1,588.93
$1,688.47
$2,042.11

$266.27

Toc - Plan #60 Oscar Health Plan of Georgia

Catastrophic

(HMO) Secure

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$236.62
$268.55
$302.39
$422.59
$642.16

$417.63
$449.56
$483.40
$603.60

$598.64
$630.57
$664.41
$784.61

$779.65
$811.58
$845.42
$965.62

$181.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$473.24
$537.10
$604.78
$845.18
$1,284.32

$654.25
$718.11
$785.79
$1,026.19

$835.26
$899.12
$966.80
$1,207.20

$1,016.27
$1,080.13
$1,147.81
$1,388.21

$181.01

Toc - Plan #61 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Elite- $0 Ded+Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$326.30
$370.34
$417.00
$582.75
$885.55

$575.91
$619.95
$666.61
$832.36

$825.52
$869.56
$916.22
$1,081.97

$1,075.13
$1,119.17
$1,165.83
$1,331.58

$249.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$652.60
$740.68
$834.00
$1,165.50
$1,771.10

$902.21
$990.29
$1,083.61
$1,415.11

$1,151.82
$1,239.90
$1,333.22
$1,664.72

$1,401.43
$1,489.51
$1,582.83
$1,914.33

$249.61

Toc - Plan #62 Oscar Health Plan of Georgia

Gold

(HMO) Gold Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 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

$371.93
$422.13
$475.31
$664.25
$1,009.38

$656.45
$706.65
$759.83
$948.77

$940.97
$991.17
$1,044.35
$1,233.29

$1,225.49
$1,275.69
$1,328.87
$1,517.81

$284.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$743.86
$844.26
$950.62
$1,328.50
$2,018.76

$1,028.38
$1,128.78
$1,235.14
$1,613.02

$1,312.90
$1,413.30
$1,519.66
$1,897.54

$1,597.42
$1,697.82
$1,804.18
$2,182.06

$284.52

Toc - Plan #63 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,200 $10,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$289.49
$328.56
$369.95
$517.01
$785.64

$510.94
$550.01
$591.40
$738.46

$732.39
$771.46
$812.85
$959.91

$953.84
$992.91
$1,034.30
$1,181.36

$221.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.98
$657.12
$739.90
$1,034.02
$1,571.28

$800.43
$878.57
$961.35
$1,255.47

$1,021.88
$1,100.02
$1,182.80
$1,476.92

$1,243.33
$1,321.47
$1,404.25
$1,698.37

$221.45

Toc - Plan #64 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,400 $8,800 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

$348.26
$395.26
$445.06
$621.97
$945.14

$614.67
$661.67
$711.47
$888.38

$881.08
$928.08
$977.88
$1,154.79

$1,147.49
$1,194.49
$1,244.29
$1,421.20

$266.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$696.52
$790.52
$890.12
$1,243.94
$1,890.28

$962.93
$1,056.93
$1,156.53
$1,510.35

$1,229.34
$1,323.34
$1,422.94
$1,776.76

$1,495.75
$1,589.75
$1,689.35
$2,043.17

$266.41

Toc - Plan #65 Oscar Health Plan of Georgia

Silver

(HMO) Silver Classic- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$364.97
$414.23
$466.42
$651.83
$990.51

$644.17
$693.43
$745.62
$931.03

$923.37
$972.63
$1,024.82
$1,210.23

$1,202.57
$1,251.83
$1,304.02
$1,489.43

$279.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$729.94
$828.46
$932.84
$1,303.66
$1,981.02

$1,009.14
$1,107.66
$1,212.04
$1,582.86

$1,288.34
$1,386.86
$1,491.24
$1,862.06

$1,567.54
$1,666.06
$1,770.44
$2,141.26

$279.20

Toc - Plan #66 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$288.15
$327.04
$368.24
$514.62
$782.01

$508.58
$547.47
$588.67
$735.05

$729.01
$767.90
$809.10
$955.48

$949.44
$988.33
$1,029.53
$1,175.91

$220.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$576.30
$654.08
$736.48
$1,029.24
$1,564.02

$796.73
$874.51
$956.91
$1,249.67

$1,017.16
$1,094.94
$1,177.34
$1,470.10

$1,237.59
$1,315.37
$1,397.77
$1,690.53

$220.43

Toc - Plan #67 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- $3000 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$318.15
$361.09
$406.58
$568.20
$863.43

$561.53
$604.47
$649.96
$811.58

$804.91
$847.85
$893.34
$1,054.96

$1,048.29
$1,091.23
$1,136.72
$1,298.34

$243.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$636.30
$722.18
$813.16
$1,136.40
$1,726.86

$879.68
$965.56
$1,056.54
$1,379.78

$1,123.06
$1,208.94
$1,299.92
$1,623.16

$1,366.44
$1,452.32
$1,543.30
$1,866.54

$243.38

Toc - Plan #68 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,700 $9,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$293.13
$332.69
$374.61
$523.52
$795.53

$517.37
$556.93
$598.85
$747.76

$741.61
$781.17
$823.09
$972.00

$965.85
$1,005.41
$1,047.33
$1,196.24

$224.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$586.26
$665.38
$749.22
$1,047.04
$1,591.06

$810.50
$889.62
$973.46
$1,271.28

$1,034.74
$1,113.86
$1,197.70
$1,495.52

$1,258.98
$1,338.10
$1,421.94
$1,719.76

$224.24

Toc - Plan #69 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$341.07
$387.11
$435.88
$609.14
$925.64

$601.98
$648.02
$696.79
$870.05

$862.89
$908.93
$957.70
$1,130.96

$1,123.80
$1,169.84
$1,218.61
$1,391.87

$260.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$682.14
$774.22
$871.76
$1,218.28
$1,851.28

$943.05
$1,035.13
$1,132.67
$1,479.19

$1,203.96
$1,296.04
$1,393.58
$1,740.10

$1,464.87
$1,556.95
$1,654.49
$2,001.01

$260.91

Toc - Plan #70 Oscar Health Plan of Georgia

Silver

(HMO) Silver Elite- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 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

$360.54
$409.20
$460.76
$643.90
$978.47

$636.34
$685.00
$736.56
$919.70

$912.14
$960.80
$1,012.36
$1,195.50

$1,187.94
$1,236.60
$1,288.16
$1,471.30

$275.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$721.08
$818.40
$921.52
$1,287.80
$1,956.94

$996.88
$1,094.20
$1,197.32
$1,563.60

$1,272.68
$1,370.00
$1,473.12
$1,839.40

$1,548.48
$1,645.80
$1,748.92
$2,115.20

$275.80

Toc - Plan #71 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,850 $9,700 Annual Deductible

$4,850 $9,700 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

$353.90
$401.66
$452.27
$632.04
$960.45

$624.62
$672.38
$722.99
$902.76

$895.34
$943.10
$993.71
$1,173.48

$1,166.06
$1,213.82
$1,264.43
$1,444.20

$270.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.80
$803.32
$904.54
$1,264.08
$1,920.90

$978.52
$1,074.04
$1,175.26
$1,534.80

$1,249.24
$1,344.76
$1,445.98
$1,805.52

$1,519.96
$1,615.48
$1,716.70
$2,076.24

$270.72

Toc - Plan #72 Oscar Health Plan of Georgia

Silver

(HMO) Silver Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$355.03
$402.94
$453.71
$634.06
$963.51

$626.62
$674.53
$725.30
$905.65

$898.21
$946.12
$996.89
$1,177.24

$1,169.80
$1,217.71
$1,268.48
$1,448.83

$271.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$710.06
$805.88
$907.42
$1,268.12
$1,927.02

$981.65
$1,077.47
$1,179.01
$1,539.71

$1,253.24
$1,349.06
$1,450.60
$1,811.30

$1,524.83
$1,620.65
$1,722.19
$2,082.89

$271.59

Toc - Plan #73 Oscar Health Plan of Georgia

Gold

(HMO) Gold Elite- $0 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

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

$404.89
$459.54
$517.44
$723.12
$1,098.86

$714.63
$769.28
$827.18
$1,032.86

$1,024.37
$1,079.02
$1,136.92
$1,342.60

$1,334.11
$1,388.76
$1,446.66
$1,652.34

$309.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$809.78
$919.08
$1,034.88
$1,446.24
$2,197.72

$1,119.52
$1,228.82
$1,344.62
$1,755.98

$1,429.26
$1,538.56
$1,654.36
$2,065.72

$1,739.00
$1,848.30
$1,964.10
$2,375.46

$309.74

Toc - Plan #74 Oscar Health Plan of Georgia

Gold

(HMO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 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

$383.01
$434.70
$489.47
$684.03
$1,039.45

$676.00
$727.69
$782.46
$977.02

$968.99
$1,020.68
$1,075.45
$1,270.01

$1,261.98
$1,313.67
$1,368.44
$1,563.00

$292.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.02
$869.40
$978.94
$1,368.06
$2,078.90

