Cook County, Georgia Obamacare 2024 Rates

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

The health insurance rates listed below are for calendar year 2024.

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

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

Obamacare Providers, 108 Plans and 2024 Rates for Cook County, Georgia

Below, you’ll find a summary of the 108 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.


Obamacare Rates and Providers for Other Years

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Anthem Blue Cross and Blue Shield

Local: 1-855-738-6652 | Toll Free: 

Toc - Plan #1 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Value 4500($0 Virtual Visits + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$8,800 $17,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.46
$362.59
$408.27
$570.56
$867.01
$563.85
$606.98
$652.66
$814.95
$808.24
$851.37
$897.05
$1,059.34
$1,052.63
$1,095.76
$1,141.44
$1,303.73
$244.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$638.92
$725.18
$816.54
$1,141.12
$1,734.02
$883.31
$969.57
$1,060.93
$1,385.51
$1,127.70
$1,213.96
$1,305.32
$1,629.90
$1,372.09
$1,458.35
$1,549.71
$1,874.29
$244.39
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Value 5500($0 Virtual Visits + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$316.10
$358.77
$403.98
$564.55
$857.90
$557.92
$600.59
$645.80
$806.37
$799.74
$842.41
$887.62
$1,048.19
$1,041.56
$1,084.23
$1,129.44
$1,290.01
$241.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.20
$717.54
$807.96
$1,129.10
$1,715.80
$874.02
$959.36
$1,049.78
$1,370.92
$1,115.84
$1,201.18
$1,291.60
$1,612.74
$1,357.66
$1,443.00
$1,533.42
$1,854.56
$241.82
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Value 6500($0 Virtual Visits + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,450 $16,900 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
$312.21
$354.36
$399.00
$557.61
$847.34
$551.05
$593.20
$637.84
$796.45
$789.89
$832.04
$876.68
$1,035.29
$1,028.73
$1,070.88
$1,115.52
$1,274.13
$238.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$624.42
$708.72
$798.00
$1,115.22
$1,694.68
$863.26
$947.56
$1,036.84
$1,354.06
$1,102.10
$1,186.40
$1,275.68
$1,592.90
$1,340.94
$1,425.24
$1,514.52
$1,831.74
$238.84
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Value 3000($0 Virtual Visits + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$361.70
$410.53
$462.25
$646.00
$981.65
$638.40
$687.23
$738.95
$922.70
$915.10
$963.93
$1,015.65
$1,199.40
$1,191.80
$1,240.63
$1,292.35
$1,476.10
$276.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.40
$821.06
$924.50
$1,292.00
$1,963.30
$1,000.10
$1,097.76
$1,201.20
$1,568.70
$1,276.80
$1,374.46
$1,477.90
$1,845.40
$1,553.50
$1,651.16
$1,754.60
$2,122.10
$276.70
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Blue Value 1500/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.28
$436.16
$491.11
$686.32
$1,042.94
$678.25
$730.13
$785.08
$980.29
$972.22
$1,024.10
$1,079.05
$1,274.26
$1,266.19
$1,318.07
$1,373.02
$1,568.23
$293.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.56
$872.32
$982.22
$1,372.64
$2,085.88
$1,062.53
$1,166.29
$1,276.19
$1,666.61
$1,356.50
$1,460.26
$1,570.16
$1,960.58
$1,650.47
$1,754.23
$1,864.13
$2,254.55
$293.97
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Blue Value 5900/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.67
$356.02
$400.87
$560.21
$851.30
$553.63
$595.98
$640.83
$800.17
$793.59
$835.94
$880.79
$1,040.13
$1,033.55
$1,075.90
$1,120.75
$1,280.09
$239.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$627.34
$712.04
$801.74
$1,120.42
$1,702.60
$867.30
$952.00
$1,041.70
$1,360.38
$1,107.26
$1,191.96
$1,281.66
$1,600.34
$1,347.22
$1,431.92
$1,521.62
$1,840.30
$239.96
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway X HMO 9450

