Obamacare 2023 Rates for Cook County

Obamacare > Rates > Georgia > Cook 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 Cook 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, 103 Plans and 2023 Rates for Cook County, Georgia

Below, you’ll find a summary of the 103 plans for Cook County, Georgia and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

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

Toc - Plan #1 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Catastrophic

(HMO) Anthem Catastrophic Pathway X 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

$188.84
$214.33
$241.34
$337.27
$512.51

$333.30
$358.79
$385.80
$481.73

$477.76
$503.25
$530.26
$626.19

$622.22
$647.71
$674.72
$770.65

$144.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$377.68
$428.66
$482.68
$674.54
$1,025.02

$522.14
$573.12
$627.14
$819.00

$666.60
$717.58
$771.60
$963.46

$811.06
$862.04
$916.06
$1,107.92

$144.46

Toc - Plan #2 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X 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

$274.50
$311.56
$350.81
$490.26
$744.99

$484.49
$521.55
$560.80
$700.25

$694.48
$731.54
$770.79
$910.24

$904.47
$941.53
$980.78
$1,120.23

$209.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$549.00
$623.12
$701.62
$980.52
$1,489.98

$758.99
$833.11
$911.61
$1,190.51

$968.98
$1,043.10
$1,121.60
$1,400.50

$1,178.97
$1,253.09
$1,331.59
$1,610.49

$209.99

Toc - Plan #3 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X 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

$265.87
$301.76
$339.78
$474.84
$721.57

$469.26
$505.15
$543.17
$678.23

$672.65
$708.54
$746.56
$881.62

$876.04
$911.93
$949.95
$1,085.01

$203.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$531.74
$603.52
$679.56
$949.68
$1,443.14

$735.13
$806.91
$882.95
$1,153.07

$938.52
$1,010.30
$1,086.34
$1,356.46

$1,141.91
$1,213.69
$1,289.73
$1,559.85

$203.39

Toc - Plan #4 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X 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

$261.34
$296.62
$333.99
$466.75
$709.28

$461.27
$496.55
$533.92
$666.68

$661.20
$696.48
$733.85
$866.61

$861.13
$896.41
$933.78
$1,066.54

$199.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$522.68
$593.24
$667.98
$933.50
$1,418.56

$722.61
$793.17
$867.91
$1,133.43

$922.54
$993.10
$1,067.84
$1,333.36

$1,122.47
$1,193.03
$1,267.77
$1,533.29

$199.93

Toc - Plan #5 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X 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

$328.02
$372.30
$419.21
$585.84
$890.25

$578.96
$623.24
$670.15
$836.78

$829.90
$874.18
$921.09
$1,087.72

$1,080.84
$1,125.12
$1,172.03
$1,338.66

$250.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$656.04
$744.60
$838.42
$1,171.68
$1,780.50

$906.98
$995.54
$1,089.36
$1,422.62

$1,157.92
$1,246.48
$1,340.30
$1,673.56

$1,408.86
$1,497.42
$1,591.24
$1,924.50

$250.94

Toc - Plan #6 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X 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

$330.50
$375.12
$422.38
$590.27
$896.98

$583.33
$627.95
$675.21
$843.10

$836.16
$880.78
$928.04
$1,095.93

$1,088.99
$1,133.61
$1,180.87
$1,348.76

$252.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$661.00
$750.24
$844.76
$1,180.54
$1,793.96

$913.83
$1,003.07
$1,097.59
$1,433.37

$1,166.66
$1,255.90
$1,350.42
$1,686.20

$1,419.49
$1,508.73
$1,603.25
$1,939.03

$252.83

Toc - Plan #7 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Bronze

(HMO) Anthem Bronze Pathway X 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

$250.99
$284.87
$320.77
$448.27
$681.19

$443.00
$476.88
$512.78
$640.28

$635.01
$668.89
$704.79
$832.29

$827.02
$860.90
$896.80
$1,024.30

$192.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$501.98
$569.74
$641.54
$896.54
$1,362.38

$693.99
$761.75
$833.55
$1,088.55

$886.00
$953.76
$1,025.56
$1,280.56

$1,078.01
$1,145.77
$1,217.57
$1,472.57

$192.01

Toc - Plan #8 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X 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

$332.56
$377.46
$425.01
$593.95
$902.57

$586.97
$631.87
$679.42
$848.36

$841.38
$886.28
$933.83
$1,102.77

$1,095.79
$1,140.69
$1,188.24
$1,357.18

$254.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$665.12
$754.92
$850.02
$1,187.90
$1,805.14

$919.53
$1,009.33
$1,104.43
$1,442.31

$1,173.94
$1,263.74
$1,358.84
$1,696.72

$1,428.35
$1,518.15
$1,613.25
$1,951.13

$254.41

Toc - Plan #9 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X 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

$326.62
$370.71
$417.42
$583.34
$886.45

$576.48
$620.57
$667.28
$833.20

$826.34
$870.43
$917.14
$1,083.06

$1,076.20
$1,120.29
$1,167.00
$1,332.92

$249.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$653.24
$741.42
$834.84
$1,166.68
$1,772.90

$903.10
$991.28
$1,084.70
$1,416.54

$1,152.96
$1,241.14
$1,334.56
$1,666.40

$1,402.82
$1,491.00
$1,584.42
$1,916.26

$249.86

Toc - Plan #10 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Gold

(HMO) Anthem Gold Pathway X 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

$364.99
$414.26
$466.46
$651.87
$990.58

$644.21
$693.48
$745.68
$931.09

$923.43
$972.70
$1,024.90
$1,210.31

$1,202.65
$1,251.92
$1,304.12
$1,489.53

$279.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$729.98
$828.52
$932.92
$1,303.74
$1,981.16

$1,009.20
$1,107.74
$1,212.14
$1,582.96

$1,288.42
$1,386.96
$1,491.36
$1,862.18

$1,567.64
$1,666.18
$1,770.58
$2,141.40

$279.22

Toc - Plan #11 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X 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

$277.14
$314.55
$354.18
$494.97
$752.16

$489.15
$526.56
$566.19
$706.98

$701.16
$738.57
$778.20
$918.99

$913.17
$950.58
$990.21
$1,131.00

$212.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$554.28
$629.10
$708.36
$989.94
$1,504.32

$766.29
$841.11
$920.37
$1,201.95

$978.30
$1,053.12
$1,132.38
$1,413.96

$1,190.31
$1,265.13
$1,344.39
$1,625.97

$212.01

Toc - Plan #12 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X 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

$348.41
$395.45
$445.27
$622.26
$945.58

$614.94
$661.98
$711.80
$888.79

$881.47
$928.51
$978.33
$1,155.32

$1,148.00
$1,195.04
$1,244.86
$1,421.85

$266.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$696.82
$790.90
$890.54
$1,244.52
$1,891.16

$963.35
$1,057.43
$1,157.07
$1,511.05

$1,229.88
$1,323.96
$1,423.60
$1,777.58

$1,496.41
$1,590.49
$1,690.13
$2,044.11

$266.53

Toc - Plan #13 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Bronze

(HMO) Anthem Bronze Pathway X 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

$258.50
$293.40
$330.36
$461.68
$701.57

$456.25
$491.15
$528.11
$659.43

$654.00
$688.90
$725.86
$857.18

$851.75
$886.65
$923.61
$1,054.93

$197.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$517.00
$586.80
$660.72
$923.36
$1,403.14

$714.75
$784.55
$858.47
$1,121.11

$912.50
$982.30
$1,056.22
$1,318.86

$1,110.25
$1,180.05
$1,253.97
$1,516.61

$197.75

Toc - Plan #14 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

(HMO) Anthem Bronze Pathway X 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

$282.77
$320.94
$361.38
$505.03
$767.44

$499.09
$537.26
$577.70
$721.35

$715.41
$753.58
$794.02
$937.67

$931.73
$969.90
$1,010.34
$1,153.99

$216.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$565.54
$641.88
$722.76
$1,010.06
$1,534.88

$781.86
$858.20
$939.08
$1,226.38

$998.18
$1,074.52
$1,155.40
$1,442.70

$1,214.50
$1,290.84
$1,371.72
$1,659.02

$216.32

Toc - Plan #15 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

(HMO) Anthem Silver Pathway X 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

$331.70
$376.48
$423.91
$592.42
$900.23

$585.45
$630.23
$677.66
$846.17

$839.20
$883.98
$931.41
$1,099.92

$1,092.95
$1,137.73
$1,185.16
$1,353.67

$253.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$663.40
$752.96
$847.82
$1,184.84
$1,800.46