$1,059.01
$1,162.39
$1,271.93
$1,661.05

$1,352.00
$1,455.38
$1,564.92
$1,954.04

$1,644.99
$1,748.37
$1,857.91
$2,247.03

$292.99

Toc - Plan #75 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Elite- $1000 Ded

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 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

$323.63
$367.31
$413.59
$577.99
$878.31

$571.20
$614.88
$661.16
$825.56

$818.77
$862.45
$908.73
$1,073.13

$1,066.34
$1,110.02
$1,156.30
$1,320.70

$247.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$647.26
$734.62
$827.18
$1,155.98
$1,756.62

$894.83
$982.19
$1,074.75
$1,403.55

$1,142.40
$1,229.76
$1,322.32
$1,651.12

$1,389.97
$1,477.33
$1,569.89
$1,898.69

$247.57

Toc - Plan #76 Oscar Health Plan of Georgia

Silver

(HMO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,450 $12,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$349.09
$396.20
$446.12
$623.45
$947.40

$616.14
$663.25
$713.17
$890.50

$883.19
$930.30
$980.22
$1,157.55

$1,150.24
$1,197.35
$1,247.27
$1,424.60

$267.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$698.18
$792.40
$892.24
$1,246.90
$1,894.80

$965.23
$1,059.45
$1,159.29
$1,513.95

$1,232.28
$1,326.50
$1,426.34
$1,781.00

$1,499.33
$1,593.55
$1,693.39
$2,048.05

$267.05

Toc - Plan #77 Oscar Health Plan of Georgia

Expanded Bronze

(HMO) Bronze Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$287.08
$325.82
$366.88
$512.71
$779.11

$506.69
$545.43
$586.49
$732.32

$726.30
$765.04
$806.10
$951.93

$945.91
$984.65
$1,025.71
$1,171.54

$219.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$574.16
$651.64
$733.76
$1,025.42
$1,558.22

$793.77
$871.25
$953.37
$1,245.03

$1,013.38
$1,090.86
$1,172.98
$1,464.64

$1,232.99
$1,310.47
$1,392.59
$1,684.25

$219.61

Toc - Plan #78 Oscar Health Plan of Georgia

Bronze

(HMO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$261.55
$296.85
$334.25
$467.11
$709.82

$461.63
$496.93
$534.33
$667.19

$661.71
$697.01
$734.41
$867.27

$861.79
$897.09
$934.49
$1,067.35

$200.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$523.10
$593.70
$668.50
$934.22
$1,419.64

$723.18
$793.78
$868.58
$1,134.30

$923.26
$993.86
$1,068.66
$1,334.38

$1,123.34
$1,193.94
$1,268.74
$1,534.46

$200.08

Toc - Plan #79 Oscar Health Plan of Georgia

Silver

(HMO) Silver Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$343.69
$390.08
$439.23
$613.82
$932.76

$606.61
$653.00
$702.15
$876.74

$869.53
$915.92
$965.07
$1,139.66

$1,132.45
$1,178.84
$1,227.99
$1,402.58

$262.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$687.38
$780.16
$878.46
$1,227.64
$1,865.52

$950.30
$1,043.08
$1,141.38
$1,490.56

$1,213.22
$1,306.00
$1,404.30
$1,753.48

$1,476.14
$1,568.92
$1,667.22
$2,016.40

$262.92

Toc - Plan #80 Oscar Health Plan of Georgia

Gold

(HMO) Gold Classic- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$353.26
$400.94
$451.46
$630.91
$958.73

$623.50
$671.18
$721.70
$901.15

$893.74
$941.42
$991.94
$1,171.39

$1,163.98
$1,211.66
$1,262.18
$1,441.63

$270.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$706.52
$801.88
$902.92
$1,261.82
$1,917.46

$976.76
$1,072.12
$1,173.16
$1,532.06

$1,247.00
$1,342.36
$1,443.40
$1,802.30

$1,517.24
$1,612.60
$1,713.64
$2,072.54

$270.24

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-255-0056

Toc - Plan #81 CareSource

Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$312.08
$354.20
$398.83
$557.36
$846.97

$550.82
$592.94
$637.57
$796.10

$789.56
$831.68
$876.31
$1,034.84

$1,028.30
$1,070.42
$1,115.05
$1,273.58

$238.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$624.16
$708.40
$797.66
$1,114.72
$1,693.94

$862.90
$947.14
$1,036.40
$1,353.46

$1,101.64
$1,185.88
$1,275.14
$1,592.20

$1,340.38
$1,424.62
$1,513.88
$1,830.94

$238.74

Toc - Plan #82 CareSource

Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$424.86
$482.21
$542.97
$758.80
$1,153.06

$749.88
$807.23
$867.99
$1,083.82

$1,074.90
$1,132.25
$1,193.01
$1,408.84

$1,399.92
$1,457.27
$1,518.03
$1,733.86

$325.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$849.72
$964.42
$1,085.94
$1,517.60
$2,306.12

$1,174.74
$1,289.44
$1,410.96
$1,842.62

$1,499.76
$1,614.46
$1,735.98
$2,167.64

$1,824.78
$1,939.48
$2,061.00
$2,492.66

$325.02

Toc - Plan #83 CareSource

Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$424.53
$481.84
$542.54
$758.20
$1,152.16

$749.29
$806.60
$867.30
$1,082.96

$1,074.05
$1,131.36
$1,192.06
$1,407.72

$1,398.81
$1,456.12
$1,516.82
$1,732.48

$324.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$849.06
$963.68
$1,085.08
$1,516.40
$2,304.32

$1,173.82
$1,288.44
$1,409.84
$1,841.16

$1,498.58
$1,613.20
$1,734.60
$2,165.92

$1,823.34
$1,937.96
$2,059.36
$2,490.68

$324.76

Toc - Plan #84 CareSource

Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$434.49
$493.15
$555.28
$776.00
$1,179.20

$766.87
$825.53
$887.66
$1,108.38

$1,099.25
$1,157.91
$1,220.04
$1,440.76

$1,431.63
$1,490.29
$1,552.42
$1,773.14

$332.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$868.98
$986.30
$1,110.56
$1,552.00
$2,358.40

$1,201.36
$1,318.68
$1,442.94
$1,884.38

$1,533.74
$1,651.06
$1,775.32
$2,216.76

$1,866.12
$1,983.44
$2,107.70
$2,549.14

$332.38

Toc - Plan #85 CareSource

Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$344.08
$390.53
$439.73
$614.52
$933.82

$607.30
$653.75
$702.95
$877.74

$870.52
$916.97
$966.17
$1,140.96

$1,133.74
$1,180.19
$1,229.39
$1,404.18

$263.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$688.16
$781.06
$879.46
$1,229.04
$1,867.64

$951.38
$1,044.28
$1,142.68
$1,492.26

$1,214.60
$1,307.50
$1,405.90
$1,755.48

$1,477.82
$1,570.72
$1,669.12
$2,018.70

$263.22

Toc - Plan #86 CareSource

Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$294.89
$334.70
$376.87
$526.67
$800.33

$520.48
$560.29
$602.46
$752.26

$746.07
$785.88
$828.05
$977.85

$971.66
$1,011.47
$1,053.64
$1,203.44

$225.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$589.78
$669.40
$753.74
$1,053.34
$1,600.66

$815.37
$894.99
$979.33
$1,278.93

$1,040.96
$1,120.58
$1,204.92
$1,504.52

$1,266.55
$1,346.17
$1,430.51
$1,730.11

$225.59

Toc - Plan #87 CareSource

Silver

(HMO) CareSource Marketplace Essential Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,150 $12,300 Annual Deductible

$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$462.91
$525.40
$591.59
$826.75
$1,256.33

$817.03
$879.52
$945.71
$1,180.87

$1,171.15
$1,233.64
$1,299.83
$1,534.99

$1,525.27
$1,587.76
$1,653.95
$1,889.11

$354.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$925.82
$1,050.80
$1,183.18
$1,653.50
$2,512.66

$1,279.94
$1,404.92
$1,537.30
$2,007.62

$1,634.06
$1,759.04
$1,891.42
$2,361.74

$1,988.18
$2,113.16
$2,245.54
$2,715.86

$354.12

Toc - Plan #88 CareSource

Silver

(HMO) CareSource Marketplace Federal Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$434.08
$492.67
$554.75
$775.26
$1,178.08

$766.15
$824.74
$886.82
$1,107.33

$1,098.22
$1,156.81
$1,218.89
$1,439.40

$1,430.29
$1,488.88
$1,550.96
$1,771.47

$332.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$868.16
$985.34
$1,109.50
$1,550.52
$2,356.16

$1,200.23
$1,317.41
$1,441.57
$1,882.59

$1,532.30
$1,649.48
$1,773.64
$2,214.66

$1,864.37
$1,981.55
$2,105.71
$2,546.73

$332.07

Toc - Plan #89 CareSource

Gold

(HMO) CareSource Marketplace Federal Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$433.07
$491.53
$553.46
$773.46
$1,175.34