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$244.37
$277.36
$312.30
$436.44
$663.22
$431.31
$464.30
$499.24
$623.38
$618.25
$651.24
$686.18
$810.32
$805.19
$838.18
$873.12
$997.26
$186.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$488.74
$554.72
$624.60
$872.88
$1,326.44
$675.68
$741.66
$811.54
$1,059.82
$862.62
$928.60
$998.48
$1,246.76
$1,049.56
$1,115.54
$1,185.42
$1,433.70
$186.94
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway 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
$346.36
$393.12
$442.65
$618.60
$940.02
$611.33
$658.09
$707.62
$883.57
$876.30
$923.06
$972.59
$1,148.54
$1,141.27
$1,188.03
$1,237.56
$1,413.51
$264.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$692.72
$786.24
$885.30
$1,237.20
$1,880.04
$957.69
$1,051.21
$1,150.27
$1,502.17
$1,222.66
$1,316.18
$1,415.24
$1,767.14
$1,487.63
$1,581.15
$1,680.21
$2,032.11
$264.97
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.65
$374.15
$421.29
$588.75
$894.67
$581.83
$626.33
$673.47
$840.93
$834.01
$878.51
$925.65
$1,093.11
$1,086.19
$1,130.69
$1,177.83
$1,345.29
$252.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.30
$748.30
$842.58
$1,177.50
$1,789.34
$911.48
$1,000.48
$1,094.76
$1,429.68
$1,163.66
$1,252.66
$1,346.94
$1,681.86
$1,415.84
$1,504.84
$1,599.12
$1,934.04
$252.18
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$426.70
$484.30
$545.32
$762.09
$1,158.06
$753.13
$810.73
$871.75
$1,088.52
$1,079.56
$1,137.16
$1,198.18
$1,414.95
$1,405.99
$1,463.59
$1,524.61
$1,741.38
$326.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.40
$968.60
$1,090.64
$1,524.18
$2,316.12
$1,179.83
$1,295.03
$1,417.07
$1,850.61
$1,506.26
$1,621.46
$1,743.50
$2,177.04
$1,832.69
$1,947.89
$2,069.93
$2,503.47
$326.43
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.65
$460.41
$518.42
$724.49
$1,100.93
$715.97
$770.73
$828.74
$1,034.81
$1,026.29
$1,081.05
$1,139.06
$1,345.13
$1,336.61
$1,391.37
$1,449.38
$1,655.45
$310.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.30
$920.82
$1,036.84
$1,448.98
$2,201.86
$1,121.62
$1,231.14
$1,347.16
$1,759.30
$1,431.94
$1,541.46
$1,657.48
$2,069.62
$1,742.26
$1,851.78
$1,967.80
$2,379.94
$310.32
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318.98
$362.04
$407.66
$569.70
$865.71
$563.00
$606.06
$651.68
$813.72
$807.02
$850.08
$895.70
$1,057.74
$1,051.04
$1,094.10
$1,139.72
$1,301.76
$244.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$637.96
$724.08
$815.32
$1,139.40
$1,731.42
$881.98
$968.10
$1,059.34
$1,383.42
$1,126.00
$1,212.12
$1,303.36
$1,627.44
$1,370.02
$1,456.14
$1,547.38
$1,871.46
$244.02
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.75
$463.93
$522.38
$730.03
$1,109.35
$721.44
$776.62
$835.07
$1,042.72
$1,034.13
$1,089.31
$1,147.76
$1,355.41
$1,346.82
$1,402.00
$1,460.45
$1,668.10
$312.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817.50
$927.86
$1,044.76
$1,460.06
$2,218.70
$1,130.19
$1,240.55
$1,357.45
$1,772.75
$1,442.88
$1,553.24
$1,670.14
$2,085.44
$1,755.57
$1,865.93
$1,982.83
$2,398.13
$312.69
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway HMO 6450($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
$6,450 $12,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$400.29
$454.33
$511.57
$714.92
$1,086.39
$706.51
$760.55
$817.79
$1,021.14
$1,012.73
$1,066.77
$1,124.01
$1,327.36
$1,318.95
$1,372.99
$1,430.23
$1,633.58
$306.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.58
$908.66
$1,023.14
$1,429.84
$2,172.78
$1,106.80
$1,214.88
$1,329.36
$1,736.06
$1,413.02
$1,521.10
$1,635.58
$2,042.28
$1,719.24
$1,827.32
$1,941.80
$2,348.50
$306.22
Toc - Plan #15 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway HMO 1350($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
$1,350 $2,700 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
$462.46
$524.89
$591.02
$825.95
$1,255.12
$816.24
$878.67
$944.80
$1,179.73
$1,170.02
$1,232.45
$1,298.58
$1,533.51
$1,523.80
$1,586.23
$1,652.36
$1,887.29
$353.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$924.92
$1,049.78
$1,182.04
$1,651.90
$2,510.24
$1,278.70
$1,403.56
$1,535.82
$2,005.68
$1,632.48
$1,757.34
$1,889.60
$2,359.46
$1,986.26
$2,111.12
$2,243.38
$2,713.24
$353.78
Toc - Plan #16 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.77
$387.91
$436.78
$610.40
$927.56
$603.22
$649.36
$698.23
$871.85
$864.67
$910.81
$959.68
$1,133.30
$1,126.12
$1,172.26
$1,221.13
$1,394.75
$261.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.54
$775.82
$873.56
$1,220.80
$1,855.12
$944.99
$1,037.27
$1,135.01
$1,482.25
$1,206.44
$1,298.72
$1,396.46
$1,743.70
$1,467.89
$1,560.17
$1,657.91
$2,005.15
$261.45
Toc - Plan #17 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.30
$380.57
$428.51
$598.85
$910.00
$591.80
$637.07
$685.01
$855.35
$848.30
$893.57
$941.51
$1,111.85
$1,104.80
$1,150.07
$1,198.01
$1,368.35
$256.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.60
$761.14
$857.02
$1,197.70
$1,820.00
$927.10
$1,017.64
$1,113.52
$1,454.20
$1,183.60
$1,274.14
$1,370.02
$1,710.70
$1,440.10
$1,530.64
$1,626.52
$1,967.20
$256.50
Toc - Plan #18 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5900/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$408.85
$464.04
$522.51
$730.21
$1,109.62
$721.62
$776.81
$835.28
$1,042.98
$1,034.39
$1,089.58
$1,148.05
$1,355.75
$1,347.16
$1,402.35
$1,460.82
$1,668.52
$312.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$817.70
$928.08
$1,045.02
$1,460.42
$2,219.24
$1,130.47
$1,240.85
$1,357.79
$1,773.19
$1,443.24
$1,553.62
$1,670.56
$2,085.96
$1,756.01
$1,866.39
$1,983.33
$2,398.73
$312.77
Toc - Plan #19 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X HMO 1500/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$480.88
$545.80
$614.56
$858.85
$1,305.11
$848.75
$913.67
$982.43
$1,226.72
$1,216.62
$1,281.54
$1,350.30
$1,594.59
$1,584.49
$1,649.41
$1,718.17
$1,962.46
$367.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$961.76
$1,091.60
$1,229.12
$1,717.70
$2,610.22
$1,329.63
$1,459.47
$1,596.99
$2,085.57
$1,697.50
$1,827.34
$1,964.86
$2,453.44
$2,065.37
$2,195.21
$2,332.73
$2,821.31
$367.87

ADVERTISEMENT

CareSource

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

Toc - Plan #20 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
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280.75
$318.65
$358.80
$501.42
$761.95
$495.52
$533.42
$573.57
$716.19
$710.29
$748.19
$788.34
$930.96
$925.06
$962.96
$1,003.11
$1,145.73
$214.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$561.50
$637.30
$717.60
$1,002.84
$1,523.90
$776.27
$852.07
$932.37
$1,217.61
$991.04
$1,066.84
$1,147.14
$1,432.38
$1,205.81
$1,281.61
$1,361.91
$1,647.15
$214.77
Toc - Plan #21 CareSource
Gold

(HMO) CareSource Marketplace Core 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
$444.49
$504.49
$568.06
$793.86
$1,206.34
$784.52
$844.52
$908.09
$1,133.89
$1,124.55
$1,184.55
$1,248.12
$1,473.92
$1,464.58
$1,524.58
$1,588.15
$1,813.95
$340.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.98
$1,008.98
$1,136.12
$1,587.72
$2,412.68
$1,229.01
$1,349.01
$1,476.15
$1,927.75
$1,569.04
$1,689.04
$1,816.18
$2,267.78
$1,909.07
$2,029.07
$2,156.21
$2,607.81
$340.03
Toc - Plan #22 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
$369.62
$419.52
$472.37
$660.14
$1,003.15
$652.38
$702.28
$755.13
$942.90
$935.14
$985.04
$1,037.89
$1,225.66
$1,217.90
$1,267.80
$1,320.65
$1,508.42
$282.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$739.24
$839.04
$944.74
$1,320.28
$2,006.30
$1,022.00
$1,121.80
$1,227.50
$1,603.04
$1,304.76
$1,404.56
$1,510.26
$1,885.80
$1,587.52
$1,687.32
$1,793.02
$2,168.56
$282.76
Toc - Plan #23 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
$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$308.84
$350.52
$394.69
$551.57
$838.17
$545.10
$586.78
$630.95
$787.83
$781.36
$823.04
$867.21
$1,024.09
$1,017.62
$1,059.30
$1,103.47
$1,260.35
$236.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.68
$701.04
$789.38
$1,103.14
$1,676.34
$853.94
$937.30
$1,025.64
$1,339.40
$1,090.20
$1,173.56
$1,261.90
$1,575.66
$1,326.46
$1,409.82
$1,498.16
$1,811.92
$236.26
Toc - Plan #24 CareSource
Silver