$917.15
$1,006.71
$1,101.57
$1,438.59

$1,170.90
$1,260.46
$1,355.32
$1,692.34

$1,424.65
$1,514.21
$1,609.07
$1,946.09

$253.75

Toc - Plan #16 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Gold

(HMO) Anthem Gold Pathway X 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

$375.08
$425.72
$479.35
$669.89
$1,017.97

$662.02
$712.66
$766.29
$956.83

$948.96
$999.60
$1,053.23
$1,243.77

$1,235.90
$1,286.54
$1,340.17
$1,530.71

$286.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$750.16
$851.44
$958.70
$1,339.78
$2,035.94

$1,037.10
$1,138.38
$1,245.64
$1,626.72

$1,324.04
$1,425.32
$1,532.58
$1,913.66

$1,610.98
$1,712.26
$1,819.52
$2,200.60

$286.94

CareSource

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

Toc - Plan #17 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

$236.39
$268.30
$302.10
$422.18
$641.54

$417.22
$449.13
$482.93
$603.01

$598.05
$629.96
$663.76
$783.84

$778.88
$810.79
$844.59
$964.67

$180.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$472.78
$536.60
$604.20
$844.36
$1,283.08

$653.61
$717.43
$785.03
$1,025.19

$834.44
$898.26
$965.86
$1,206.02

$1,015.27
$1,079.09
$1,146.69
$1,386.85

$180.83

Toc - Plan #18 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

$321.82
$365.26
$411.28
$574.76
$873.40

$568.01
$611.45
$657.47
$820.95

$814.20
$857.64
$903.66
$1,067.14

$1,060.39
$1,103.83
$1,149.85
$1,313.33

$246.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$643.64
$730.52
$822.56
$1,149.52
$1,746.80

$889.83
$976.71
$1,068.75
$1,395.71

$1,136.02
$1,222.90
$1,314.94
$1,641.90

$1,382.21
$1,469.09
$1,561.13
$1,888.09

$246.19

Toc - Plan #19 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

$321.56
$364.97
$410.95
$574.31
$872.71

$567.55
$610.96
$656.94
$820.30

$813.54
$856.95
$902.93
$1,066.29

$1,059.53
$1,102.94
$1,148.92
$1,312.28

$245.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$643.12
$729.94
$821.90
$1,148.62
$1,745.42

$889.11
$975.93
$1,067.89
$1,394.61

$1,135.10
$1,221.92
$1,313.88
$1,640.60

$1,381.09
$1,467.91
$1,559.87
$1,886.59

$245.99

Toc - Plan #20 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

$329.11
$373.54
$420.60
$587.79
$893.20

$580.88
$625.31
$672.37
$839.56

$832.65
$877.08
$924.14
$1,091.33

$1,084.42
$1,128.85
$1,175.91
$1,343.10

$251.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$658.22
$747.08
$841.20
$1,175.58
$1,786.40

$909.99
$998.85
$1,092.97
$1,427.35

$1,161.76
$1,250.62
$1,344.74
$1,679.12

$1,413.53
$1,502.39
$1,596.51
$1,930.89

$251.77

Toc - Plan #21 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

$260.63
$295.81
$333.08
$465.47
$707.33

$460.01
$495.19
$532.46
$664.85

$659.39
$694.57
$731.84
$864.23

$858.77
$893.95
$931.22
$1,063.61

$199.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$521.26
$591.62
$666.16
$930.94
$1,414.66

$720.64
$791.00
$865.54
$1,130.32

$920.02
$990.38
$1,064.92
$1,329.70

$1,119.40
$1,189.76
$1,264.30
$1,529.08

$199.38

Toc - Plan #22 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

$223.37
$253.52
$285.46
$398.93
$606.22

$394.25
$424.40
$456.34
$569.81

$565.13
$595.28
$627.22
$740.69

$736.01
$766.16
$798.10
$911.57

$170.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$446.74
$507.04
$570.92
$797.86
$1,212.44

$617.62
$677.92
$741.80
$968.74

$788.50
$848.80
$912.68
$1,139.62

$959.38
$1,019.68
$1,083.56
$1,310.50

$170.88

Toc - Plan #23 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

$350.64
$397.97
$448.11
$626.23
$951.62

$618.87
$666.20
$716.34
$894.46

$887.10
$934.43
$984.57
$1,162.69

$1,155.33
$1,202.66
$1,252.80
$1,430.92

$268.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$701.28
$795.94
$896.22
$1,252.46
$1,903.24

$969.51
$1,064.17
$1,164.45
$1,520.69

$1,237.74
$1,332.40
$1,432.68
$1,788.92

$1,505.97
$1,600.63
$1,700.91
$2,057.15

$268.23

Toc - Plan #24 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

$328.80
$373.18
$420.20
$587.22
$892.34

$580.33
$624.71
$671.73
$838.75

$831.86
$876.24
$923.26
$1,090.28

$1,083.39
$1,127.77
$1,174.79
$1,341.81

$251.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$657.60
$746.36
$840.40
$1,174.44
$1,784.68

$909.13
$997.89
$1,091.93
$1,425.97

$1,160.66
$1,249.42
$1,343.46
$1,677.50

$1,412.19
$1,500.95
$1,594.99
$1,929.03

$251.53

Toc - Plan #25 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

$328.03
$372.31
$419.22
$585.86
$890.27

$578.97
$623.25
$670.16
$836.80

$829.91
$874.19
$921.10
$1,087.74

$1,080.85
$1,125.13
$1,172.04
$1,338.68

$250.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$656.06
$744.62
$838.44
$1,171.72
$1,780.54

$907.00
$995.56
$1,089.38
$1,422.66

$1,157.94
$1,246.50
$1,340.32
$1,673.60

$1,408.88
$1,497.44
$1,591.26
$1,924.54

$250.94

Toc - Plan #26 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

$244.16
$277.12
$312.04
$436.07
$662.65

$430.94
$463.90
$498.82
$622.85

$617.72
$650.68
$685.60
$809.63

$804.50
$837.46
$872.38
$996.41

$186.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$488.32
$554.24
$624.08
$872.14
$1,325.30

$675.10
$741.02
$810.86
$1,058.92

$861.88
$927.80
$997.64
$1,245.70

$1,048.66
$1,114.58
$1,184.42
$1,432.48

$186.78

Toc - Plan #27 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

$329.87
$374.40
$421.58
$589.15
$895.27

$582.22
$626.75
$673.93
$841.50

$834.57
$879.10
$926.28
$1,093.85

$1,086.92
$1,131.45
$1,178.63
$1,346.20

$252.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$659.74
$748.80
$843.16
$1,178.30
$1,790.54

$912.09
$1,001.15
$1,095.51
$1,430.65

$1,164.44
$1,253.50
$1,347.86
$1,683.00

$1,416.79
$1,505.85
$1,600.21
$1,935.35

$252.35

Toc - Plan #28 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

$329.24
$373.68
$420.76
$588.01
$893.54

$581.10
$625.54
$672.62
$839.87

$832.96
$877.40
$924.48
$1,091.73

$1,084.82
$1,129.26
$1,176.34
$1,343.59

$251.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$658.48
$747.36
$841.52
$1,176.02
$1,787.08

$910.34
$999.22
$1,093.38
$1,427.88

$1,162.20
$1,251.08
$1,345.24
$1,679.74

$1,414.06
$1,502.94
$1,597.10
$1,931.60

$251.86

Toc - Plan #29 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

$336.78
$382.25
$430.41
$601.49
$914.02

$594.42
$639.89
$688.05
$859.13

$852.06
$897.53
$945.69
$1,116.77

$1,109.70
$1,155.17
$1,203.33
$1,374.41

$257.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$673.56
$764.50
$860.82
$1,202.98
$1,828.04

$931.20
$1,022.14
$1,118.46
$1,460.62

$1,188.84
$1,279.78
$1,376.10
$1,718.26

$1,446.48
$1,537.42
$1,633.74
$1,975.90

$257.64

Toc - Plan #30 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

$230.52
$261.63
$294.59
$411.69
$625.61

$406.86
$437.97
$470.93
$588.03

$583.20
$614.31
$647.27
$764.37

$759.54
$790.65
$823.61
$940.71

$176.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$461.04
$523.26
$589.18
$823.38
$1,251.22