$764.37
$822.83
$884.76
$1,104.76

$1,095.67
$1,154.13
$1,216.06
$1,436.06

$1,426.97
$1,485.43
$1,547.36
$1,767.36

$331.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$866.14
$983.06
$1,106.92
$1,546.92
$2,350.68

$1,197.44
$1,314.36
$1,438.22
$1,878.22

$1,528.74
$1,645.66
$1,769.52
$2,209.52

$1,860.04
$1,976.96
$2,100.82
$2,540.82

$331.30

Toc - Plan #90 CareSource

Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$322.34
$365.86
$411.95
$575.70
$874.83

$568.93
$612.45
$658.54
$822.29

$815.52
$859.04
$905.13
$1,068.88

$1,062.11
$1,105.63
$1,151.72
$1,315.47

$246.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$644.68
$731.72
$823.90
$1,151.40
$1,749.66

$891.27
$978.31
$1,070.49
$1,397.99

$1,137.86
$1,224.90
$1,317.08
$1,644.58

$1,384.45
$1,471.49
$1,563.67
$1,891.17

$246.59

Toc - Plan #91 CareSource

Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$435.50
$494.29
$556.56
$777.80
$1,181.94

$768.66
$827.45
$889.72
$1,110.96

$1,101.82
$1,160.61
$1,222.88
$1,444.12

$1,434.98
$1,493.77
$1,556.04
$1,777.28

$333.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$871.00
$988.58
$1,113.12
$1,555.60
$2,363.88

$1,204.16
$1,321.74
$1,446.28
$1,888.76

$1,537.32
$1,654.90
$1,779.44
$2,221.92

$1,870.48
$1,988.06
$2,112.60
$2,555.08

$333.16

Toc - Plan #92 CareSource

Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$434.66
$493.33
$555.49
$776.29
$1,179.65

$767.17
$825.84
$888.00
$1,108.80

$1,099.68
$1,158.35
$1,220.51
$1,441.31

$1,432.19
$1,490.86
$1,553.02
$1,773.82

$332.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$869.32
$986.66
$1,110.98
$1,552.58
$2,359.30

$1,201.83
$1,319.17
$1,443.49
$1,885.09

$1,534.34
$1,651.68
$1,776.00
$2,217.60

$1,866.85
$1,984.19
$2,108.51
$2,550.11

$332.51

Toc - Plan #93 CareSource

Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$444.62
$504.64
$568.22
$794.09
$1,206.70

$784.75
$844.77
$908.35
$1,134.22

$1,124.88
$1,184.90
$1,248.48
$1,474.35

$1,465.01
$1,525.03
$1,588.61
$1,814.48

$340.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$889.24
$1,009.28
$1,136.44
$1,588.18
$2,413.40

$1,229.37
$1,349.41
$1,476.57
$1,928.31

$1,569.50
$1,689.54
$1,816.70
$2,268.44

$1,909.63
$2,029.67
$2,156.83
$2,608.57

$340.13

Toc - Plan #94 CareSource

Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$304.33
$345.41
$388.92
$543.52
$825.93

$537.14
$578.22
$621.73
$776.33

$769.95
$811.03
$854.54
$1,009.14

$1,002.76
$1,043.84
$1,087.35
$1,241.95

$232.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$608.66
$690.82
$777.84
$1,087.04
$1,651.86

$841.47
$923.63
$1,010.65
$1,319.85

$1,074.28
$1,156.44
$1,243.46
$1,552.66

$1,307.09
$1,389.25
$1,476.27
$1,785.47

$232.81

Toc - Plan #95 CareSource

Silver

(HMO) CareSource Marketplace Essential Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,150 $12,300 Annual Deductible

$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$472.54
$536.33
$603.90
$843.95
$1,282.47

$834.03
$897.82
$965.39
$1,205.44

$1,195.52
$1,259.31
$1,326.88
$1,566.93

$1,557.01
$1,620.80
$1,688.37
$1,928.42

$361.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$945.08
$1,072.66
$1,207.80
$1,687.90
$2,564.94

$1,306.57
$1,434.15
$1,569.29
$2,049.39

$1,668.06
$1,795.64
$1,930.78
$2,410.88

$2,029.55
$2,157.13
$2,292.27
$2,772.37

$361.49

Toc - Plan #96 CareSource

Silver

(HMO) CareSource Marketplace Federal Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$444.21
$504.17
$567.69
$793.35
$1,205.57

$784.03
$843.99
$907.51
$1,133.17

$1,123.85
$1,183.81
$1,247.33
$1,472.99

$1,463.67
$1,523.63
$1,587.15
$1,812.81

$339.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$888.42
$1,008.34
$1,135.38
$1,586.70
$2,411.14

$1,228.24
$1,348.16
$1,475.20
$1,926.52

$1,568.06
$1,687.98
$1,815.02
$2,266.34

$1,907.88
$2,027.80
$2,154.84
$2,606.16

$339.82

Toc - Plan #97 CareSource

Gold

(HMO) CareSource Marketplace Federal Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$443.71
$503.61
$567.05
$792.46
$1,204.22

$783.14
$843.04
$906.48
$1,131.89

$1,122.57
$1,182.47
$1,245.91
$1,471.32

$1,462.00
$1,521.90
$1,585.34
$1,810.75

$339.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$887.42
$1,007.22
$1,134.10
$1,584.92
$2,408.44

$1,226.85
$1,346.65
$1,473.53
$1,924.35

$1,566.28
$1,686.08
$1,812.96
$2,263.78

$1,905.71
$2,025.51
$2,152.39
$2,603.21

$339.43

Ambetter from Peach State Health Plan

Local: 1-877-687-1180 | Toll Free: 1-877-687-1180 | TTY: 1-877-941-9231

Toc - Plan #98 Ambetter from Peach State Health Plan

Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$328.58
$372.93
$419.92
$586.83
$891.75

$579.94
$624.29
$671.28
$838.19

$831.30
$875.65
$922.64
$1,089.55

$1,082.66
$1,127.01
$1,174.00
$1,340.91

$251.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$657.16
$745.86
$839.84
$1,173.66
$1,783.50

$908.52
$997.22
$1,091.20
$1,425.02

$1,159.88
$1,248.58
$1,342.56
$1,676.38

$1,411.24
$1,499.94
$1,593.92
$1,927.74

$251.36

Toc - Plan #99 Ambetter from Peach State Health Plan

Silver

(HMO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$394.60
$447.86
$504.28
$704.74
$1,070.91

$696.46
$749.72
$806.14
$1,006.60

$998.32
$1,051.58
$1,108.00
$1,308.46

$1,300.18
$1,353.44
$1,409.86
$1,610.32

$301.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$789.20
$895.72
$1,008.56
$1,409.48
$2,141.82

$1,091.06
$1,197.58
$1,310.42
$1,711.34

$1,392.92
$1,499.44
$1,612.28
$2,013.20

$1,694.78
$1,801.30
$1,914.14
$2,315.06

$301.86

Toc - Plan #100 Ambetter from Peach State Health Plan

Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$390.22
$442.89
$498.69
$696.91
$1,059.03

$688.73
$741.40
$797.20
$995.42

$987.24
$1,039.91
$1,095.71
$1,293.93

$1,285.75
$1,338.42
$1,394.22
$1,592.44

$298.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$780.44
$885.78
$997.38
$1,393.82
$2,118.06

$1,078.95
$1,184.29
$1,295.89
$1,692.33

$1,377.46
$1,482.80
$1,594.40
$1,990.84

$1,675.97
$1,781.31
$1,892.91
$2,289.35

$298.51

Toc - Plan #101 Ambetter from Peach State Health Plan

Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$412.87
$468.59
$527.63
$737.36
$1,120.50

$728.71
$784.43
$843.47
$1,053.20

$1,044.55
$1,100.27
$1,159.31
$1,369.04

$1,360.39
$1,416.11
$1,475.15
$1,684.88

$315.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$825.74
$937.18
$1,055.26
$1,474.72
$2,241.00

$1,141.58
$1,253.02
$1,371.10
$1,790.56

$1,457.42
$1,568.86
$1,686.94
$2,106.40

$1,773.26
$1,884.70
$2,002.78
$2,422.24

$315.84

Toc - Plan #102 Ambetter from Peach State Health Plan

Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$386.15
$438.27
$493.49
$689.65
$1,048.00

$681.55
$733.67
$788.89
$985.05

$976.95
$1,029.07
$1,084.29
$1,280.45

$1,272.35
$1,324.47
$1,379.69
$1,575.85

$295.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$772.30
$876.54
$986.98
$1,379.30
$2,096.00

$1,067.70
$1,171.94
$1,282.38
$1,674.70

$1,363.10
$1,467.34
$1,577.78
$1,970.10

$1,658.50
$1,762.74
$1,873.18
$2,265.50

$295.40

Toc - Plan #103 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$361.06
$409.79
$461.42
$644.83
$979.89