(HMO) CareSource Marketplace Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.48
$417.09
$469.64
$656.32
$997.34
$648.60
$698.21
$750.76
$937.44
$929.72
$979.33
$1,031.88
$1,218.56
$1,210.84
$1,260.45
$1,313.00
$1,499.68
$281.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.96
$834.18
$939.28
$1,312.64
$1,994.68
$1,016.08
$1,115.30
$1,220.40
$1,593.76
$1,297.20
$1,396.42
$1,501.52
$1,874.88
$1,578.32
$1,677.54
$1,782.64
$2,156.00
$281.12
Toc - Plan #25 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$463.56
$526.13
$592.42
$827.91
$1,258.09
$818.18
$880.75
$947.04
$1,182.53
$1,172.80
$1,235.37
$1,301.66
$1,537.15
$1,527.42
$1,589.99
$1,656.28
$1,891.77
$354.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$927.12
$1,052.26
$1,184.84
$1,655.82
$2,516.18
$1,281.74
$1,406.88
$1,539.46
$2,010.44
$1,636.36
$1,761.50
$1,894.08
$2,365.06
$1,990.98
$2,116.12
$2,248.70
$2,719.68
$354.62
Toc - Plan #26 CareSource
Gold

(HMO) CareSource Marketplace Diabetes Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$476.05
$540.31
$608.39
$850.22
$1,291.99
$840.23
$904.49
$972.57
$1,214.40
$1,204.41
$1,268.67
$1,336.75
$1,578.58
$1,568.59
$1,632.85
$1,700.93
$1,942.76
$364.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$952.10
$1,080.62
$1,216.78
$1,700.44
$2,583.98
$1,316.28
$1,444.80
$1,580.96
$2,064.62
$1,680.46
$1,808.98
$1,945.14
$2,428.80
$2,044.64
$2,173.16
$2,309.32
$2,792.98
$364.18
Toc - Plan #27 CareSource
Silver

(HMO) CareSource Marketplace Diabetes Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.84
$433.39
$487.99
$681.97
$1,036.32
$673.95
$725.50
$780.10
$974.08
$966.06
$1,017.61
$1,072.21
$1,266.19
$1,258.17
$1,309.72
$1,364.32
$1,558.30
$292.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.68
$866.78
$975.98
$1,363.94
$2,072.64
$1,055.79
$1,158.89
$1,268.09
$1,656.05
$1,347.90
$1,451.00
$1,560.20
$1,948.16
$1,640.01
$1,743.11
$1,852.31
$2,240.27
$292.11
Toc - Plan #28 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$287.21
$325.98
$367.05
$512.95
$779.48
$506.92
$545.69
$586.76
$732.66
$726.63
$765.40
$806.47
$952.37
$946.34
$985.11
$1,026.18
$1,172.08
$219.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$574.42
$651.96
$734.10
$1,025.90
$1,558.96
$794.13
$871.67
$953.81
$1,245.61
$1,013.84
$1,091.38
$1,173.52
$1,465.32
$1,233.55
$1,311.09
$1,393.23
$1,685.03
$219.71
Toc - Plan #29 CareSource
Gold

(HMO) CareSource Marketplace Core Gold Dental, Vision, & Fitness

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
$452.49
$513.57
$578.28
$808.14
$1,228.04
$798.64
$859.72
$924.43
$1,154.29
$1,144.79
$1,205.87
$1,270.58
$1,500.44
$1,490.94
$1,552.02
$1,616.73
$1,846.59
$346.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$904.98
$1,027.14
$1,156.56
$1,616.28
$2,456.08
$1,251.13
$1,373.29
$1,502.71
$1,962.43
$1,597.28
$1,719.44
$1,848.86
$2,308.58
$1,943.43
$2,065.59
$2,195.01
$2,654.73
$346.15
Toc - Plan #30 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $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
$376.13
$426.90
$480.69
$671.76
$1,020.80
$663.86
$714.63
$768.42
$959.49
$951.59
$1,002.36
$1,056.15
$1,247.22
$1,239.32
$1,290.09
$1,343.88
$1,534.95
$287.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.26
$853.80
$961.38
$1,343.52
$2,041.60
$1,039.99
$1,141.53
$1,249.11
$1,631.25
$1,327.72
$1,429.26
$1,536.84
$1,918.98
$1,615.45
$1,716.99
$1,824.57
$2,206.71
$287.73
Toc - Plan #31 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.99
$424.47
$477.95
$667.94
$1,014.99
$660.09
$710.57
$764.05
$954.04
$946.19
$996.67
$1,050.15
$1,240.14
$1,232.29
$1,282.77
$1,336.25
$1,526.24
$286.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.98
$848.94
$955.90
$1,335.88
$2,029.98
$1,034.08
$1,135.04
$1,242.00
$1,621.98
$1,320.18
$1,421.14
$1,528.10
$1,908.08
$1,606.28
$1,707.24
$1,814.20
$2,194.18
$286.10
Toc - Plan #32 CareSource
Gold

(HMO) CareSource Marketplace Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$471.55
$535.21
$602.64
$842.19
$1,279.79
$832.29
$895.95
$963.38
$1,202.93
$1,193.03
$1,256.69
$1,324.12
$1,563.67
$1,553.77
$1,617.43
$1,684.86
$1,924.41
$360.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$943.10
$1,070.42
$1,205.28
$1,684.38
$2,559.58
$1,303.84
$1,431.16
$1,566.02
$2,045.12
$1,664.58
$1,791.90
$1,926.76
$2,405.86
$2,025.32
$2,152.64
$2,287.50
$2,766.60
$360.74
Toc - Plan #33 CareSource
Gold

(HMO) CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$484.04
$549.38
$618.60
$864.49
$1,313.67
$854.33
$919.67
$988.89
$1,234.78
$1,224.62
$1,289.96
$1,359.18
$1,605.07
$1,594.91
$1,660.25
$1,729.47
$1,975.36
$370.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$968.08
$1,098.76
$1,237.20
$1,728.98
$2,627.34
$1,338.37
$1,469.05
$1,607.49
$2,099.27
$1,708.66
$1,839.34
$1,977.78
$2,469.56
$2,078.95
$2,209.63
$2,348.07
$2,839.85
$370.29
Toc - Plan #34 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.35
$440.77
$496.31
$693.58
$1,053.97
$685.43
$737.85
$793.39
$990.66
$982.51
$1,034.93
$1,090.47
$1,287.74
$1,279.59
$1,332.01
$1,387.55
$1,584.82
$297.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.70
$881.54
$992.62
$1,387.16
$2,107.94
$1,073.78
$1,178.62
$1,289.70
$1,684.24
$1,370.86
$1,475.70
$1,586.78
$1,981.32
$1,667.94
$1,772.78
$1,883.86
$2,278.40
$297.08