$637.38
$699.60
$765.52
$999.72

$813.72
$875.94
$941.86
$1,176.06

$990.06
$1,052.28
$1,118.20
$1,352.40

$176.34

Toc - Plan #31 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

$357.93
$406.25
$457.43
$639.26
$971.42

$631.74
$680.06
$731.24
$913.07

$905.55
$953.87
$1,005.05
$1,186.88

$1,179.36
$1,227.68
$1,278.86
$1,460.69

$273.81

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

$989.67
$1,086.31
$1,188.67
$1,552.33

$1,263.48
$1,360.12
$1,462.48
$1,826.14

$1,537.29
$1,633.93
$1,736.29
$2,099.95

$273.81

Toc - Plan #32 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

$336.47
$381.89
$430.00
$600.93
$913.17

$593.87
$639.29
$687.40
$858.33

$851.27
$896.69
$944.80
$1,115.73

$1,108.67
$1,154.09
$1,202.20
$1,373.13

$257.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$672.94
$763.78
$860.00
$1,201.86
$1,826.34

$930.34
$1,021.18
$1,117.40
$1,459.26

$1,187.74
$1,278.58
$1,374.80
$1,716.66

$1,445.14
$1,535.98
$1,632.20
$1,974.06

$257.40

Toc - Plan #33 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

$336.09
$381.46
$429.52
$600.25
$912.14

$593.20
$638.57
$686.63
$857.36

$850.31
$895.68
$943.74
$1,114.47

$1,107.42
$1,152.79
$1,200.85
$1,371.58

$257.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$672.18
$762.92
$859.04
$1,200.50
$1,824.28

$929.29
$1,020.03
$1,116.15
$1,457.61

$1,186.40
$1,277.14
$1,373.26
$1,714.72

$1,443.51
$1,534.25
$1,630.37
$1,971.83

$257.11

Ambetter from Peach State Health Plan

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

Toc - Plan #34 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

$243.62
$276.50
$311.34
$435.10
$661.17

$429.99
$462.87
$497.71
$621.47

$616.36
$649.24
$684.08
$807.84

$802.73
$835.61
$870.45
$994.21

$186.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$487.24
$553.00
$622.68
$870.20
$1,322.34

$673.61
$739.37
$809.05
$1,056.57

$859.98
$925.74
$995.42
$1,242.94

$1,046.35
$1,112.11
$1,181.79
$1,429.31

$186.37

Toc - Plan #35 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

$292.57
$332.06
$373.89
$522.51
$794.01

$516.38
$555.87
$597.70
$746.32

$740.19
$779.68
$821.51
$970.13

$964.00
$1,003.49
$1,045.32
$1,193.94

$223.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$585.14
$664.12
$747.78
$1,045.02
$1,588.02

$808.95
$887.93
$971.59
$1,268.83

$1,032.76
$1,111.74
$1,195.40
$1,492.64

$1,256.57
$1,335.55
$1,419.21
$1,716.45

$223.81

Toc - Plan #36 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

$289.32
$328.37
$369.74
$516.71
$785.19

$510.64
$549.69
$591.06
$738.03

$731.96
$771.01
$812.38
$959.35

$953.28
$992.33
$1,033.70
$1,180.67

$221.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.64
$656.74
$739.48
$1,033.42
$1,570.38

$799.96
$878.06
$960.80
$1,254.74

$1,021.28
$1,099.38
$1,182.12
$1,476.06

$1,242.60
$1,320.70
$1,403.44
$1,697.38

$221.32

Toc - Plan #37 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

$306.12
$347.43
$391.20
$546.70
$830.77

$540.29
$581.60
$625.37
$780.87

$774.46
$815.77
$859.54
$1,015.04

$1,008.63
$1,049.94
$1,093.71
$1,249.21

$234.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$612.24
$694.86
$782.40
$1,093.40
$1,661.54

$846.41
$929.03
$1,016.57
$1,327.57

$1,080.58
$1,163.20
$1,250.74
$1,561.74

$1,314.75
$1,397.37
$1,484.91
$1,795.91

$234.17

Toc - Plan #38 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

$286.31
$324.95
$365.89
$511.33
$777.02

$505.33
$543.97
$584.91
$730.35

$724.35
$762.99
$803.93
$949.37

$943.37
$982.01
$1,022.95
$1,168.39

$219.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$572.62
$649.90
$731.78
$1,022.66
$1,554.04

$791.64
$868.92
$950.80
$1,241.68

$1,010.66
$1,087.94
$1,169.82
$1,460.70

$1,229.68
$1,306.96
$1,388.84
$1,679.72

$219.02

Toc - Plan #39 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

$267.70
$303.83
$342.11
$478.10
$726.52

$472.48
$508.61
$546.89
$682.88

$677.26
$713.39
$751.67
$887.66

$882.04
$918.17
$956.45
$1,092.44

$204.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$535.40
$607.66
$684.22
$956.20
$1,453.04

$740.18
$812.44
$889.00
$1,160.98

$944.96
$1,017.22
$1,093.78
$1,365.76

$1,149.74
$1,222.00
$1,298.56
$1,570.54

$204.78

Toc - Plan #40 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

$262.11
$297.49
$334.97
$468.12
$711.35

$462.62
$498.00
$535.48
$668.63

$663.13
$698.51
$735.99
$869.14

$863.64
$899.02
$936.50
$1,069.65

$200.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$524.22
$594.98
$669.94
$936.24
$1,422.70

$724.73
$795.49
$870.45
$1,136.75

$925.24
$996.00
$1,070.96
$1,337.26

$1,125.75
$1,196.51
$1,271.47
$1,537.77

$200.51

Toc - Plan #41 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

$296.58
$336.60
$379.01
$529.67
$804.88

$523.45
$563.47
$605.88
$756.54

$750.32
$790.34
$832.75
$983.41

$977.19
$1,017.21
$1,059.62
$1,210.28

$226.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$593.16
$673.20
$758.02
$1,059.34
$1,609.76

$820.03
$900.07
$984.89
$1,286.21

$1,046.90
$1,126.94
$1,211.76
$1,513.08

$1,273.77
$1,353.81
$1,438.63
$1,739.95

$226.87

Toc - Plan #42 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

$282.04
$320.10
$360.43
$503.70
$765.42

$497.79
$535.85
$576.18
$719.45

$713.54
$751.60
$791.93
$935.20

$929.29
$967.35
$1,007.68
$1,150.95

$215.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$564.08
$640.20
$720.86
$1,007.40
$1,530.84

$779.83
$855.95
$936.61
$1,223.15

$995.58
$1,071.70
$1,152.36
$1,438.90

$1,211.33
$1,287.45
$1,368.11
$1,654.65

$215.75

Toc - Plan #43 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

$285.23
$323.72
$364.51
$509.40
$774.08

$503.42
$541.91
$582.70
$727.59

$721.61
$760.10
$800.89
$945.78

$939.80
$978.29
$1,019.08
$1,163.97

$218.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$570.46
$647.44
$729.02
$1,018.80
$1,548.16

$788.65
$865.63
$947.21
$1,236.99

$1,006.84
$1,083.82
$1,165.40
$1,455.18

$1,225.03
$1,302.01
$1,383.59
$1,673.37

$218.19

Toc - Plan #44 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

$292.60
$332.09
$373.93
$522.56
$794.09

$516.43
$555.92
$597.76
$746.39

$740.26
$779.75
$821.59
$970.22

$964.09
$1,003.58
$1,045.42
$1,194.05

$223.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$585.20
$664.18
$747.86
$1,045.12
$1,588.18

$809.03
$888.01
$971.69
$1,268.95

$1,032.86
$1,111.84
$1,195.52
$1,492.78

$1,256.69
$1,335.67
$1,419.35
$1,716.61

$223.83

Toc - Plan #45 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

$289.21
$328.24
$369.59
$516.50
$784.88

$510.44
$549.47
$590.82
$737.73

$731.67
$770.70
$812.05
$958.96

$952.90
$991.93
$1,033.28
$1,180.19

$221.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.42
$656.48
$739.18
$1,033.00
$1,569.76

$799.65
$877.71
$960.41
$1,254.23

$1,020.88
$1,098.94
$1,181.64
$1,475.46

$1,242.11
$1,320.17
$1,402.87
$1,696.69

$221.23

Toc - Plan #46 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

$337.71
$383.29
$431.58
$603.14
$916.52

$596.05
$641.63
$689.92
$861.48

$854.39
$899.97
$948.26
$1,119.82

$1,112.73
$1,158.31
$1,206.60
$1,378.16

$258.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.42
$766.58
$863.16
$1,206.28
$1,833.04