$637.26
$685.99
$737.62
$921.03

$913.46
$962.19
$1,013.82
$1,197.23

$1,189.66
$1,238.39
$1,290.02
$1,473.43

$276.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$722.12
$819.58
$922.84
$1,289.66
$1,959.78

$998.32
$1,095.78
$1,199.04
$1,565.86

$1,274.52
$1,371.98
$1,475.24
$1,842.06

$1,550.72
$1,648.18
$1,751.44
$2,118.26

$276.20

Toc - Plan #104 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$353.52
$401.24
$451.79
$631.37
$959.43

$623.96
$671.68
$722.23
$901.81

$894.40
$942.12
$992.67
$1,172.25

$1,164.84
$1,212.56
$1,263.11
$1,442.69

$270.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.04
$802.48
$903.58
$1,262.74
$1,918.86

$977.48
$1,072.92
$1,174.02
$1,533.18

$1,247.92
$1,343.36
$1,444.46
$1,803.62

$1,518.36
$1,613.80
$1,714.90
$2,074.06

$270.44

Toc - Plan #105 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$400.00
$453.99
$511.19
$714.39
$1,085.58

$706.00
$759.99
$817.19
$1,020.39

$1,012.00
$1,065.99
$1,123.19
$1,326.39

$1,318.00
$1,371.99
$1,429.19
$1,632.39

$306.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$800.00
$907.98
$1,022.38
$1,428.78
$2,171.16

$1,106.00
$1,213.98
$1,328.38
$1,734.78

$1,412.00
$1,519.98
$1,634.38
$2,040.78

$1,718.00
$1,825.98
$1,940.38
$2,346.78

$306.00

Toc - Plan #106 Ambetter from Peach State Health Plan

Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$380.39
$431.74
$486.13
$679.36
$1,032.36

$671.38
$722.73
$777.12
$970.35

$962.37
$1,013.72
$1,068.11
$1,261.34

$1,253.36
$1,304.71
$1,359.10
$1,552.33

$290.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$760.78
$863.48
$972.26
$1,358.72
$2,064.72

$1,051.77
$1,154.47
$1,263.25
$1,649.71

$1,342.76
$1,445.46
$1,554.24
$1,940.70

$1,633.75
$1,736.45
$1,845.23
$2,231.69

$290.99

Toc - Plan #107 Ambetter from Peach State Health Plan

Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$384.69
$436.62
$491.63
$687.05
$1,044.03

$678.97
$730.90
$785.91
$981.33

$973.25
$1,025.18
$1,080.19
$1,275.61

$1,267.53
$1,319.46
$1,374.47
$1,569.89

$294.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$769.38
$873.24
$983.26
$1,374.10
$2,088.06

$1,063.66
$1,167.52
$1,277.54
$1,668.38

$1,357.94
$1,461.80
$1,571.82
$1,962.66

$1,652.22
$1,756.08
$1,866.10
$2,256.94

$294.28

Toc - Plan #108 Ambetter from Peach State Health Plan

Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$394.64
$447.90
$504.33
$704.81
$1,071.02

$696.53
$749.79
$806.22
$1,006.70

$998.42
$1,051.68
$1,108.11
$1,308.59

$1,300.31
$1,353.57
$1,410.00
$1,610.48

$301.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$789.28
$895.80
$1,008.66
$1,409.62
$2,142.04

$1,091.17
$1,197.69
$1,310.55
$1,711.51

$1,393.06
$1,499.58
$1,612.44
$2,013.40

$1,694.95
$1,801.47
$1,914.33
$2,315.29

$301.89

Toc - Plan #109 Ambetter from Peach State Health Plan

Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$900 $1,800 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

$390.06
$442.71
$498.48
$696.63
$1,058.60

$688.45
$741.10
$796.87
$995.02

$986.84
$1,039.49
$1,095.26
$1,293.41

$1,285.23
$1,337.88
$1,393.65
$1,591.80

$298.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$780.12
$885.42
$996.96
$1,393.26
$2,117.20

$1,078.51
$1,183.81
$1,295.35
$1,691.65

$1,376.90
$1,482.20
$1,593.74
$1,990.04

$1,675.29
$1,780.59
$1,892.13
$2,288.43

$298.39

Toc - Plan #110 Ambetter from Peach State Health Plan

Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$455.48
$516.96
$582.10
$813.48
$1,236.16

$803.92
$865.40
$930.54
$1,161.92

$1,152.36
$1,213.84
$1,278.98
$1,510.36

$1,500.80
$1,562.28
$1,627.42
$1,858.80

$348.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$910.96
$1,033.92
$1,164.20
$1,626.96
$2,472.32

$1,259.40
$1,382.36
$1,512.64
$1,975.40

$1,607.84
$1,730.80
$1,861.08
$2,323.84

$1,956.28
$2,079.24
$2,209.52
$2,672.28

$348.44

Toc - Plan #111 Ambetter from Peach State Health Plan

Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$312.80
$355.02
$399.75
$558.64
$848.91

$552.08
$594.30
$639.03
$797.92

$791.36
$833.58
$878.31
$1,037.20

$1,030.64
$1,072.86
$1,117.59
$1,276.48

$239.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$625.60
$710.04
$799.50
$1,117.28
$1,697.82

$864.88
$949.32
$1,038.78
$1,356.56

$1,104.16
$1,188.60
$1,278.06
$1,595.84

$1,343.44
$1,427.88
$1,517.34
$1,835.12

$239.28

Toc - Plan #112 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$346.10
$392.82
$442.31
$618.12
$939.30

$610.86
$657.58
$707.07
$882.88

$875.62
$922.34
$971.83
$1,147.64

$1,140.38
$1,187.10
$1,236.59
$1,412.40

$264.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$692.20
$785.64
$884.62
$1,236.24
$1,878.60

$956.96
$1,050.40
$1,149.38
$1,501.00

$1,221.72
$1,315.16
$1,414.14
$1,765.76

$1,486.48
$1,579.92
$1,678.90
$2,030.52

$264.76

Toc - Plan #113 Ambetter from Peach State Health Plan

Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$381.22
$432.68
$487.19
$680.84
$1,034.61

$672.85
$724.31
$778.82
$972.47

$964.48
$1,015.94
$1,070.45
$1,264.10

$1,256.11
$1,307.57
$1,362.08
$1,555.73

$291.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$762.44
$865.36
$974.38
$1,361.68
$2,069.22

$1,054.07
$1,156.99
$1,266.01
$1,653.31

$1,345.70
$1,448.62
$1,557.64
$1,944.94

$1,637.33
$1,740.25
$1,849.27
$2,236.57

$291.63

Toc - Plan #114 Ambetter from Peach State Health Plan

Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$390.93
$443.69
$499.59
$698.18
$1,060.95

$689.98
$742.74
$798.64
$997.23

$989.03
$1,041.79
$1,097.69
$1,296.28

$1,288.08
$1,340.84
$1,396.74
$1,595.33

$299.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$781.86
$887.38
$999.18
$1,396.36
$2,121.90

$1,080.91
$1,186.43
$1,298.23
$1,695.41

$1,379.96
$1,485.48
$1,597.28
$1,994.46

$1,679.01
$1,784.53
$1,896.33
$2,293.51

$299.05

Toc - Plan #115 Ambetter from Peach State Health Plan

Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$401.45
$455.63
$513.04
$716.97
$1,089.51

$708.55
$762.73
$820.14
$1,024.07

$1,015.65
$1,069.83
$1,127.24
$1,331.17

$1,322.75
$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

$802.90
$911.26
$1,026.08
$1,433.94
$2,179.02

$1,110.00
$1,218.36
$1,333.18
$1,741.04

$1,417.10
$1,525.46
$1,640.28
$2,048.14

$1,724.20
$1,832.56
$1,947.38
$2,355.24

$307.10

Toc - Plan #116 Ambetter from Peach State Health Plan

Silver

(HMO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$410.23
$465.60
$524.26
$732.65
$1,113.33

$724.05
$779.42
$838.08
$1,046.47

$1,037.87
$1,093.24
$1,151.90
$1,360.29

$1,351.69
$1,407.06
$1,465.72
$1,674.11

$313.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$820.46
$931.20
$1,048.52
$1,465.30
$2,226.66

$1,134.28
$1,245.02
$1,362.34
$1,779.12

$1,448.10
$1,558.84
$1,676.16
$2,092.94

$1,761.92
$1,872.66
$1,989.98
$2,406.76

$313.82

Toc - Plan #117 Ambetter from Peach State Health Plan

Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$405.67
$460.43
$518.44
$724.52
$1,100.97

$716.00
$770.76
$828.77
$1,034.85

$1,026.33
$1,081.09
$1,139.10
$1,345.18

$1,336.66
$1,391.42
$1,449.43
$1,655.51

$310.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.34
$920.86
$1,036.88
$1,449.04
$2,201.94