ADVERTISEMENT

Ambetter from Peach State Health Plan

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

Toc - Plan #35 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
$9,000 $18,000 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
$258.93
$293.87
$330.90
$462.43
$702.70
$457.00
$491.94
$528.97
$660.50
$655.07
$690.01
$727.04
$858.57
$853.14
$888.08
$925.11
$1,056.64
$198.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$517.86
$587.74
$661.80
$924.86
$1,405.40
$715.93
$785.81
$859.87
$1,122.93
$914.00
$983.88
$1,057.94
$1,321.00
$1,112.07
$1,181.95
$1,256.01
$1,519.07
$198.07
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
$307.37
$348.85
$392.80
$548.94
$834.17
$542.50
$583.98
$627.93
$784.07
$777.63
$819.11
$863.06
$1,019.20
$1,012.76
$1,054.24
$1,098.19
$1,254.33
$235.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614.74
$697.70
$785.60
$1,097.88
$1,668.34
$849.87
$932.83
$1,020.73
$1,333.01
$1,085.00
$1,167.96
$1,255.86
$1,568.14
$1,320.13
$1,403.09
$1,490.99
$1,803.27
$235.13
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
$323.90
$367.62
$413.93
$578.47
$879.04
$571.68
$615.40
$661.71
$826.25
$819.46
$863.18
$909.49
$1,074.03
$1,067.24
$1,110.96
$1,157.27
$1,321.81
$247.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.80
$735.24
$827.86
$1,156.94
$1,758.08
$895.58
$983.02
$1,075.64
$1,404.72
$1,143.36
$1,230.80
$1,323.42
$1,652.50
$1,391.14
$1,478.58
$1,571.20
$1,900.28
$247.78
Toc - Plan #38 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.94
$324.53
$365.42
$510.67
$776.01
$504.67
$543.26
$584.15
$729.40
$723.40
$761.99
$802.88
$948.13
$942.13
$980.72
$1,021.61
$1,166.86
$218.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$571.88
$649.06
$730.84
$1,021.34
$1,552.02
$790.61
$867.79
$949.57
$1,240.07
$1,009.34
$1,086.52
$1,168.30
$1,458.80
$1,228.07
$1,305.25
$1,387.03
$1,677.53
$218.73
Toc - Plan #39 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$280.15
$317.96
$358.02
$500.33
$760.30
$494.46
$532.27
$572.33
$714.64
$708.77
$746.58
$786.64
$928.95
$923.08
$960.89
$1,000.95
$1,143.26
$214.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$560.30
$635.92
$716.04
$1,000.66
$1,520.60
$774.61
$850.23
$930.35
$1,214.97
$988.92
$1,064.54
$1,144.66
$1,429.28
$1,203.23
$1,278.85
$1,358.97
$1,643.59
$214.31
Toc - Plan #40 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
$298.17
$338.41
$381.04
$532.51
$809.20
$526.26
$566.50
$609.13
$760.60
$754.35
$794.59
$837.22
$988.69
$982.44
$1,022.68
$1,065.31
$1,216.78
$228.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.34
$676.82
$762.08
$1,065.02
$1,618.40
$824.43
$904.91
$990.17
$1,293.11
$1,052.52
$1,133.00
$1,218.26
$1,521.20
$1,280.61
$1,361.09
$1,446.35
$1,749.29
$228.09
Toc - Plan #41 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
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$302.62
$343.46
$386.73
$540.46
$821.28
$534.12
$574.96
$618.23
$771.96
$765.62
$806.46
$849.73
$1,003.46
$997.12
$1,037.96
$1,081.23
$1,234.96
$231.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$605.24
$686.92
$773.46
$1,080.92
$1,642.56
$836.74
$918.42
$1,004.96
$1,312.42
$1,068.24
$1,149.92
$1,236.46
$1,543.92
$1,299.74
$1,381.42
$1,467.96
$1,775.42
$231.50
Toc - Plan #42 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
$310.13
$351.98
$396.33
$553.87
$841.66
$547.37
$589.22
$633.57
$791.11
$784.61
$826.46
$870.81
$1,028.35
$1,021.85
$1,063.70
$1,108.05
$1,265.59
$237.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.26
$703.96
$792.66
$1,107.74
$1,683.32
$857.50
$941.20
$1,029.90
$1,344.98
$1,094.74
$1,178.44
$1,267.14
$1,582.22
$1,331.98
$1,415.68
$1,504.38
$1,819.46
$237.24
Toc - Plan #43 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
$305.74
$347.00
$390.72
$546.03
$829.74
$539.62
$580.88
$624.60
$779.91
$773.50
$814.76
$858.48
$1,013.79
$1,007.38
$1,048.64
$1,092.36
$1,247.67
$233.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$611.48
$694.00
$781.44
$1,092.06
$1,659.48
$845.36
$927.88
$1,015.32
$1,325.94
$1,079.24
$1,161.76
$1,249.20
$1,559.82
$1,313.12
$1,395.64
$1,483.08
$1,793.70
$233.88
Toc - Plan #44 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
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.88
$401.64
$452.25
$632.01
$960.40
$624.59
$672.35
$722.96
$902.72
$895.30
$943.06
$993.67
$1,173.43
$1,166.01
$1,213.77
$1,264.38
$1,444.14
$270.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.76
$803.28
$904.50
$1,264.02
$1,920.80
$978.47
$1,073.99
$1,175.21
$1,534.73
$1,249.18
$1,344.70
$1,445.92
$1,805.44
$1,519.89
$1,615.41
$1,716.63
$2,076.15
$270.71
Toc - Plan #45 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) 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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.43
$312.60
$351.99
$491.90
$747.49
$486.13
$523.30
$562.69
$702.60
$696.83
$734.00
$773.39
$913.30
$907.53
$944.70
$984.09
$1,124.00
$210.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$550.86
$625.20
$703.98
$983.80
$1,494.98
$761.56
$835.90
$914.68
$1,194.50
$972.26
$1,046.60
$1,125.38
$1,405.20
$1,182.96
$1,257.30
$1,336.08
$1,615.90
$210.70
Toc - Plan #46 Ambetter from Peach State Health Plan
Silver

(HMO) Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$296.83
$336.89
$379.34
$530.12
$805.57
$523.90
$563.96
$606.41
$757.19
$750.97
$791.03
$833.48
$984.26
$978.04
$1,018.10
$1,060.55
$1,211.33
$227.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$593.66
$673.78
$758.68
$1,060.24
$1,611.14
$820.73
$900.85
$985.75
$1,287.31
$1,047.80
$1,127.92
$1,212.82
$1,514.38
$1,274.87
$1,354.99
$1,439.89
$1,741.45
$227.07
Toc - Plan #47 Ambetter from Peach State Health Plan
Gold