$933.76
$1,024.92
$1,121.50
$1,464.62

$1,192.10
$1,283.26
$1,379.84
$1,722.96

$1,450.44
$1,541.60
$1,638.18
$1,981.30

$258.34

Toc - Plan #47 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

$231.92
$263.22
$296.38
$414.19
$629.41

$409.33
$440.63
$473.79
$591.60

$586.74
$618.04
$651.20
$769.01

$764.15
$795.45
$828.61
$946.42

$177.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$463.84
$526.44
$592.76
$828.38
$1,258.82

$641.25
$703.85
$770.17
$1,005.79

$818.66
$881.26
$947.58
$1,183.20

$996.07
$1,058.67
$1,124.99
$1,360.61

$177.41

Toc - Plan #48 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

$256.61
$291.25
$327.94
$458.29
$696.42

$452.91
$487.55
$524.24
$654.59

$649.21
$683.85
$720.54
$850.89

$845.51
$880.15
$916.84
$1,047.19

$196.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$513.22
$582.50
$655.88
$916.58
$1,392.84

$709.52
$778.80
$852.18
$1,112.88

$905.82
$975.10
$1,048.48
$1,309.18

$1,102.12
$1,171.40
$1,244.78
$1,505.48

$196.30

Toc - Plan #49 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

$282.65
$320.80
$361.22
$504.80
$767.09

$498.87
$537.02
$577.44
$721.02

$715.09
$753.24
$793.66
$937.24

$931.31
$969.46
$1,009.88
$1,153.46

$216.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$565.30
$641.60
$722.44
$1,009.60
$1,534.18

$781.52
$857.82
$938.66
$1,225.82

$997.74
$1,074.04
$1,154.88
$1,442.04

$1,213.96
$1,290.26
$1,371.10
$1,658.26

$216.22

Toc - Plan #50 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

$289.85
$328.97
$370.41
$517.65
$786.62

$511.58
$550.70
$592.14
$739.38

$733.31
$772.43
$813.87
$961.11

$955.04
$994.16
$1,035.60
$1,182.84

$221.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$579.70
$657.94
$740.82
$1,035.30
$1,573.24

$801.43
$879.67
$962.55
$1,257.03

$1,023.16
$1,101.40
$1,184.28
$1,478.76

$1,244.89
$1,323.13
$1,406.01
$1,700.49

$221.73

Toc - Plan #51 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

$297.65
$337.82
$380.38
$531.58
$807.79

$525.34
$565.51
$608.07
$759.27

$753.03
$793.20
$835.76
$986.96

$980.72
$1,020.89
$1,063.45
$1,214.65

$227.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$595.30
$675.64
$760.76
$1,063.16
$1,615.58

$822.99
$903.33
$988.45
$1,290.85

$1,050.68
$1,131.02
$1,216.14
$1,518.54

$1,278.37
$1,358.71
$1,443.83
$1,746.23

$227.69

Toc - Plan #52 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

$304.16
$345.21
$388.70
$543.21
$825.46

$536.83
$577.88
$621.37
$775.88

$769.50
$810.55
$854.04
$1,008.55

$1,002.17
$1,043.22
$1,086.71
$1,241.22

$232.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$608.32
$690.42
$777.40
$1,086.42
$1,650.92

$840.99
$923.09
$1,010.07
$1,319.09

$1,073.66
$1,155.76
$1,242.74
$1,551.76

$1,306.33
$1,388.43
$1,475.41
$1,784.43

$232.67

Toc - Plan #53 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

$300.78
$341.38
$384.39
$537.18
$816.29

$530.87
$571.47
$614.48
$767.27

$760.96
$801.56
$844.57
$997.36

$991.05
$1,031.65
$1,074.66
$1,227.45

$230.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$601.56
$682.76
$768.78
$1,074.36
$1,632.58

$831.65
$912.85
$998.87
$1,304.45

$1,061.74
$1,142.94
$1,228.96
$1,534.54

$1,291.83
$1,373.03
$1,459.05
$1,764.63

$230.09

Toc - Plan #54 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

$253.27
$287.45
$323.67
$452.33
$687.36

$447.02
$481.20
$517.42
$646.08

$640.77
$674.95
$711.17
$839.83

$834.52
$868.70
$904.92
$1,033.58

$193.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$506.54
$574.90
$647.34
$904.66
$1,374.72

$700.29
$768.65
$841.09
$1,098.41

$894.04
$962.40
$1,034.84
$1,292.16

$1,087.79
$1,156.15
$1,228.59
$1,485.91

$193.75

Toc - Plan #55 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

$318.24
$361.19
$406.70
$568.36
$863.68

$561.69
$604.64
$650.15
$811.81

$805.14
$848.09
$893.60
$1,055.26

$1,048.59
$1,091.54
$1,137.05
$1,298.71

$243.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$636.48
$722.38
$813.40
$1,136.72
$1,727.36

$879.93
$965.83
$1,056.85
$1,380.17

$1,123.38
$1,209.28
$1,300.30
$1,623.62

$1,366.83
$1,452.73
$1,543.75
$1,867.07

$243.45

Toc - Plan #56 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

$278.31
$315.87
$355.66
$497.04
$755.29

$491.21
$528.77
$568.56
$709.94

$704.11
$741.67
$781.46
$922.84

$917.01
$954.57
$994.36
$1,135.74

$212.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$556.62
$631.74
$711.32
$994.08
$1,510.58

$769.52
$844.64
$924.22
$1,206.98

$982.42
$1,057.54
$1,137.12
$1,419.88

$1,195.32
$1,270.44
$1,350.02
$1,632.78

$212.90

Toc - Plan #57 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

$272.50
$309.27
$348.24
$486.66
$739.53

$480.95
$517.72
$556.69
$695.11

$689.40
$726.17
$765.14
$903.56

$897.85
$934.62
$973.59
$1,112.01

$208.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$545.00
$618.54
$696.48
$973.32
$1,479.06

$753.45
$826.99
$904.93
$1,181.77

$961.90
$1,035.44
$1,113.38
$1,390.22

$1,170.35
$1,243.89
$1,321.83
$1,598.67

$208.45

Toc - Plan #58 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

$308.32
$349.94
$394.03
$550.65
$836.77

$544.18
$585.80
$629.89
$786.51

$780.04
$821.66
$865.75
$1,022.37

$1,015.90
$1,057.52
$1,101.61
$1,258.23

$235.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$616.64
$699.88
$788.06
$1,101.30
$1,673.54

$852.50
$935.74
$1,023.92
$1,337.16

$1,088.36
$1,171.60
$1,259.78
$1,573.02

$1,324.22
$1,407.46
$1,495.64
$1,808.88

$235.86

Toc - Plan #59 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

$296.52
$336.54
$378.94
$529.57
$804.74

$523.35
$563.37
$605.77
$756.40

$750.18
$790.20
$832.60
$983.23

$977.01
$1,017.03
$1,059.43
$1,210.06

$226.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$593.04
$673.08
$757.88
$1,059.14
$1,609.48

$819.87
$899.91
$984.71
$1,285.97

$1,046.70
$1,126.74
$1,211.54
$1,512.80

$1,273.53
$1,353.57
$1,438.37
$1,739.63

$226.83

Toc - Plan #60 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

$304.19
$345.24
$388.74
$543.26
$825.54

$536.89
$577.94
$621.44
$775.96

$769.59
$810.64
$854.14
$1,008.66

$1,002.29
$1,043.34
$1,086.84
$1,241.36

$232.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$608.38
$690.48
$777.48
$1,086.52
$1,651.08

$841.08
$923.18
$1,010.18
$1,319.22

$1,073.78
$1,155.88
$1,242.88
$1,551.92

$1,306.48
$1,388.58
$1,475.58
$1,784.62

$232.70

Toc - Plan #61 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

$293.21
$332.78
$374.71
$523.65
$795.74

$517.51
$557.08
$599.01
$747.95

$741.81
$781.38
$823.31
$972.25

$966.11
$1,005.68
$1,047.61
$1,196.55

$224.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$586.42
$665.56
$749.42
$1,047.30
$1,591.48

$810.72
$889.86
$973.72
$1,271.60

$1,035.02
$1,114.16
$1,198.02
$1,495.90

$1,259.32
$1,338.46
$1,422.32
$1,720.20

$224.30

Toc - Plan #62 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

$300.66
$341.24
$384.23
$536.96
$815.96

$530.66
$571.24
$614.23
$766.96

$760.66
$801.24
$844.23
$996.96

$990.66
$1,031.24
$1,074.23
$1,226.96

$230.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$601.32
$682.48
$768.46
$1,073.92
$1,631.92