$1,121.67
$1,231.19
$1,347.21
$1,759.37

$1,432.00
$1,541.52
$1,657.54
$2,069.70

$1,742.33
$1,851.85
$1,967.87
$2,380.03

$310.33

Toc - Plan #118 Ambetter from Peach State Health Plan

Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$341.60
$387.70
$436.55
$610.08
$927.07

$602.92
$649.02
$697.87
$871.40

$864.24
$910.34
$959.19
$1,132.72

$1,125.56
$1,171.66
$1,220.51
$1,394.04

$261.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$683.20
$775.40
$873.10
$1,220.16
$1,854.14

$944.52
$1,036.72
$1,134.42
$1,481.48

$1,205.84
$1,298.04
$1,395.74
$1,742.80

$1,467.16
$1,559.36
$1,657.06
$2,004.12

$261.32

Toc - Plan #119 Ambetter from Peach State Health Plan

Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$429.22
$487.15
$548.53
$766.57
$1,164.88

$757.57
$815.50
$876.88
$1,094.92

$1,085.92
$1,143.85
$1,205.23
$1,423.27

$1,414.27
$1,472.20
$1,533.58
$1,751.62

$328.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$858.44
$974.30
$1,097.06
$1,533.14
$2,329.76

$1,186.79
$1,302.65
$1,425.41
$1,861.49

$1,515.14
$1,631.00
$1,753.76
$2,189.84

$1,843.49
$1,959.35
$2,082.11
$2,518.19

$328.35

Toc - Plan #120 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$375.36
$426.02
$479.70
$670.37
$1,018.70

$662.50
$713.16
$766.84
$957.51

$949.64
$1,000.30
$1,053.98
$1,244.65

$1,236.78
$1,287.44
$1,341.12
$1,531.79

$287.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$750.72
$852.04
$959.40
$1,340.74
$2,037.40

$1,037.86
$1,139.18
$1,246.54
$1,627.88

$1,325.00
$1,426.32
$1,533.68
$1,915.02

$1,612.14
$1,713.46
$1,820.82
$2,202.16

$287.14

Toc - Plan #121 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$367.52
$417.13
$469.68
$656.38
$997.43

$648.67
$698.28
$750.83
$937.53

$929.82
$979.43
$1,031.98
$1,218.68

$1,210.97
$1,260.58
$1,313.13
$1,499.83

$281.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$735.04
$834.26
$939.36
$1,312.76
$1,994.86

$1,016.19
$1,115.41
$1,220.51
$1,593.91

$1,297.34
$1,396.56
$1,501.66
$1,875.06

$1,578.49
$1,677.71
$1,782.81
$2,156.21

$281.15

Toc - Plan #122 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$415.85
$471.98
$531.44
$742.69
$1,128.58

$733.97
$790.10
$849.56
$1,060.81

$1,052.09
$1,108.22
$1,167.68
$1,378.93

$1,370.21
$1,426.34
$1,485.80
$1,697.05

$318.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$831.70
$943.96
$1,062.88
$1,485.38
$2,257.16

$1,149.82
$1,262.08
$1,381.00
$1,803.50

$1,467.94
$1,580.20
$1,699.12
$2,121.62

$1,786.06
$1,898.32
$2,017.24
$2,439.74

$318.12

Toc - Plan #123 Ambetter from Peach State Health Plan

Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$399.93
$453.91
$511.10
$714.26
$1,085.39

$705.87
$759.85
$817.04
$1,020.20

$1,011.81
$1,065.79
$1,122.98
$1,326.14

$1,317.75
$1,371.73
$1,428.92
$1,632.08

$305.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$799.86
$907.82
$1,022.20
$1,428.52
$2,170.78

$1,105.80
$1,213.76
$1,328.14
$1,734.46

$1,411.74
$1,519.70
$1,634.08
$2,040.40

$1,717.68
$1,825.64
$1,940.02
$2,346.34

$305.94

Toc - Plan #124 Ambetter from Peach State Health Plan

Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$410.27
$465.64
$524.31
$732.72
$1,113.44

$724.12
$779.49
$838.16
$1,046.57

$1,037.97
$1,093.34
$1,152.01
$1,360.42

$1,351.82
$1,407.19
$1,465.86
$1,674.27

$313.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$820.54
$931.28
$1,048.62
$1,465.44
$2,226.88

$1,134.39
$1,245.13
$1,362.47
$1,779.29

$1,448.24
$1,558.98
$1,676.32
$2,093.14

$1,762.09
$1,872.83
$1,990.17
$2,406.99

$313.85

Toc - Plan #125 Ambetter from Peach State Health Plan

Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$395.46
$448.84
$505.39
$706.27
$1,073.25

$697.98
$751.36
$807.91
$1,008.79

$1,000.50
$1,053.88
$1,110.43
$1,311.31

$1,303.02
$1,356.40
$1,412.95
$1,613.83

$302.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$790.92
$897.68
$1,010.78
$1,412.54
$2,146.50

$1,093.44
$1,200.20
$1,313.30
$1,715.06

$1,395.96
$1,502.72
$1,615.82
$2,017.58

$1,698.48
$1,805.24
$1,918.34
$2,320.10

$302.52

Toc - Plan #126 Ambetter from Peach State Health Plan

Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$900 $1,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$405.51
$460.24
$518.23
$724.22
$1,100.53

$715.72
$770.45
$828.44
$1,034.43

$1,025.93
$1,080.66
$1,138.65
$1,344.64

$1,336.14
$1,390.87
$1,448.86
$1,654.85

$310.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.02
$920.48
$1,036.46
$1,448.44
$2,201.06

$1,121.23
$1,230.69
$1,346.67
$1,758.65

$1,431.44
$1,540.90
$1,656.88
$2,068.86

$1,741.65
$1,851.11
$1,967.09
$2,379.07

$310.21

Toc - Plan #127 Ambetter from Peach State Health Plan

Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$473.52
$537.44
$605.15
$845.70
$1,285.12

$835.76
$899.68
$967.39
$1,207.94

$1,198.00
$1,261.92
$1,329.63
$1,570.18

$1,560.24
$1,624.16
$1,691.87
$1,932.42

$362.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$947.04
$1,074.88
$1,210.30
$1,691.40
$2,570.24

$1,309.28
$1,437.12
$1,572.54
$2,053.64

$1,671.52
$1,799.36
$1,934.78
$2,415.88

$2,033.76
$2,161.60
$2,297.02
$2,778.12

$362.24

Toc - Plan #128 Ambetter from Peach State Health Plan

Silver

(HMO) Complete Plus SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$359.16
$407.64
$459.00
$641.45
$974.75

$633.91
$682.39
$733.75
$916.20

$908.66
$957.14
$1,008.50
$1,190.95

$1,183.41
$1,231.89
$1,283.25
$1,465.70

$274.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$718.32
$815.28
$918.00
$1,282.90
$1,949.50

$993.07
$1,090.03
$1,192.75
$1,557.65

$1,267.82
$1,364.78
$1,467.50
$1,832.40

$1,542.57
$1,639.53
$1,742.25
$2,107.15

$274.75

Toc - Plan #129 Ambetter from Peach State Health Plan

Silver

(HMO) Clear Plus SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$350.13
$397.38
$447.45
$625.31
$950.22

$617.97
$665.22
$715.29
$893.15

$885.81
$933.06
$983.13
$1,160.99

$1,153.65
$1,200.90
$1,250.97
$1,428.83

$267.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$700.26
$794.76
$894.90
$1,250.62
$1,900.44

$968.10
$1,062.60
$1,162.74
$1,518.46

$1,235.94
$1,330.44
$1,430.58
$1,786.30

$1,503.78
$1,598.28
$1,698.42
$2,054.14

$267.84

Toc - Plan #130 Ambetter from Peach State Health Plan

Silver

(HMO) Focused Plus SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$354.11
$401.91
$452.54
$632.43
$961.04

$625.00
$672.80
$723.43
$903.32

$895.89
$943.69
$994.32
$1,174.21

$1,166.78
$1,214.58
$1,265.21
$1,445.10

$270.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$708.22
$803.82
$905.08
$1,264.86
$1,922.08

$979.11
$1,074.71
$1,175.97
$1,535.75

$1,250.00
$1,345.60
$1,446.86
$1,806.64

$1,520.89
$1,616.49
$1,717.75
$2,077.53

$270.89

Toc - Plan #131 Ambetter from Peach State Health Plan

Gold

(HMO) Everyday Plus SELECT Gold with Select Providers

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$363.27
$412.30
$464.24
$648.78
$985.88

$641.16
$690.19
$742.13
$926.67

$919.05
$968.08
$1,020.02
$1,204.56

$1,196.94
$1,245.97
$1,297.91
$1,482.45

$277.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$726.54
$824.60
$928.48
$1,297.56
$1,971.76