(HMO) Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$311.40
$353.43
$397.96
$556.15
$845.13
$549.62
$591.65
$636.18
$794.37
$787.84
$829.87
$874.40
$1,032.59
$1,026.06
$1,068.09
$1,112.62
$1,270.81
$238.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$622.80
$706.86
$795.92
$1,112.30
$1,690.26
$861.02
$945.08
$1,034.14
$1,350.52
$1,099.24
$1,183.30
$1,272.36
$1,588.74
$1,337.46
$1,421.52
$1,510.58
$1,826.96
$238.22
Toc - Plan #48 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
$318.37
$361.33
$406.86
$568.58
$864.02
$561.91
$604.87
$650.40
$812.12
$805.45
$848.41
$893.94
$1,055.66
$1,048.99
$1,091.95
$1,137.48
$1,299.20
$243.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$636.74
$722.66
$813.72
$1,137.16
$1,728.04
$880.28
$966.20
$1,057.26
$1,380.70
$1,123.82
$1,209.74
$1,300.80
$1,624.24
$1,367.36
$1,453.28
$1,544.34
$1,867.78
$243.54
Toc - Plan #49 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
$9,000 $18,000 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
$268.19
$304.39
$342.74
$478.97
$727.84
$473.35
$509.55
$547.90
$684.13
$678.51
$714.71
$753.06
$889.29
$883.67
$919.87
$958.22
$1,094.45
$205.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$536.38
$608.78
$685.48
$957.94
$1,455.68
$741.54
$813.94
$890.64
$1,163.10
$946.70
$1,019.10
$1,095.80
$1,368.26
$1,151.86
$1,224.26
$1,300.96
$1,573.42
$205.16
Toc - Plan #50 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
$335.49
$380.77
$428.74
$599.17
$910.49
$592.13
$637.41
$685.38
$855.81
$848.77
$894.05
$942.02
$1,112.45
$1,105.41
$1,150.69
$1,198.66
$1,369.09
$256.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.98
$761.54
$857.48
$1,198.34
$1,820.98
$927.62
$1,018.18
$1,114.12
$1,454.98
$1,184.26
$1,274.82
$1,370.76
$1,711.62
$1,440.90
$1,531.46
$1,627.40
$1,968.26
$256.64
Toc - Plan #51 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$296.17
$336.14
$378.49
$528.94
$803.77
$522.73
$562.70
$605.05
$755.50
$749.29
$789.26
$831.61
$982.06
$975.85
$1,015.82
$1,058.17
$1,208.62
$226.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$592.34
$672.28
$756.98
$1,057.88
$1,607.54
$818.90
$898.84
$983.54
$1,284.44
$1,045.46
$1,125.40
$1,210.10
$1,511.00
$1,272.02
$1,351.96
$1,436.66
$1,737.56
$226.56
Toc - Plan #52 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$290.17
$329.34
$370.83
$518.23
$787.50
$512.14
$551.31
$592.80
$740.20
$734.11
$773.28
$814.77
$962.17
$956.08
$995.25
$1,036.74
$1,184.14
$221.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$580.34
$658.68
$741.66
$1,036.46
$1,575.00
$802.31
$880.65
$963.63
$1,258.43
$1,024.28
$1,102.62
$1,185.60
$1,480.40
$1,246.25
$1,324.59
$1,407.57
$1,702.37
$221.97
Toc - Plan #53 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
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.45
$355.75
$400.57
$559.80
$850.67
$553.23
$595.53
$640.35
$799.58
$793.01
$835.31
$880.13
$1,039.36
$1,032.79
$1,075.09
$1,119.91
$1,279.14
$239.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.90
$711.50
$801.14
$1,119.60
$1,701.34
$866.68
$951.28
$1,040.92
$1,359.38
$1,106.46
$1,191.06
$1,280.70
$1,599.16
$1,346.24
$1,430.84
$1,520.48
$1,838.94
$239.78
Toc - Plan #54 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
$321.22
$364.58
$410.51
$573.69
$871.78
$566.95
$610.31
$656.24
$819.42
$812.68
$856.04
$901.97
$1,065.15
$1,058.41
$1,101.77
$1,147.70
$1,310.88
$245.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.44
$729.16
$821.02
$1,147.38
$1,743.56
$888.17
$974.89
$1,066.75
$1,393.11
$1,133.90
$1,220.62
$1,312.48
$1,638.84
$1,379.63
$1,466.35
$1,558.21
$1,884.57
$245.73
Toc - Plan #55 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
$308.84
$350.52
$394.68
$551.56
$838.15
$545.09
$586.77
$630.93
$787.81
$781.34
$823.02
$867.18
$1,024.06
$1,017.59
$1,059.27
$1,103.43
$1,260.31
$236.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$617.68
$701.04
$789.36
$1,103.12
$1,676.30
$853.93
$937.29
$1,025.61
$1,339.37
$1,090.18
$1,173.54
$1,261.86
$1,575.62
$1,326.43
$1,409.79
$1,498.11
$1,811.87
$236.25
Toc - Plan #56 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
$316.67
$359.41
$404.70
$565.56
$859.43
$558.92
$601.66
$646.95
$807.81
$801.17
$843.91
$889.20
$1,050.06
$1,043.42
$1,086.16
$1,131.45
$1,292.31
$242.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.34
$718.82
$809.40
$1,131.12
$1,718.86
$875.59
$961.07
$1,051.65
$1,373.37
$1,117.84
$1,203.32
$1,293.90
$1,615.62
$1,360.09
$1,445.57
$1,536.15
$1,857.87
$242.25
Toc - Plan #57 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
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.54
$416.01
$468.43
$654.63
$994.77
$646.94
$696.41
$748.83
$935.03
$927.34
$976.81
$1,029.23
$1,215.43
$1,207.74
$1,257.21
$1,309.63
$1,495.83
$280.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.08
$832.02
$936.86
$1,309.26
$1,989.54
$1,013.48
$1,112.42
$1,217.26
$1,589.66
$1,293.88
$1,392.82
$1,497.66
$1,870.06
$1,574.28
$1,673.22
$1,778.06
$2,150.46
$280.40
Toc - Plan #58 Ambetter from Peach State Health Plan
Expanded Bronze

(HMO) Standard Expanded Bronze + Vision + Adult Dental

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.29
$323.79
$364.58
$509.50
$774.24
$503.53
$542.03
$582.82
$727.74
$721.77
$760.27
$801.06
$945.98
$940.01
$978.51
$1,019.30
$1,164.22
$218.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$570.58
$647.58
$729.16
$1,019.00
$1,548.48
$788.82
$865.82
$947.40
$1,237.24
$1,007.06
$1,084.06
$1,165.64
$1,455.48
$1,225.30
$1,302.30
$1,383.88
$1,673.72
$218.24
Toc - Plan #59 Ambetter from Peach State Health Plan
Silver