$831.32
$912.48
$998.46
$1,303.92

$1,061.32
$1,142.48
$1,228.46
$1,533.92

$1,291.32
$1,372.48
$1,458.46
$1,763.92

$230.00

Toc - Plan #63 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

$351.09
$398.47
$448.68
$627.02
$952.82

$619.66
$667.04
$717.25
$895.59

$888.23
$935.61
$985.82
$1,164.16

$1,156.80
$1,204.18
$1,254.39
$1,432.73

$268.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$702.18
$796.94
$897.36
$1,254.04
$1,905.64

$970.75
$1,065.51
$1,165.93
$1,522.61

$1,239.32
$1,334.08
$1,434.50
$1,791.18

$1,507.89
$1,602.65
$1,703.07
$2,059.75

$268.57

Toc - Plan #64 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

$255.06
$289.49
$325.96
$455.53
$692.22

$450.18
$484.61
$521.08
$650.65

$645.30
$679.73
$716.20
$845.77

$840.42
$874.85
$911.32
$1,040.89

$195.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$510.12
$578.98
$651.92
$911.06
$1,384.44

$705.24
$774.10
$847.04
$1,106.18

$900.36
$969.22
$1,042.16
$1,301.30

$1,095.48
$1,164.34
$1,237.28
$1,496.42

$195.12

Toc - Plan #65 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

$279.08
$316.75
$356.65
$498.42
$757.40

$492.57
$530.24
$570.14
$711.91

$706.06
$743.73
$783.63
$925.40

$919.55
$957.22
$997.12
$1,138.89

$213.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$558.16
$633.50
$713.30
$996.84
$1,514.80

$771.65
$846.99
$926.79
$1,210.33

$985.14
$1,060.48
$1,140.28
$1,423.82

$1,198.63
$1,273.97
$1,353.77
$1,637.31

$213.49

Toc - Plan #66 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

$297.37
$337.50
$380.02
$531.08
$807.03

$524.85
$564.98
$607.50
$758.56

$752.33
$792.46
$834.98
$986.04

$979.81
$1,019.94
$1,062.46
$1,213.52

$227.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.74
$675.00
$760.04
$1,062.16
$1,614.06

$822.22
$902.48
$987.52
$1,289.64

$1,049.70
$1,129.96
$1,215.00
$1,517.12

$1,277.18
$1,357.44
$1,442.48
$1,744.60

$227.48

Alliant Health Plans

Local: 1-800-811-4793 | Toll Free: 1-800-811-4793

Toc - Plan #67 Alliant Health Plans

Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits) 40002

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 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

$289.27
$328.31
$369.68
$516.62
$785.05

$510.55
$549.59
$590.96
$737.90

$731.83
$770.87
$812.24
$959.18

$953.11
$992.15
$1,033.52
$1,180.46

$221.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$578.54
$656.62
$739.36
$1,033.24
$1,570.10

$799.82
$877.90
$960.64
$1,254.52

$1,021.10
$1,099.18
$1,181.92
$1,475.80

$1,242.38
$1,320.46
$1,403.20
$1,697.08

$221.28

Toc - Plan #68 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40017

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 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

$284.72
$323.15
$363.87
$508.50
$772.72

$502.53
$540.96
$581.68
$726.31

$720.34
$758.77
$799.49
$944.12

$938.15
$976.58
$1,017.30
$1,161.93

$217.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$569.44
$646.30
$727.74
$1,017.00
$1,545.44

$787.25
$864.11
$945.55
$1,234.81

$1,005.06
$1,081.92
$1,163.36
$1,452.62

$1,222.87
$1,299.73
$1,381.17
$1,670.43

$217.81

Toc - Plan #69 Alliant Health Plans

Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits) 40184

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$378.62
$429.72
$483.87
$676.20
$1,027.55

$668.26
$719.36
$773.51
$965.84

$957.90
$1,009.00
$1,063.15
$1,255.48

$1,247.54
$1,298.64
$1,352.79
$1,545.12

$289.64

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$757.24
$859.44
$967.74
$1,352.40
$2,055.10

$1,046.88
$1,149.08
$1,257.38
$1,642.04

$1,336.52
$1,438.72
$1,547.02
$1,931.68

$1,626.16
$1,728.36
$1,836.66
$2,221.32

$289.64

Toc - Plan #70 Alliant Health Plans

Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits) 40330

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$300.63
$341.20
$384.19
$536.91
$815.89

$530.60
$571.17
$614.16
$766.88

$760.57
$801.14
$844.13
$996.85

$990.54
$1,031.11
$1,074.10
$1,226.82

$229.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$601.26
$682.40
$768.38
$1,073.82
$1,631.78

$831.23
$912.37
$998.35
$1,303.79

$1,061.20
$1,142.34
$1,228.32
$1,533.76

$1,291.17
$1,372.31
$1,458.29
$1,763.73

$229.97

Toc - Plan #71 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40331

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$9,050 $18,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$283.21
$321.43
$361.93
$505.80
$768.61

$499.86
$538.08
$578.58
$722.45

$716.51
$754.73
$795.23
$939.10

$933.16
$971.38
$1,011.88
$1,155.75

$216.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$566.42
$642.86
$723.86
$1,011.60
$1,537.22

$783.07
$859.51
$940.51
$1,228.25

$999.72
$1,076.16
$1,157.16
$1,444.90

$1,216.37
$1,292.81
$1,373.81
$1,661.55

$216.65

Toc - Plan #72 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40336

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$291.54
$330.89
$372.57
$520.67
$791.21

$514.56
$553.91
$595.59
$743.69

$737.58
$776.93
$818.61
$966.71

$960.60
$999.95
$1,041.63
$1,189.73

$223.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$583.08
$661.78
$745.14
$1,041.34
$1,582.42

$806.10
$884.80
$968.16
$1,264.36

$1,029.12
$1,107.82
$1,191.18
$1,487.38

$1,252.14
$1,330.84
$1,414.20
$1,710.40

$223.02

Toc - Plan #73 Alliant Health Plans

Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits + Dental) 40348

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$393.76
$446.91
$503.22
$703.24
$1,068.64

$694.98
$748.13
$804.44
$1,004.46

$996.20
$1,049.35
$1,105.66
$1,305.68

$1,297.42
$1,350.57
$1,406.88
$1,606.90

$301.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$787.52
$893.82
$1,006.44
$1,406.48
$2,137.28

$1,088.74
$1,195.04
$1,307.66
$1,707.70

$1,389.96
$1,496.26
$1,608.88
$2,008.92

$1,691.18
$1,797.48
$1,910.10
$2,310.14

$301.22

Toc - Plan #74 Alliant Health Plans

Platinum

(PPO) SoloCare Platinum PPO Copay Plan (3 Free PCP Visits + Chiro + Dental) 40349

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$397.55
$451.21
$508.06
$710.01
$1,078.93

$701.67
$755.33
$812.18
$1,014.13

$1,005.79
$1,059.45
$1,116.30
$1,318.25

$1,309.91
$1,363.57
$1,420.42
$1,622.37

$304.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$795.10
$902.42
$1,016.12
$1,420.02
$2,157.86

$1,099.22
$1,206.54
$1,320.24
$1,724.14

$1,403.34
$1,510.66
$1,624.36
$2,028.26

$1,707.46
$1,814.78
$1,928.48
$2,332.38

$304.12

Toc - Plan #75 Alliant Health Plans

Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Dental) 40354

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 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

$301.00
$341.63
$384.67
$537.58
$816.90

$531.26
$571.89
$614.93
$767.84

$761.52
$802.15
$845.19
$998.10

$991.78
$1,032.41
$1,075.45
$1,228.36

$230.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$602.00
$683.26
$769.34
$1,075.16
$1,633.80

$832.26
$913.52
$999.60
$1,305.42

$1,062.52
$1,143.78
$1,229.86
$1,535.68

$1,292.78
$1,374.04
$1,460.12
$1,765.94

$230.26

Toc - Plan #76 Alliant Health Plans

Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Chiro + Dental) 40355

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 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

$304.04
$345.07
$388.55
$542.99
$825.13

$536.62
$577.65
$621.13
$775.57

$769.20
$810.23
$853.71
$1,008.15

$1,001.78
$1,042.81
$1,086.29
$1,240.73

$232.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$608.08
$690.14
$777.10
$1,085.98
$1,650.26