$1,004.43
$1,102.49
$1,206.37
$1,575.45

$1,282.32
$1,380.38
$1,484.26
$1,853.34

$1,560.21
$1,658.27
$1,762.15
$2,131.23

$277.89

Toc - Plan #132 Ambetter from Peach State Health Plan

Silver

(HMO) Enhanced Plus SELECT Silver with Select Providers

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$3,850 $7,700 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

$354.31
$402.13
$452.80
$632.78
$961.57

$625.35
$673.17
$723.84
$903.82

$896.39
$944.21
$994.88
$1,174.86

$1,167.43
$1,215.25
$1,265.92
$1,445.90

$271.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$708.62
$804.26
$905.60
$1,265.56
$1,923.14

$979.66
$1,075.30
$1,176.64
$1,536.60

$1,250.70
$1,346.34
$1,447.68
$1,807.64

$1,521.74
$1,617.38
$1,718.72
$2,078.68

$271.04

Toc - Plan #133 Ambetter from Peach State Health Plan

Gold

(HMO) Clear Plus SELECT Gold with Select Providers

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$900 $1,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$359.05
$407.51
$458.85
$641.24
$974.42

$633.71
$682.17
$733.51
$915.90

$908.37
$956.83
$1,008.17
$1,190.56

$1,183.03
$1,231.49
$1,282.83
$1,465.22

$274.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$718.10
$815.02
$917.70
$1,282.48
$1,948.84

$992.76
$1,089.68
$1,192.36
$1,557.14

$1,267.42
$1,364.34
$1,467.02
$1,831.80

$1,542.08
$1,639.00
$1,741.68
$2,106.46

$274.66

Toc - Plan #134 Ambetter from Peach State Health Plan

Silver

(HMO) CMS Standard Silver SELECT Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$350.92
$398.28
$448.46
$626.72
$952.36

$619.36
$666.72
$716.90
$895.16

$887.80
$935.16
$985.34
$1,163.60

$1,156.24
$1,203.60
$1,253.78
$1,432.04

$268.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$701.84
$796.56
$896.92
$1,253.44
$1,904.72

$970.28
$1,065.00
$1,165.36
$1,521.88

$1,238.72
$1,333.44
$1,433.80
$1,790.32

$1,507.16
$1,601.88
$1,702.24
$2,058.76

$268.44

Toc - Plan #135 Ambetter from Peach State Health Plan

Gold

(HMO) CMS Standard Gold SELECT Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

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

$359.84
$408.40
$459.86
$642.65
$976.57

$635.11
$683.67
$735.13
$917.92

$910.38
$958.94
$1,010.40
$1,193.19

$1,185.65
$1,234.21
$1,285.67
$1,468.46

$275.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$719.68
$816.80
$919.72
$1,285.30
$1,953.14

$994.95
$1,092.07
$1,194.99
$1,560.57

$1,270.22
$1,367.34
$1,470.26
$1,835.84

$1,545.49
$1,642.61
$1,745.53
$2,111.11

$275.27

Toc - Plan #136 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 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

$344.01
$390.44
$439.63
$614.39
$933.62

$607.17
$653.60
$702.79
$877.55

$870.33
$916.76
$965.95
$1,140.71

$1,133.49
$1,179.92
$1,229.11
$1,403.87

$263.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$688.02
$780.88
$879.26
$1,228.78
$1,867.24

$951.18
$1,044.04
$1,142.42
$1,491.94

$1,214.34
$1,307.20
$1,405.58
$1,755.10

$1,477.50
$1,570.36
$1,668.74
$2,018.26

$263.16

Toc - Plan #137 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$5,700 $11,400 Annual Deductible

$7,400 $14,800 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

$376.41
$427.21
$481.04
$672.25
$1,021.54

$664.35
$715.15
$768.98
$960.19

$952.29
$1,003.09
$1,056.92
$1,248.13

$1,240.23
$1,291.03
$1,344.86
$1,536.07

$287.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$752.82
$854.42
$962.08
$1,344.50
$2,043.08

$1,040.76
$1,142.36
$1,250.02
$1,632.44

$1,328.70
$1,430.30
$1,537.96
$1,920.38

$1,616.64
$1,718.24
$1,825.90
$2,208.32

$287.94

Toc - Plan #138 Ambetter from Peach State Health Plan

Gold

(HMO) Ambetter Virtual Access Gold - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$950 $1,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$401.07
$455.20
$512.55
$716.29
$1,088.48

$707.88
$762.01
$819.36
$1,023.10

$1,014.69
$1,068.82
$1,126.17
$1,329.91

$1,321.50
$1,375.63
$1,432.98
$1,636.72

$306.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$802.14
$910.40
$1,025.10
$1,432.58
$2,176.96

$1,108.95
$1,217.21
$1,331.91
$1,739.39

$1,415.76
$1,524.02
$1,638.72
$2,046.20

$1,722.57
$1,830.83
$1,945.53
$2,353.01

$306.81

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #139 Aetna CVS Health

Gold

(HMO) Gold: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

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

$419.52
$476.16
$536.15
$749.27
$1,138.59

$740.46
$797.10
$857.09
$1,070.21

$1,061.40
$1,118.04
$1,178.03
$1,391.15

$1,382.34
$1,438.98
$1,498.97
$1,712.09

$320.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$839.04
$952.32
$1,072.30
$1,498.54
$2,277.18

$1,159.98
$1,273.26
$1,393.24
$1,819.48

$1,480.92
$1,594.20
$1,714.18
$2,140.42

$1,801.86
$1,915.14
$2,035.12
$2,461.36

$320.94

Toc - Plan #140 Aetna CVS Health

Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$358.47
$406.87
$458.13
$640.23
$972.89

$632.70
$681.10
$732.36
$914.46

$906.93
$955.33
$1,006.59
$1,188.69

$1,181.16
$1,229.56
$1,280.82
$1,462.92

$274.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$716.94
$813.74
$916.26
$1,280.46
$1,945.78

$991.17
$1,087.97
$1,190.49
$1,554.69

$1,265.40
$1,362.20
$1,464.72
$1,828.92

$1,539.63
$1,636.43
$1,738.95
$2,103.15

$274.23

Toc - Plan #141 Aetna CVS Health

Silver

(HMO) Silver 1: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 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

$372.44
$422.72
$475.98
$665.17
$1,010.80

$657.35
$707.63
$760.89
$950.08

$942.26
$992.54
$1,045.80
$1,234.99

$1,227.17
$1,277.45
$1,330.71
$1,519.90

$284.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$744.88
$845.44
$951.96
$1,330.34
$2,021.60

$1,029.79
$1,130.35
$1,236.87
$1,615.25

$1,314.70
$1,415.26
$1,521.78
$1,900.16

$1,599.61
$1,700.17
$1,806.69
$2,185.07

$284.91

Toc - Plan #142 Aetna CVS Health

Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

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

$317.36
$360.21
$405.59
$566.81
$861.32

$560.14
$602.99
$648.37
$809.59

$802.92
$845.77
$891.15
$1,052.37

$1,045.70
$1,088.55
$1,133.93
$1,295.15

$242.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$634.72
$720.42
$811.18
$1,133.62
$1,722.64

$877.50
$963.20
$1,053.96
$1,376.40

$1,120.28
$1,205.98
$1,296.74
$1,619.18

$1,363.06
$1,448.76
$1,539.52
$1,861.96

$242.78

Toc - Plan #143 Aetna CVS Health

Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

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

$411.41
$466.95
$525.78
$734.78
$1,116.57

$726.14
$781.68
$840.51
$1,049.51

$1,040.87
$1,096.41
$1,155.24
$1,364.24

$1,355.60
$1,411.14
$1,469.97
$1,678.97

$314.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$822.82
$933.90
$1,051.56
$1,469.56
$2,233.14

$1,137.55
$1,248.63
$1,366.29
$1,784.29

$1,452.28
$1,563.36
$1,681.02
$2,099.02

$1,767.01
$1,878.09
$1,995.75
$2,413.75

$314.73

Toc - Plan #144 Aetna CVS Health

Silver

(HMO) Silver 3: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$387.86
$440.22
$495.69
$692.72
$1,052.66

$684.57
$736.93
$792.40
$989.43

$981.28
$1,033.64
$1,089.11
$1,286.14

$1,277.99
$1,330.35
$1,385.82
$1,582.85

$296.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$775.72
$880.44
$991.38
$1,385.44
$2,105.32

$1,072.43
$1,177.15
$1,288.09
$1,682.15

$1,369.14
$1,473.86
$1,584.80
$1,978.86

$1,665.85
$1,770.57
$1,881.51
$2,275.57

$296.71

Toc - Plan #145 Aetna CVS Health

Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 Walk-in clinic + $0 Telehealth 24/7

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

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

$350.09
$397.35
$447.42
$625.26
$950.15

$617.91
$665.17
$715.24
$893.08

$885.73
$932.99
$983.06
$1,160.90

$1,153.55
$1,200.81
$1,250.88
$1,428.72

$267.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$700.18
$794.70
$894.84
$1,250.52
$1,900.30