(HMO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307.45
$348.95
$392.91
$549.09
$834.40
$542.64
$584.14
$628.10
$784.28
$777.83
$819.33
$863.29
$1,019.47
$1,013.02
$1,054.52
$1,098.48
$1,254.66
$235.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614.90
$697.90
$785.82
$1,098.18
$1,668.80
$850.09
$933.09
$1,021.01
$1,333.37
$1,085.28
$1,168.28
$1,256.20
$1,568.56
$1,320.47
$1,403.47
$1,491.39
$1,803.75
$235.19
Toc - Plan #60 Ambetter from Peach State Health Plan
Gold

(HMO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$322.55
$366.08
$412.20
$576.05
$875.37
$569.29
$612.82
$658.94
$822.79
$816.03
$859.56
$905.68
$1,069.53
$1,062.77
$1,106.30
$1,152.42
$1,316.27
$246.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645.10
$732.16
$824.40
$1,152.10
$1,750.74
$891.84
$978.90
$1,071.14
$1,398.84
$1,138.58
$1,225.64
$1,317.88
$1,645.58
$1,385.32
$1,472.38
$1,564.62
$1,892.32
$246.74

ADVERTISEMENT

Alliant Health Plans

Local: 1-866-403-2785 | Toll Free: 1-866-403-2785 | TTY: 1-866-403-2785

Toc - Plan #61 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO 2300 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$349.24
$396.38
$446.32
$623.73
$947.82
$616.40
$663.54
$713.48
$890.89
$883.56
$930.70
$980.64
$1,158.05
$1,150.72
$1,197.86
$1,247.80
$1,425.21
$267.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.48
$792.76
$892.64
$1,247.46
$1,895.64
$965.64
$1,059.92
$1,159.80
$1,514.62
$1,232.80
$1,327.08
$1,426.96
$1,781.78
$1,499.96
$1,594.24
$1,694.12
$2,048.94
$267.16
Toc - Plan #62 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO 7000 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346.83
$393.64
$443.24
$619.42
$941.27
$612.15
$658.96
$708.56
$884.74
$877.47
$924.28
$973.88
$1,150.06
$1,142.79
$1,189.60
$1,239.20
$1,415.38
$265.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.66
$787.28
$886.48
$1,238.84
$1,882.54
$958.98
$1,052.60
$1,151.80
$1,504.16
$1,224.30
$1,317.92
$1,417.12
$1,769.48
$1,489.62
$1,583.24
$1,682.44
$2,034.80
$265.32
Toc - Plan #63 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO 1500 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$374.28
$424.80
$478.32
$668.45
$1,015.77
$660.60
$711.12
$764.64
$954.77
$946.92
$997.44
$1,050.96
$1,241.09
$1,233.24
$1,283.76
$1,337.28
$1,527.41
$286.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748.56
$849.60
$956.64
$1,336.90
$2,031.54
$1,034.88
$1,135.92
$1,242.96
$1,623.22
$1,321.20
$1,422.24
$1,529.28
$1,909.54
$1,607.52
$1,708.56
$1,815.60
$2,195.86
$286.32
Toc - Plan #64 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO 6000/60 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$356.46
$404.57
$455.54
$636.62
$967.41
$629.14
$677.25
$728.22
$909.30
$901.82
$949.93
$1,000.90
$1,181.98
$1,174.50
$1,222.61
$1,273.58
$1,454.66
$272.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.92
$809.14
$911.08
$1,273.24
$1,934.82
$985.60
$1,081.82
$1,183.76
$1,545.92
$1,258.28
$1,354.50
$1,456.44
$1,818.60
$1,530.96
$1,627.18
$1,729.12
$2,091.28
$272.68
Toc - Plan #65 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO Chiro 2300 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.09
$400.75
$451.24
$630.61
$958.27
$623.20
$670.86
$721.35
$900.72
$893.31
$940.97
$991.46
$1,170.83
$1,163.42
$1,211.08
$1,261.57
$1,440.94
$270.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.18
$801.50
$902.48
$1,261.22
$1,916.54
$976.29
$1,071.61
$1,172.59
$1,531.33
$1,246.40
$1,341.72
$1,442.70
$1,801.44
$1,516.51
$1,611.83
$1,712.81
$2,071.55
$270.11
Toc - Plan #66 Alliant Health Plans
Gold

(PPO) SoloCare Gold PPO Chiro 1500 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$378.14
$429.18
$483.25
$675.35
$1,026.25
$667.41
$718.45
$772.52
$964.62
$956.68
$1,007.72
$1,061.79
$1,253.89
$1,245.95
$1,296.99
$1,351.06
$1,543.16
$289.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.28
$858.36
$966.50
$1,350.70
$2,052.50
$1,045.55
$1,147.63
$1,255.77
$1,639.97
$1,334.82
$1,436.90
$1,545.04
$1,929.24
$1,624.09
$1,726.17
$1,834.31
$2,218.51
$289.27
Toc - Plan #67 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO Chiro 7000 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$349.24
$396.38
$446.32
$623.73
$947.82
$616.40
$663.54
$713.48
$890.89
$883.56
$930.70
$980.64
$1,158.05
$1,150.72
$1,197.86
$1,247.80
$1,425.21
$267.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.48
$792.76
$892.64
$1,247.46
$1,895.64
$965.64
$1,059.92
$1,159.80
$1,514.62
$1,232.80
$1,327.08
$1,426.96
$1,781.78
$1,499.96
$1,594.24
$1,694.12
$2,048.94
$267.16
Toc - Plan #68 Alliant Health Plans
Silver

(PPO) SoloCare Silver PPO Chiro 6000/60 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$359.35
$407.85
$459.24
$641.78
$975.25
$634.24
$682.74
$734.13
$916.67
$909.13
$957.63
$1,009.02
$1,191.56
$1,184.02
$1,232.52
$1,283.91
$1,466.45
$274.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.70
$815.70
$918.48
$1,283.56
$1,950.50
$993.59
$1,090.59
$1,193.37
$1,558.45
$1,268.48
$1,365.48
$1,468.26
$1,833.34
$1,543.37
$1,640.37
$1,743.15
$2,108.23
$274.89
Toc - Plan #69 Alliant Health Plans
Platinum

(PPO) SoloCare PPO Standard Platinum

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 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
$481.70
$546.72
$615.60
$860.30
$1,307.32
$850.20
$915.22
$984.10
$1,228.80
$1,218.70
$1,283.72
$1,352.60
$1,597.30
$1,587.20
$1,652.22
$1,721.10
$1,965.80
$368.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$963.40
$1,093.44
$1,231.20
$1,720.60
$2,614.64
$1,331.90
$1,461.94
$1,599.70
$2,089.10
$1,700.40
$1,830.44
$1,968.20
$2,457.60
$2,068.90
$2,198.94
$2,336.70
$2,826.10
$368.50
Toc - Plan #70 Alliant Health Plans
Gold