$840.66
$922.72
$1,009.68
$1,318.56

$1,073.24
$1,155.30
$1,242.26
$1,551.14

$1,305.82
$1,387.88
$1,474.84
$1,783.72

$232.58

Toc - Plan #77 Alliant Health Plans

Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Dental) 40357

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$7,100 $14,200 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

$312.36
$354.52
$399.19
$557.87
$847.73

$551.31
$593.47
$638.14
$796.82

$790.26
$832.42
$877.09
$1,035.77

$1,029.21
$1,071.37
$1,116.04
$1,274.72

$238.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$624.72
$709.04
$798.38
$1,115.74
$1,695.46

$863.67
$947.99
$1,037.33
$1,354.69

$1,102.62
$1,186.94
$1,276.28
$1,593.64

$1,341.57
$1,425.89
$1,515.23
$1,832.59

$238.95

Toc - Plan #78 Alliant Health Plans

Gold

(PPO) SoloCare Gold PPO (3 Free PCP Visits + Chiro + Dental) 40358

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$315.77
$358.39
$403.54
$563.95
$856.98

$557.33
$599.95
$645.10
$805.51

$798.89
$841.51
$886.66
$1,047.07

$1,040.45
$1,083.07
$1,128.22
$1,288.63

$241.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$631.54
$716.78
$807.08
$1,127.90
$1,713.96

$873.10
$958.34
$1,048.64
$1,369.46

$1,114.66
$1,199.90
$1,290.20
$1,611.02

$1,356.22
$1,441.46
$1,531.76
$1,852.58

$241.56

Toc - Plan #79 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits +$225 Specialty Drug Copay + Dental) 40368

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 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

$296.09
$336.05
$378.38
$528.79
$803.55

$522.59
$562.55
$604.88
$755.29

$749.09
$789.05
$831.38
$981.79

$975.59
$1,015.55
$1,057.88
$1,208.29

$226.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$592.18
$672.10
$756.76
$1,057.58
$1,607.10

$818.68
$898.60
$983.26
$1,284.08

$1,045.18
$1,125.10
$1,209.76
$1,510.58

$1,271.68
$1,351.60
$1,436.26
$1,737.08

$226.50

Toc - Plan #80 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40369

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 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

$298.35
$338.62
$381.28
$532.84
$809.70

$526.58
$566.85
$609.51
$761.07

$754.81
$795.08
$837.74
$989.30

$983.04
$1,023.31
$1,065.97
$1,217.53

$228.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$596.70
$677.24
$762.56
$1,065.68
$1,619.40

$824.93
$905.47
$990.79
$1,293.91

$1,053.16
$1,133.70
$1,219.02
$1,522.14

$1,281.39
$1,361.93
$1,447.25
$1,750.37

$228.23

Toc - Plan #81 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay + Dental) 40372

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$9,050 $18,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$294.57
$334.33
$376.45
$526.09
$799.44

$519.91
$559.67
$601.79
$751.43

$745.25
$785.01
$827.13
$976.77

$970.59
$1,010.35
$1,052.47
$1,202.11

$225.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$589.14
$668.66
$752.90
$1,052.18
$1,598.88

$814.48
$894.00
$978.24
$1,277.52

$1,039.82
$1,119.34
$1,203.58
$1,502.86

$1,265.16
$1,344.68
$1,428.92
$1,728.20

$225.34

Toc - Plan #82 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40373

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$9,050 $18,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$297.22
$337.34
$379.84
$530.82
$806.64

$524.59
$564.71
$607.21
$758.19

$751.96
$792.08
$834.58
$985.56

$979.33
$1,019.45
$1,061.95
$1,212.93

$227.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.44
$674.68
$759.68
$1,061.64
$1,613.28

$821.81
$902.05
$987.05
$1,289.01

$1,049.18
$1,129.42
$1,214.42
$1,516.38

$1,276.55
$1,356.79
$1,441.79
$1,743.75

$227.37

Toc - Plan #83 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay + Dental) 40375

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$303.28
$344.21
$387.58
$541.64
$823.08

$535.28
$576.21
$619.58
$773.64

$767.28
$808.21
$851.58
$1,005.64

$999.28
$1,040.21
$1,083.58
$1,237.64

$232.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$606.56
$688.42
$775.16
$1,083.28
$1,646.16

$838.56
$920.42
$1,007.16
$1,315.28

$1,070.56
$1,152.42
$1,239.16
$1,547.28

$1,302.56
$1,384.42
$1,471.16
$1,779.28

$232.00

Toc - Plan #84 Alliant Health Plans

Silver

(PPO) SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40376

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$305.55
$346.79
$390.48
$545.69
$829.24

$539.29
$580.53
$624.22
$779.43

$773.03
$814.27
$857.96
$1,013.17

$1,006.77
$1,048.01
$1,091.70
$1,246.91

$233.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$611.10
$693.58
$780.96
$1,091.38
$1,658.48

$844.84
$927.32
$1,014.70
$1,325.12

$1,078.58
$1,161.06
$1,248.44
$1,558.86

$1,312.32
$1,394.80
$1,482.18
$1,792.60

$233.74

Toc - Plan #85 Alliant Health Plans

Platinum

(PPO) SoloCare PPO Platinum Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 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

$391.11
$443.90
$499.83
$698.51
$1,061.45

$690.30
$743.09
$799.02
$997.70

$989.49
$1,042.28
$1,098.21
$1,296.89

$1,288.68
$1,341.47
$1,397.40
$1,596.08

$299.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$782.22
$887.80
$999.66
$1,397.02
$2,122.90

$1,081.41
$1,186.99
$1,298.85
$1,696.21

$1,380.60
$1,486.18
$1,598.04
$1,995.40

$1,679.79
$1,785.37
$1,897.23
$2,294.59

$299.19

Toc - Plan #86 Alliant Health Plans

Gold

(PPO) SoloCare PPO Gold Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$283.21
$321.43
$361.93
$505.80
$768.61

$499.86
$538.08
$578.58
$722.45

$716.51
$754.73
$795.23
$939.10

$933.16
$971.38
$1,011.88
$1,155.75

$216.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$566.42
$642.86
$723.86
$1,011.60
$1,537.22

$783.07
$859.51
$940.51
$1,228.25

$999.72
$1,076.16
$1,157.16
$1,444.90

$1,216.37
$1,292.81
$1,373.81
$1,661.55

$216.65

Toc - Plan #87 Alliant Health Plans

Silver

(PPO) SoloCare PPO Silver Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$268.83
$305.11
$343.55
$480.11
$729.57

$474.48
$510.76
$549.20
$685.76

$680.13
$716.41
$754.85
$891.41

$885.78
$922.06
$960.50
$1,097.06

$205.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$537.66
$610.22
$687.10
$960.22
$1,459.14

$743.31
$815.87
$892.75
$1,165.87

$948.96
$1,021.52
$1,098.40
$1,371.52

$1,154.61
$1,227.17
$1,304.05
$1,577.17

$205.65

Toc - Plan #88 Alliant Health Plans

Gold

(HMO) SoloCare Gold No Referral HMO (3 Free PCP Visits) 110003

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 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

$287.76
$326.59
$367.74
$513.92
$780.95

$507.89
$546.72
$587.87
$734.05

$728.02
$766.85
$808.00
$954.18

$948.15
$986.98
$1,028.13
$1,174.31

$220.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$575.52
$653.18
$735.48
$1,027.84
$1,561.90

$795.65
$873.31
$955.61
$1,247.97

$1,015.78
$1,093.44
$1,175.74
$1,468.10

$1,235.91
$1,313.57
$1,395.87
$1,688.23

$220.13

Toc - Plan #89 Alliant Health Plans

Gold

(HMO) SoloCare Gold No Referral HMO (3 Free PCP Visits) 110004

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$7,100 $14,200 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

$299.49
$339.91
$382.74
$534.88
$812.79

$528.59
$569.01
$611.84
$763.98

$757.69
$798.11
$840.94
$993.08

$986.79
$1,027.21
$1,070.04
$1,222.18

$229.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$598.98
$679.82
$765.48
$1,069.76
$1,625.58

$828.08
$908.92
$994.58
$1,298.86

$1,057.18
$1,138.02
$1,223.68
$1,527.96

$1,286.28
$1,367.12
$1,452.78
$1,757.06

$229.10

Toc - Plan #90 Alliant Health Plans

Silver

(HMO) SoloCare Silver No Referral HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110008

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 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

$280.94
$318.86
$359.03
$501.75
$762.46

$495.85
$533.77
$573.94
$716.66

$710.76
$748.68
$788.85
$931.57

$925.67
$963.59
$1,003.76
$1,146.48

$214.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$561.88
$637.72
$718.06
$1,003.50
$1,524.92