$968.00
$1,062.52
$1,162.66
$1,518.34

$1,235.82
$1,330.34
$1,430.48
$1,786.16

$1,503.64
$1,598.16
$1,698.30
$2,053.98

$267.82

Kaiser Permanente

Local: 1-800-494-5314 | Toll Free: 1-800-494-5314

Toc - Plan #146 Kaiser Permanente

Gold

(HMO) KP GA Signature Gold 500/20

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$372.52
$422.81
$476.09
$665.33
$1,011.03

$657.50
$707.79
$761.07
$950.31

$942.48
$992.77
$1,046.05
$1,235.29

$1,227.46
$1,277.75
$1,331.03
$1,520.27

$284.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$745.04
$845.62
$952.18
$1,330.66
$2,022.06

$1,030.02
$1,130.60
$1,237.16
$1,615.64

$1,315.00
$1,415.58
$1,522.14
$1,900.62

$1,599.98
$1,700.56
$1,807.12
$2,185.60

$284.98

Toc - Plan #147 Kaiser Permanente

Silver

(HMO) KP GA Signature Silver 3400/30

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$3,400 $6,800 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

$373.61
$424.05
$477.47
$667.27
$1,013.97

$659.42
$709.86
$763.28
$953.08

$945.23
$995.67
$1,049.09
$1,238.89

$1,231.04
$1,281.48
$1,334.90
$1,524.70

$285.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$747.22
$848.10
$954.94
$1,334.54
$2,027.94

$1,033.03
$1,133.91
$1,240.75
$1,620.35

$1,318.84
$1,419.72
$1,526.56
$1,906.16

$1,604.65
$1,705.53
$1,812.37
$2,191.97

$285.81

Toc - Plan #148 Kaiser Permanente

Silver

(HMO) KP GA Signature Silver 3500/20%/HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$363.62
$412.71
$464.71
$649.43
$986.87

$641.79
$690.88
$742.88
$927.60

$919.96
$969.05
$1,021.05
$1,205.77

$1,198.13
$1,247.22
$1,299.22
$1,483.94

$278.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$727.24
$825.42
$929.42
$1,298.86
$1,973.74

$1,005.41
$1,103.59
$1,207.59
$1,577.03

$1,283.58
$1,381.76
$1,485.76
$1,855.20

$1,561.75
$1,659.93
$1,763.93
$2,133.37

$278.17

Toc - Plan #149 Kaiser Permanente

Expanded Bronze

(HMO) KP GA Signature Bronze Virtual Complete 5500/60

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$270.75
$307.30
$346.02
$483.56
$734.82

$477.88
$514.43
$553.15
$690.69

$685.01
$721.56
$760.28
$897.82

$892.14
$928.69
$967.41
$1,104.95

$207.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$541.50
$614.60
$692.04
$967.12
$1,469.64

$748.63
$821.73
$899.17
$1,174.25

$955.76
$1,028.86
$1,106.30
$1,381.38

$1,162.89
$1,235.99
$1,313.43
$1,588.51

$207.13

Toc - Plan #150 Kaiser Permanente

Expanded Bronze

(HMO) KP GA Signature Bronze 6500/40%/HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$271.90
$308.61
$347.49
$485.62
$737.95

$479.91
$516.62
$555.50
$693.63

$687.92
$724.63
$763.51
$901.64

$895.93
$932.64
$971.52
$1,109.65

$208.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$543.80
$617.22
$694.98
$971.24
$1,475.90

$751.81
$825.23
$902.99
$1,179.25

$959.82
$1,033.24
$1,111.00
$1,387.26

$1,167.83
$1,241.25
$1,319.01
$1,595.27

$208.01

Toc - Plan #151 Kaiser Permanente

Catastrophic

(HMO) KP GA Signature Catastrophic 9100/0

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

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

$235.46
$267.25
$300.92
$420.53
$639.04

$415.59
$447.38
$481.05
$600.66

$595.72
$627.51
$661.18
$780.79

$775.85
$807.64
$841.31
$960.92

$180.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$470.92
$534.50
$601.84
$841.06
$1,278.08

$651.05
$714.63
$781.97
$1,021.19

$831.18
$894.76
$962.10
$1,201.32

$1,011.31
$1,074.89
$1,142.23
$1,381.45

$180.13

Toc - Plan #152 Kaiser Permanente

Gold

(HMO) KP GA Signature Gold 1500/20

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$6,500 $13,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$357.93
$406.25
$457.43
$639.26
$971.42

$631.75
$680.07
$731.25
$913.08

$905.57
$953.89
$1,005.07
$1,186.90

$1,179.39
$1,227.71
$1,278.89
$1,460.72

$273.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$715.86
$812.50
$914.86
$1,278.52
$1,942.84

$989.68
$1,086.32
$1,188.68
$1,552.34

$1,263.50
$1,360.14
$1,462.50
$1,826.16

$1,537.32
$1,633.96
$1,736.32
$2,099.98

$273.82

Toc - Plan #153 Kaiser Permanente

Silver

(HMO) KP GA Signature Silver 4500/35

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$362.26
$411.16
$462.97
$647.00
$983.17

$639.39
$688.29
$740.10
$924.13

$916.52
$965.42
$1,017.23
$1,201.26

$1,193.65
$1,242.55
$1,294.36
$1,478.39

$277.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$724.52
$822.32
$925.94
$1,294.00
$1,966.34

$1,001.65
$1,099.45
$1,203.07
$1,571.13

$1,278.78
$1,376.58
$1,480.20
$1,848.26

$1,555.91
$1,653.71
$1,757.33
$2,125.39

$277.13

Toc - Plan #154 Kaiser Permanente

Gold

(HMO) KP GA Signature Gold 1800/25

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$1,800 $3,600 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

$341.80
$387.94
$436.82
$610.45
$927.65

$603.28
$649.42
$698.30
$871.93

$864.76
$910.90
$959.78
$1,133.41

$1,126.24
$1,172.38
$1,221.26
$1,394.89

$261.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$683.60
$775.88
$873.64
$1,220.90
$1,855.30

$945.08
$1,037.36
$1,135.12
$1,482.38

$1,206.56
$1,298.84
$1,396.60
$1,743.86

$1,468.04
$1,560.32
$1,658.08
$2,005.34

$261.48

Toc - Plan #155 Kaiser Permanente

Silver

(HMO) KP GA Signature Silver Virtual Complete 4800/40

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

Annual Out of Pocket Expenses:

Individual Family

$4,800 $9,600 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

$342.74
$389.01
$438.02
$612.13
$930.19

$604.94
$651.21
$700.22
$874.33

$867.14
$913.41
$962.42
$1,136.53

$1,129.34
$1,175.61
$1,224.62
$1,398.73

$262.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$685.48
$778.02
$876.04
$1,224.26
$1,860.38

$947.68
$1,040.22
$1,138.24
$1,486.46

$1,209.88
$1,302.42
$1,400.44
$1,748.66

$1,472.08
$1,564.62
$1,662.64
$2,010.86

$262.20

Toc - Plan #156 Kaiser Permanente

Gold

(HMO) KP GA Signature Standard Gold 2000/30

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

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

$351.40
$398.84
$449.09
$627.60
$953.70

$620.22
$667.66
$717.91
$896.42

$889.04
$936.48
$986.73
$1,165.24

$1,157.86
$1,205.30
$1,255.55
$1,434.06

$268.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$702.80
$797.68
$898.18
$1,255.20
$1,907.40

$971.62
$1,066.50
$1,167.00
$1,524.02

$1,240.44
$1,335.32
$1,435.82
$1,792.84

$1,509.26
$1,604.14
$1,704.64
$2,061.66

$268.82

Toc - Plan #157 Kaiser Permanente

Silver

(HMO) KP GA Signature Standard Silver 5800/40

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

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

$349.09
$396.22
$446.14
$623.48
$947.44

$616.15
$663.28
$713.20
$890.54

$883.21
$930.34
$980.26
$1,157.60

$1,150.27
$1,197.40
$1,247.32
$1,424.66

$267.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$698.18
$792.44
$892.28
$1,246.96
$1,894.88

$965.24
$1,059.50
$1,159.34
$1,514.02

$1,232.30
$1,326.56
$1,426.40
$1,781.08

$1,499.36
$1,593.62
$1,693.46
$2,048.14

$267.06

Toc - Plan #158 Kaiser Permanente

Expanded Bronze

(HMO) KP GA Signature Standard Bronze 7500/50

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-494-5314

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

$283.81
$322.12
$362.71
$506.88
$770.26

$500.92
$539.23
$579.82
$723.99

$718.03
$756.34
$796.93
$941.10

$935.14
$973.45
$1,014.04
$1,158.21

$217.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$567.62
$644.24
$725.42
$1,013.76
$1,540.52