(PPO) SoloCare PPO Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$355.98
$404.03
$454.93
$635.77
$966.11
$628.30
$676.35
$727.25
$908.09
$900.62
$948.67
$999.57
$1,180.41
$1,172.94
$1,220.99
$1,271.89
$1,452.73
$272.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.96
$808.06
$909.86
$1,271.54
$1,932.22
$984.28
$1,080.38
$1,182.18
$1,543.86
$1,256.60
$1,352.70
$1,454.50
$1,816.18
$1,528.92
$1,625.02
$1,726.82
$2,088.50
$272.32
Toc - Plan #71 Alliant Health Plans
Silver

(PPO) SoloCare PPO Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.01
$373.41
$420.46
$587.59
$892.90
$580.69
$625.09
$672.14
$839.27
$832.37
$876.77
$923.82
$1,090.95
$1,084.05
$1,128.45
$1,175.50
$1,342.63
$251.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$658.02
$746.82
$840.92
$1,175.18
$1,785.80
$909.70
$998.50
$1,092.60
$1,426.86
$1,161.38
$1,250.18
$1,344.28
$1,678.54
$1,413.06
$1,501.86
$1,595.96
$1,930.22
$251.68
Toc - Plan #72 Alliant Health Plans
Platinum

(PPO) SoloCare Platinum PPO - $0 PCP, $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$1,500 $3,000 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
$463.40
$525.94
$592.21
$827.61
$1,257.63
$817.89
$880.43
$946.70
$1,182.10
$1,172.38
$1,234.92
$1,301.19
$1,536.59
$1,526.87
$1,589.41
$1,655.68
$1,891.08
$354.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.80
$1,051.88
$1,184.42
$1,655.22
$2,515.26
$1,281.29
$1,406.37
$1,538.91
$2,009.71
$1,635.78
$1,760.86
$1,893.40
$2,364.20
$1,990.27
$2,115.35
$2,247.89
$2,718.69
$354.49
Toc - Plan #73 Alliant Health Plans
Expanded Bronze

(PPO) SoloCare Exp Bronze PPO 9450 - $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$276.99
$314.37
$353.97
$494.68
$751.71
$488.88
$526.26
$565.86
$706.57
$700.77
$738.15
$777.75
$918.46
$912.66
$950.04
$989.64
$1,130.35
$211.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$553.98
$628.74
$707.94
$989.36
$1,503.42
$765.87
$840.63
$919.83
$1,201.25
$977.76
$1,052.52
$1,131.72
$1,413.14
$1,189.65
$1,264.41
$1,343.61
$1,625.03
$211.89
Toc - Plan #74 Alliant Health Plans
Expanded Bronze

(PPO) SoloCare Bronze PPO HDHP 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$276.02
$313.27
$352.74
$492.96
$749.10
$487.17
$524.42
$563.89
$704.11
$698.32
$735.57
$775.04
$915.26
$909.47
$946.72
$986.19
$1,126.41
$211.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$552.04
$626.54
$705.48
$985.92
$1,498.20
$763.19
$837.69
$916.63
$1,197.07
$974.34
$1,048.84
$1,127.78
$1,408.22
$1,185.49
$1,259.99
$1,338.93
$1,619.37
$211.15
Toc - Plan #75 Alliant Health Plans
Catastrophic

(PPO) SoloCare Catastrophic PPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$207.14
$235.09
$264.71
$369.94
$562.15
$365.59
$393.54
$423.16
$528.39
$524.04
$551.99
$581.61
$686.84
$682.49
$710.44
$740.06
$845.29
$158.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$414.28
$470.18
$529.42
$739.88
$1,124.30
$572.73
$628.63
$687.87
$898.33
$731.18
$787.08
$846.32
$1,056.78
$889.63
$945.53
$1,004.77
$1,215.23
$158.45
Toc - Plan #76 Alliant Health Plans
Expanded Bronze

(PPO) SoloCare Exp Bronze PPO Chiro 9450 - $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$279.87
$317.65
$357.67
$499.84
$759.55
$493.97
$531.75
$571.77
$713.94
$708.07
$745.85
$785.87
$928.04
$922.17
$959.95
$999.97
$1,142.14
$214.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$559.74
$635.30
$715.34
$999.68
$1,519.10
$773.84
$849.40
$929.44
$1,213.78
$987.94
$1,063.50
$1,143.54
$1,427.88
$1,202.04
$1,277.60
$1,357.64
$1,641.98
$214.10
Toc - Plan #77 Alliant Health Plans
Expanded Bronze

(PPO) SoloCare Bronze PPO Chiro HDHP 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$278.42
$316.00
$355.81
$497.25
$755.62
$491.41
$528.99
$568.80
$710.24
$704.40
$741.98
$781.79
$923.23
$917.39
$954.97
$994.78
$1,136.22
$212.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$556.84
$632.00
$711.62
$994.50
$1,511.24
$769.83
$844.99
$924.61
$1,207.49
$982.82
$1,057.98
$1,137.60
$1,420.48
$1,195.81
$1,270.97
$1,350.59
$1,633.47
$212.99
Toc - Plan #78 Alliant Health Plans
Catastrophic

(PPO) SoloCare Catastrophic PPO Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$209.07
$237.28
$267.17
$373.38
$567.38
$369.00
$397.21
$427.10
$533.31
$528.93
$557.14
$587.03
$693.24
$688.86
$717.07
$746.96
$853.17
$159.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$418.14
$474.56
$534.34
$746.76
$1,134.76
$578.07
$634.49
$694.27
$906.69
$738.00
$794.42
$854.20
$1,066.62
$897.93
$954.35
$1,014.13
$1,226.55
$159.93
Toc - Plan #79 Alliant Health Plans
Expanded Bronze

(PPO) SoloCare PPO Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$238.44
$270.62
$304.72
$425.84
$647.11
$420.84
$453.02
$487.12
$608.24
$603.24
$635.42
$669.52
$790.64
$785.64
$817.82
$851.92
$973.04
$182.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$476.88
$541.24
$609.44
$851.68
$1,294.22
$659.28
$723.64
$791.84
$1,034.08
$841.68
$906.04
$974.24
$1,216.48
$1,024.08
$1,088.44
$1,156.64
$1,398.88
$182.40
Toc - Plan #80 Alliant Health Plans
Platinum

(PPO) SoloCare PPO Standard Platinum Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 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
$486.52
$552.19
$621.76
$868.90
$1,320.38
$858.70
$924.37
$993.94
$1,241.08
$1,230.88
$1,296.55
$1,366.12
$1,613.26
$1,603.06
$1,668.73
$1,738.30
$1,985.44
$372.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$973.04
$1,104.38
$1,243.52
$1,737.80
$2,640.76
$1,345.22
$1,476.56
$1,615.70
$2,109.98
$1,717.40
$1,848.74
$1,987.88
$2,482.16
$2,089.58
$2,220.92
$2,360.06
$2,854.34
$372.18
Toc - Plan #81 Alliant Health Plans
Gold