$776.79
$852.63
$932.97
$1,218.41

$991.70
$1,067.54
$1,147.88
$1,433.32

$1,206.61
$1,282.45
$1,362.79
$1,648.23

$214.91

Toc - Plan #91 Alliant Health Plans

Silver

(HMO) SoloCare Silver No Referral HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110009

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$9,050 $18,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$279.42
$317.13
$357.09
$499.03
$758.33

$493.17
$530.88
$570.84
$712.78

$706.92
$744.63
$784.59
$926.53

$920.67
$958.38
$998.34
$1,140.28

$213.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$558.84
$634.26
$714.18
$998.06
$1,516.66

$772.59
$848.01
$927.93
$1,211.81

$986.34
$1,061.76
$1,141.68
$1,425.56

$1,200.09
$1,275.51
$1,355.43
$1,639.31

$213.75

Toc - Plan #92 Alliant Health Plans

Silver

(HMO) SoloCare Silver HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110010

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$287.76
$326.59
$367.74
$513.92
$780.95

$507.89
$546.72
$587.87
$734.05

$728.02
$766.85
$808.00
$954.18

$948.15
$986.98
$1,028.13
$1,174.31

$220.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$575.52
$653.18
$735.48
$1,027.84
$1,561.90

$795.65
$873.31
$955.61
$1,247.97

$1,015.78
$1,093.44
$1,175.74
$1,468.10

$1,235.91
$1,313.57
$1,395.87
$1,688.23

$220.13

Toc - Plan #93 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO ($250 Specialty Drug Copay) 110011

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$218.09
$247.53
$278.71
$389.50
$591.88

$384.92
$414.36
$445.54
$556.33

$551.75
$581.19
$612.37
$723.16

$718.58
$748.02
$779.20
$889.99

$166.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$436.18
$495.06
$557.42
$779.00
$1,183.76

$603.01
$661.89
$724.25
$945.83

$769.84
$828.72
$891.08
$1,112.66

$936.67
$995.55
$1,057.91
$1,279.49

$166.83

Toc - Plan #94 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO ($250 Specialty Drug Copay + Dental) 110013

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$226.79
$257.40
$289.83
$405.04
$615.49

$400.28
$430.89
$463.32
$578.53

$573.77
$604.38
$636.81
$752.02

$747.26
$777.87
$810.30
$925.51

$173.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$453.58
$514.80
$579.66
$810.08
$1,230.98

$627.07
$688.29
$753.15
$983.57

$800.56
$861.78
$926.64
$1,157.06

$974.05
$1,035.27
$1,100.13
$1,330.55

$173.49

Toc - Plan #95 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO 110015

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 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

$217.71
$247.09
$278.22
$388.82
$590.84

$384.25
$413.63
$444.76
$555.36

$550.79
$580.17
$611.30
$721.90

$717.33
$746.71
$777.84
$888.44

$166.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$435.42
$494.18
$556.44
$777.64
$1,181.68

$601.96
$660.72
$722.98
$944.18

$768.50
$827.26
$889.52
$1,110.72

$935.04
$993.80
$1,056.06
$1,277.26

$166.54

Toc - Plan #96 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO (+ Dental) 110017

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 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

$226.42
$256.98
$289.35
$404.37
$614.48

$399.62
$430.18
$462.55
$577.57

$572.82
$603.38
$635.75
$750.77

$746.02
$776.58
$808.95
$923.97

$173.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$452.84
$513.96
$578.70
$808.74
$1,228.96

$626.04
$687.16
$751.90
$981.94

$799.24
$860.36
$925.10
$1,155.14

$972.44
$1,033.56
$1,098.30
$1,328.34

$173.20

Toc - Plan #97 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO HDHP 110019

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$223.39
$253.53
$285.48
$398.95
$606.25

$394.27
$424.41
$456.36
$569.83

$565.15
$595.29
$627.24
$740.71

$736.03
$766.17
$798.12
$911.59

$170.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$446.78
$507.06
$570.96
$797.90
$1,212.50

$617.66
$677.94
$741.84
$968.78

$788.54
$848.82
$912.72
$1,139.66

$959.42
$1,019.70
$1,083.60
$1,310.54

$170.88

Toc - Plan #98 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO HDHP (+ Dental) 110021

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$232.10
$263.42
$296.61
$414.51
$629.88

$409.65
$440.97
$474.16
$592.06

$587.20
$618.52
$651.71
$769.61

$764.75
$796.07
$829.26
$947.16

$177.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$464.20
$526.84
$593.22
$829.02
$1,259.76

$641.75
$704.39
$770.77
$1,006.57

$819.30
$881.94
$948.32
$1,184.12

$996.85
$1,059.49
$1,125.87
$1,361.67

$177.55

Toc - Plan #99 Alliant Health Plans

Catastrophic

(HMO) SoloCare Catastropic No Referral HMO 110023

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$162.81
$184.78
$208.06
$290.77
$441.85

$287.36
$309.33
$332.61
$415.32

$411.91
$433.88
$457.16
$539.87

$536.46
$558.43
$581.71
$664.42

$124.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$325.62
$369.56
$416.12
$581.54
$883.70

$450.17
$494.11
$540.67
$706.09

$574.72
$618.66
$665.22
$830.64

$699.27
$743.21
$789.77
$955.19

$124.55

Toc - Plan #100 Alliant Health Plans

Gold

(HMO) SoloCare HMO Gold Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$281.70
$319.72
$360.00
$503.10
$764.51

$497.19
$535.21
$575.49
$718.59

$712.68
$750.70
$790.98
$934.08

$928.17
$966.19
$1,006.47
$1,149.57

$215.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$563.40
$639.44
$720.00
$1,006.20
$1,529.02

$778.89
$854.93
$935.49
$1,221.69

$994.38
$1,070.42
$1,150.98
$1,437.18

$1,209.87
$1,285.91
$1,366.47
$1,652.67

$215.49

Toc - Plan #101 Alliant Health Plans

Silver

(HMO) SoloCare HMO Silver Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$265.79
$301.67
$339.67
$474.69
$721.34

$469.11
$504.99
$542.99
$678.01

$672.43
$708.31
$746.31
$881.33

$875.75
$911.63
$949.63
$1,084.65

$203.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$531.58
$603.34
$679.34
$949.38
$1,442.68

$734.90
$806.66
$882.66
$1,152.70

$938.22
$1,009.98
$1,085.98
$1,356.02

$1,141.54
$1,213.30
$1,289.30
$1,559.34

$203.32

Toc - Plan #102 Alliant Health Plans

Bronze

(HMO) SoloCare HMO Bronze Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$201.43
$228.61
$257.42
$359.74
$546.66

$355.52
$382.70
$411.51
$513.83

$509.61
$536.79
$565.60
$667.92

$663.70
$690.88
$719.69
$822.01

$154.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$402.86
$457.22
$514.84
$719.48
$1,093.32

$556.95
$611.31
$668.93
$873.57

$711.04
$765.40
$823.02
$1,027.66

$865.13
$919.49
$977.11
$1,181.75

$154.09

Toc - Plan #103 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare HMO Expanded Bronze Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

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

$202.57
$229.91
$258.87
$361.77
$549.75

$357.53
$384.87
$413.83
$516.73

$512.49
$539.83
$568.79
$671.69

$667.45
$694.79
$723.75
$826.65

$154.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$405.14
$459.82
$517.74
$723.54
$1,099.50

$560.10
$614.78
$672.70
$878.50

$715.06
$769.74
$827.66
$1,033.46

$870.02
$924.70
$982.62
$1,188.42

$154.96

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Cook County here.

Cook County is in “Rating Area 15” of Georgia.

Currently, there are 103 plans offered in Rating Area 15.