$784.73
$861.35
$942.53
$1,230.87

$1,001.84
$1,078.46
$1,159.64
$1,447.98

$1,218.95
$1,295.57
$1,376.75
$1,665.09

$217.11

Friday Health Plans

Local: 1-844-521-7999 | Toll Free: 1-844-521-7999 | TTY: 1-800-659-2656

Toc - Plan #159 Friday Health Plans

Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

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

$247.75
$281.19
$316.62
$442.47
$672.38

$437.27
$470.71
$506.14
$631.99

$626.79
$660.23
$695.66
$821.51

$816.31
$849.75
$885.18
$1,011.03

$189.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$495.50
$562.38
$633.24
$884.94
$1,344.76

$685.02
$751.90
$822.76
$1,074.46

$874.54
$941.42
$1,012.28
$1,263.98

$1,064.06
$1,130.94
$1,201.80
$1,453.50

$189.52

Toc - Plan #160 Friday Health Plans

Bronze

(HMO) Friday Bronze Basic + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$318.53
$361.53
$407.08
$568.90
$864.49

$562.21
$605.21
$650.76
$812.58

$805.89
$848.89
$894.44
$1,056.26

$1,049.57
$1,092.57
$1,138.12
$1,299.94

$243.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$637.06
$723.06
$814.16
$1,137.80
$1,728.98

$880.74
$966.74
$1,057.84
$1,381.48

$1,124.42
$1,210.42
$1,301.52
$1,625.16

$1,368.10
$1,454.10
$1,545.20
$1,868.84

$243.68

Toc - Plan #161 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze Plus + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

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

$320.89
$364.21
$410.10
$573.11
$870.90

$566.37
$609.69
$655.58
$818.59

$811.85
$855.17
$901.06
$1,064.07

$1,057.33
$1,100.65
$1,146.54
$1,309.55

$245.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$641.78
$728.42
$820.20
$1,146.22
$1,741.80

$887.26
$973.90
$1,065.68
$1,391.70

$1,132.74
$1,219.38
$1,311.16
$1,637.18

$1,378.22
$1,464.86
$1,556.64
$1,882.66

$245.48

Toc - Plan #162 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

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

$339.37
$385.19
$433.72
$606.12
$921.06

$598.99
$644.81
$693.34
$865.74

$858.61
$904.43
$952.96
$1,125.36

$1,118.23
$1,164.05
$1,212.58
$1,384.98

$259.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$678.74
$770.38
$867.44
$1,212.24
$1,842.12

$938.36
$1,030.00
$1,127.06
$1,471.86

$1,197.98
$1,289.62
$1,386.68
$1,731.48

$1,457.60
$1,549.24
$1,646.30
$1,991.10

$259.62

Toc - Plan #163 Friday Health Plans

Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$344.53
$391.05
$440.32
$615.34
$935.07

$608.10
$654.62
$703.89
$878.91

$871.67
$918.19
$967.46
$1,142.48

$1,135.24
$1,181.76
$1,231.03
$1,406.05

$263.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$689.06
$782.10
$880.64
$1,230.68
$1,870.14

$952.63
$1,045.67
$1,144.21
$1,494.25

$1,216.20
$1,309.24
$1,407.78
$1,757.82

$1,479.77
$1,572.81
$1,671.35
$2,021.39

$263.57

Toc - Plan #164 Friday Health Plans

Gold

(HMO) Friday Gold + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,250 $16,500 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

$412.73
$468.45
$527.48
$737.14
$1,120.16

$728.47
$784.19
$843.22
$1,052.88

$1,044.21
$1,099.93
$1,158.96
$1,368.62

$1,359.95
$1,415.67
$1,474.70
$1,684.36

$315.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$825.46
$936.90
$1,054.96
$1,474.28
$2,240.32

$1,141.20
$1,252.64
$1,370.70
$1,790.02

$1,456.94
$1,568.38
$1,686.44
$2,105.76

$1,772.68
$1,884.12
$2,002.18
$2,421.50

$315.74

Toc - Plan #165 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

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

$317.03
$359.82
$405.16
$566.21
$860.41

$559.55
$602.34
$647.68
$808.73

$802.07
$844.86
$890.20
$1,051.25

$1,044.59
$1,087.38
$1,132.72
$1,293.77

$242.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$634.06
$719.64
$810.32
$1,132.42
$1,720.82

$876.58
$962.16
$1,052.84
$1,374.94

$1,119.10
$1,204.68
$1,295.36
$1,617.46

$1,361.62
$1,447.20
$1,537.88
$1,859.98

$242.52

Toc - Plan #166 Friday Health Plans

Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 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

$366.01
$415.42
$467.76
$653.69
$993.35

$646.01
$695.42
$747.76
$933.69

$926.01
$975.42
$1,027.76
$1,213.69

$1,206.01
$1,255.42
$1,307.76
$1,493.69

$280.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$732.02
$830.84
$935.52
$1,307.38
$1,986.70

$1,012.02
$1,110.84
$1,215.52
$1,587.38

$1,292.02
$1,390.84
$1,495.52
$1,867.38

$1,572.02
$1,670.84
$1,775.52
$2,147.38

$280.00

Toc - Plan #167 Friday Health Plans

Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

$8,250 $16,500 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

$426.21
$483.75
$544.69
$761.21
$1,156.73

$752.26
$809.80
$870.74
$1,087.26

$1,078.31
$1,135.85
$1,196.79
$1,413.31

$1,404.36
$1,461.90
$1,522.84
$1,739.36

$326.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$852.42
$967.50
$1,089.38
$1,522.42
$2,313.46

$1,178.47
$1,293.55
$1,415.43
$1,848.47

$1,504.52
$1,619.60
$1,741.48
$2,174.52

$1,830.57
$1,945.65
$2,067.53
$2,500.57

$326.05

Toc - Plan #168 Friday Health Plans

Bronze

(HMO) Friday Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-521-7999

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

Obamacare Providers, 180 Plans and 2023 Rates for Clayton County, Georgia

You may also be interested in:

Do I Qualify For a Tax Credit to Pay My Premiums?

How do I sign up in Georgia?

Using a Broker to Help You Sign Up

Obamacare Rates and Providers for Other Years

How to Sign Up for Obamacare in Georgia

Where's the Georgia Health Care Exchange?

Georgia Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

Georgia Has Not Expanded Medicaid

The Medicaid Coverage Gap

Get Help Finding a Health Insurance Plan in Georgia

Get Help From Georgia's Health Insurance Exchange

Get Help From a Licensed Insurance Broker

More Information

Cigna HealthCare of Georgia, Inc

(HMO) Cigna Connect 9100

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Cigna Connect 7800

Annual Out of Pocket Expenses:

Individual Family $7,800 $15,600 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 6500

Annual Out of Pocket Expenses:

Individual Family $6,500 $13,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect HSA 7050

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Annual Out of Pocket Expenses:

Individual Family $6,800 $13,600 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 3700

Annual Out of Pocket Expenses:

Individual Family $3,700 $7,400 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 5000

Annual Out of Pocket Expenses:

Individual Family $5,000 $10,000 Annual Deductible $9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 6000

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 7200

Annual Out of Pocket Expenses:

Individual Family $7,200 $14,400 Annual Deductible $7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

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:

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Annual Out of Pocket Expenses:

Individual Family $4,200 $8,400 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 1600

Annual Out of Pocket Expenses:

Individual Family $1,600 $3,200 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

Annual Out of Pocket Expenses:

Individual Family $1,900 $3,800 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

Annual Out of Pocket Expenses:

Individual Family $7,600 $15,200 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Simple Choice 9100

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Cigna Simple Choice 7500

Annual Out of Pocket Expenses:

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,800 $15,600 Annual Deductible

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

Individual Family

$6,500 $13,000 Annual Deductible

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

Individual Family

$7,050 $14,100 Annual Deductible

$7,050 $14,100 Maximum Out of Pocket Per Year

Individual Family

$6,800 $13,600 Annual Deductible

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

Individual Family

$3,700 $7,400 Annual Deductible

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

Individual Family

$5,000 $10,000 Annual Deductible

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

Individual Family

$6,000 $12,000 Annual Deductible

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

Individual Family

$7,200 $14,400 Annual Deductible

$7,200 $14,400 Maximum Out of Pocket Per Year

Individual Family

$3,800 $7,600 Annual Deductible

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

Individual Family

$4,200 $8,400 Annual Deductible

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

Individual Family

$1,600 $3,200 Annual Deductible

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

Individual Family

$1,900 $3,800 Annual Deductible

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

Individual Family

$7,600 $15,200 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

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

Individual Family

$5,800 $11,600 Annual Deductible

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

Individual Family

$1,200 $2,400 Annual Deductible

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

Individual Family

$1,200 $2,400 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

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

Individual Family

$2,200 $4,400 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Individual Family

$4,000 $8,000 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

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

Individual Family

$7,250 $14,500 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

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

Individual Family

$4,000 $8,000 Annual Deductible

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

Individual Family

$3,000 $6,000 Annual Deductible

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

Individual Family

$3,350 $6,700 Annual Deductible

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