Top

2023 Obamacare Plans for Cook County, GA

Plan Browser: 103 Plans

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

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

1. Catastrophic Anthem Catastrophic Pathway X HMO 9100

2. Expanded Bronze Anthem Bronze Pathway X HMO 0% for HSA

3. Expanded Bronze Anthem Bronze Pathway X HMO 5600($0 Virtual PCP+$0 Select Drugs)

4. Expanded Bronze Anthem Bronze Pathway X HMO 6000($0 Virtual PCP+$0 Select Drugs)

5. Silver Anthem Silver Pathway X HMO 3000($0 Virtual PCP+$0 Select Drugs)

6. Silver Anthem Silver Pathway X HMO 5500($0 Virtual PCP+$0 Select Drugs)

7. Bronze Anthem Bronze Pathway X HMO 8000($0 Virtual PCP+$0 Select Drugs)

8. Silver Anthem Silver Pathway X HMO 4950($0 Virtual PCP+$0 Select Drugs)

9. Silver Anthem Silver Pathway X HMO 6500($0 Virtual PCP+$0 Select Drugs)

10. Gold Anthem Gold Pathway X HMO 1600($0 Virtual PCP+$0 Select Drugs)

11. Expanded Bronze Anthem Bronze Pathway X HMO 5000($0 Virtual PCP+$0 Select Drugs)

12. Silver Anthem Silver Pathway X HMO 2600($0 PCP+$0 Select Drugs)

13. Bronze Anthem Bronze Pathway X HMO 9100/0% Standard

14. Expanded Bronze Anthem Bronze Pathway X HMO 7500/50% Standard

15. Silver Anthem Silver Pathway X HMO 5800/40% Standard

16. Gold Anthem Gold Pathway X HMO 2000/25% Standard

CareSource

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

17. Expanded Bronze CareSource Marketplace Bronze First

18. Gold CareSource Marketplace Gold

19. Silver CareSource Marketplace Low Premium Silver

20. Silver CareSource Marketplace Standard Silver

21. Expanded Bronze CareSource Marketplace HSA Eligible Bronze

22. Bronze CareSource Marketplace Bronze

23. Silver CareSource Marketplace Essential Silver

24. Silver CareSource Marketplace Federal Standard Silver

25. Gold CareSource Marketplace Federal Standard Gold

26. Expanded Bronze CareSource Marketplace Bronze First

27. Gold CareSource Marketplace Gold

28. Silver CareSource Marketplace Low Premium Silver

29. Silver CareSource Marketplace Standard Silver

30. Bronze CareSource Marketplace Bronze

31. Silver CareSource Marketplace Essential Silver Dental, Vision, & Fitness

32. Silver CareSource Marketplace Federal Standard Silver

33. Gold CareSource Marketplace Federal Standard Gold

Ambetter from Peach State Health Plan

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

34. Bronze Clear Bronze

35. Silver Premier Silver

36. Silver Complete Silver

37. Gold Complete Gold

38. Silver Everyday Silver

39. Expanded Bronze Choice Bronze HSA

40. Expanded Bronze Everyday Bronze

41. Expanded Bronze Elite Bronze

42. Silver Clear Silver

43. Silver Focused Silver

44. Gold Everyday Gold

45. Gold Clear Gold

46. Gold Elite Gold

47. Bronze CMS Standard Bronze

48. Expanded Bronze CMS Standard Expanded Bronze

49. Silver CMS Standard Silver

50. Gold CMS Standard Gold

51. Silver Everyday Silver + Vision + Adult Dental

52. Silver Premier Silver + Vision + Adult Dental

53. Silver Complete Silver + Vision + Adult Dental

54. Bronze Clear Bronze + Vision + Adult Dental

55. Gold Complete Gold + Vision + Adult Dental

56. Expanded Bronze Choice Bronze HSA + Vision + Adult Dental

57. Expanded Bronze Everyday Bronze + Vision + Adult Dental

58. Expanded Bronze Elite Bronze + Vision + Adult Dental

59. Silver Focused Silver + Vision + Adult Dental

60. Gold Everyday Gold + Vision + Adult Dental

61. Silver Clear Silver + Vision + Adult Dental

62. Gold Clear Gold + Vision + Adult Dental

63. Gold Elite Gold + Vision + Adult Dental

64. Expanded Bronze Ambetter Virtual Access Bronze - Virtual PCP selection required

65. Silver Ambetter Virtual Access Silver - Virtual PCP selection required

66. Gold Ambetter Virtual Access Gold - Virtual PCP selection required

Alliant Health Plans

Local: 1-800-811-4793 | Toll Free: 1-800-811-4793

67. Gold SoloCare Gold PPO (3 Free PCP Visits) 40002

68. Silver SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40017

69. Platinum SoloCare Platinum PPO Copay Plan (3 Free PCP Visits) 40184

70. Gold SoloCare Gold PPO (3 Free PCP Visits) 40330

71. Silver SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40331

72. Silver SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay) 40336

73. Platinum SoloCare Platinum PPO Copay Plan (3 Free PCP Visits + Dental) 40348

74. Platinum SoloCare Platinum PPO Copay Plan (3 Free PCP Visits + Chiro + Dental) 40349

75. Gold SoloCare Gold PPO (3 Free PCP Visits + Dental) 40354

76. Gold SoloCare Gold PPO (3 Free PCP Visits + Chiro + Dental) 40355

77. Gold SoloCare Gold PPO (3 Free PCP Visits + Dental) 40357

78. Gold SoloCare Gold PPO (3 Free PCP Visits + Chiro + Dental) 40358

79. Silver SoloCare Silver PPO (3 Free PCP Visits +$225 Specialty Drug Copay + Dental) 40368

80. Silver SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40369

81. Silver SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay + Dental) 40372

82. Silver SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40373

83. Silver SoloCare Silver PPO (3 Free PCP Visits + $225 Specialty Drug Copay + Dental) 40375

84. Silver SoloCare Silver PPO (3 Free PCP Visits + Chiro + $225 Specialty Drug Copay + Dental) 40376

85. Platinum SoloCare PPO Platinum Standardized

86. Gold SoloCare PPO Gold Standardized

87. Silver SoloCare PPO Silver Standardized

88. Gold SoloCare Gold No Referral HMO (3 Free PCP Visits) 110003

89. Gold SoloCare Gold No Referral HMO (3 Free PCP Visits) 110004

90. Silver SoloCare Silver No Referral HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110008

91. Silver SoloCare Silver No Referral HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110009

92. Silver SoloCare Silver HMO (3 Free PCP Visits + $225 Specialty Drug Copay) 110010

93. Expanded Bronze SoloCare Bronze No Referral HMO ($250 Specialty Drug Copay) 110011

94. Expanded Bronze SoloCare Bronze No Referral HMO ($250 Specialty Drug Copay + Dental) 110013

95. Expanded Bronze SoloCare Bronze No Referral HMO 110015

96. Expanded Bronze SoloCare Bronze No Referral HMO (+ Dental) 110017

97. Expanded Bronze SoloCare Bronze No Referral HMO HDHP 110019

98. Expanded Bronze SoloCare Bronze No Referral HMO HDHP (+ Dental) 110021

99. Catastrophic SoloCare Catastropic No Referral HMO 110023

100. Gold SoloCare HMO Gold Standardized

101. Silver SoloCare HMO Silver Standardized

102. Bronze SoloCare HMO Bronze Standardized

103. Expanded Bronze SoloCare HMO Expanded Bronze Standardized

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

Obamacare Providers, 103 Plans and 2023 Rates for Cook 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

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

(HMO) Anthem Catastrophic Pathway X HMO 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) Anthem Bronze Pathway X HMO 0% for HSA

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:

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

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:

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

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

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:

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

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:

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

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:

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

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:

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

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

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:

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

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:

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

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:

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

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) Anthem Bronze Pathway X HMO 7500/50% Standard

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:

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

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:

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

Annual Out of Pocket Expenses:

Individual Family $2,000 $4,000 Annual Deductible $8,700 $17,400 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

$7,450 $14,900 Annual Deductible

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

Individual Family

$5,600 $11,200 Annual Deductible

$9,100 $18,200 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

$3,000 $6,000 Annual Deductible

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

Individual Family

$5,500 $11,000 Annual Deductible

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

Individual Family

$8,000 $16,000 Annual Deductible

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

Individual Family

$4,950 $9,900 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

$1,600 $3,200 Annual Deductible

$8,800 $17,600 Maximum Out of Pocket Per Year

Individual Family

$5,000 $10,000 Annual Deductible

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

Individual Family

$2,600 $5,200 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

$5,800 $11,600 Annual Deductible

$8,900 $17,800 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

$8,000 $16,000 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 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

$5,800 $11,600 Annual Deductible

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

Individual Family

$6,000 $12,000 Annual Deductible

$7,000 $14,000 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

$6,150 $12,300 Annual Deductible

$6,150 $12,300 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

$2,000 $4,000 Annual Deductible

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

Individual Family

$8,000 $16,000 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 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

$5,800 $11,600 Annual Deductible

$8,900 $17,800 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

$6,150 $12,300 Annual Deductible

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

Individual Family

$5,800 $11,600 Annual Deductible

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