(PPO) SoloCare PPO Standard Gold Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.84
$408.40
$459.86
$642.65
$976.57
$635.11
$683.67
$735.13
$917.92
$910.38
$958.94
$1,010.40
$1,193.19
$1,185.65
$1,234.21
$1,285.67
$1,468.46
$275.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$719.68
$816.80
$919.72
$1,285.30
$1,953.14
$994.95
$1,092.07
$1,194.99
$1,560.57
$1,270.22
$1,367.34
$1,470.26
$1,835.84
$1,545.49
$1,642.61
$1,745.53
$2,111.11
$275.27
Toc - Plan #82 Alliant Health Plans
Silver

(PPO) SoloCare PPO Standard Silver Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$331.41
$376.14
$423.53
$591.88
$899.42
$584.93
$629.66
$677.05
$845.40
$838.45
$883.18
$930.57
$1,098.92
$1,091.97
$1,136.70
$1,184.09
$1,352.44
$253.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$662.82
$752.28
$847.06
$1,183.76
$1,798.84
$916.34
$1,005.80
$1,100.58
$1,437.28
$1,169.86
$1,259.32
$1,354.10
$1,690.80
$1,423.38
$1,512.84
$1,607.62
$1,944.32
$253.52
Toc - Plan #83 Alliant Health Plans
Expanded Bronze

(PPO) SoloCare PPO Standard Expanded Bronze Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$240.86
$273.36
$307.80
$430.15
$653.66
$425.11
$457.61
$492.05
$614.40
$609.36
$641.86
$676.30
$798.65
$793.61
$826.11
$860.55
$982.90
$184.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$481.72
$546.72
$615.60
$860.30
$1,307.32
$665.97
$730.97
$799.85
$1,044.55
$850.22
$915.22
$984.10
$1,228.80
$1,034.47
$1,099.47
$1,168.35
$1,413.05
$184.25
Toc - Plan #84 Alliant Health Plans
Platinum

(PPO) SoloCare Platinum PPO Chiro - $0 PCP, $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$1,500 $3,000 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
$468.21
$531.41
$598.36
$836.21
$1,270.70
$826.38
$889.58
$956.53
$1,194.38
$1,184.55
$1,247.75
$1,314.70
$1,552.55
$1,542.72
$1,605.92
$1,672.87
$1,910.72
$358.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$936.42
$1,062.82
$1,196.72
$1,672.42
$2,541.40
$1,294.59
$1,420.99
$1,554.89
$2,030.59
$1,652.76
$1,779.16
$1,913.06
$2,388.76
$2,010.93
$2,137.33
$2,271.23
$2,746.93
$358.17
Toc - Plan #85 Alliant Health Plans
Gold

(HMO) SoloCare Gold No Referral HMO 2300 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.79
$394.73
$444.47
$621.14
$943.88
$613.84
$660.78
$710.52
$887.19
$879.89
$926.83
$976.57
$1,153.24
$1,145.94
$1,192.88
$1,242.62
$1,419.29
$266.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.58
$789.46
$888.94
$1,242.28
$1,887.76
$961.63
$1,055.51
$1,154.99
$1,508.33
$1,227.68
$1,321.56
$1,421.04
$1,774.38
$1,493.73
$1,587.61
$1,687.09
$2,040.43
$266.05
Toc - Plan #86 Alliant Health Plans
Gold

(HMO) SoloCare Gold No Referral HMO 1500 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$373.80
$424.26
$477.71
$667.60
$1,014.48
$659.75
$710.21
$763.66
$953.55
$945.70
$996.16
$1,049.61
$1,239.50
$1,231.65
$1,282.11
$1,335.56
$1,525.45
$285.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.60
$848.52
$955.42
$1,335.20
$2,028.96
$1,033.55
$1,134.47
$1,241.37
$1,621.15
$1,319.50
$1,420.42
$1,527.32
$1,907.10
$1,605.45
$1,706.37
$1,813.27
$2,193.05
$285.95
Toc - Plan #87 Alliant Health Plans
Silver

(HMO) SoloCare Silver No Referral HMO 7000 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.49
$388.72
$437.69
$611.67
$929.49
$604.49
$650.72
$699.69
$873.67
$866.49
$912.72
$961.69
$1,135.67
$1,128.49
$1,174.72
$1,223.69
$1,397.67
$262.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$684.98
$777.44
$875.38
$1,223.34
$1,858.98
$946.98
$1,039.44
$1,137.38
$1,485.34
$1,208.98
$1,301.44
$1,399.38
$1,747.34
$1,470.98
$1,563.44
$1,661.38
$2,009.34
$262.00
Toc - Plan #88 Alliant Health Plans
Silver

(HMO) SoloCare Silver No Referral HMO 6000/60 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$351.64
$399.11
$449.39
$628.02
$954.34
$620.64
$668.11
$718.39
$897.02
$889.64
$937.11
$987.39
$1,166.02
$1,158.64
$1,206.11
$1,256.39
$1,435.02
$269.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$703.28
$798.22
$898.78
$1,256.04
$1,908.68
$972.28
$1,067.22
$1,167.78
$1,525.04
$1,241.28
$1,336.22
$1,436.78
$1,794.04
$1,510.28
$1,605.22
$1,705.78
$2,063.04
$269.00
Toc - Plan #89 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO HDHP 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$272.65
$309.44
$348.43
$486.93
$739.94
$481.22
$518.01
$557.00
$695.50
$689.79
$726.58
$765.57
$904.07
$898.36
$935.15
$974.14
$1,112.64
$208.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$545.30
$618.88
$696.86
$973.86
$1,479.88
$753.87
$827.45
$905.43
$1,182.43
$962.44
$1,036.02
$1,114.00
$1,391.00
$1,171.01
$1,244.59
$1,322.57
$1,599.57
$208.57
Toc - Plan #90 Alliant Health Plans
Catastrophic

(HMO) SoloCare Catastrophic No Referral HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$203.77
$231.26
$260.40
$363.91
$552.99
$359.64
$387.13
$416.27
$519.78
$515.51
$543.00
$572.14
$675.65
$671.38
$698.87
$728.01
$831.52
$155.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$407.54
$462.52
$520.80
$727.82
$1,105.98
$563.41
$618.39
$676.67
$883.69
$719.28
$774.26
$832.54
$1,039.56
$875.15
$930.13
$988.41
$1,195.43
$155.87
Toc - Plan #91 Alliant Health Plans
Gold

(HMO) SoloCare No Referral HMO Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.53
$402.38
$453.08
$633.18
$962.18
$625.74
$673.59
$724.29
$904.39
$896.95
$944.80
$995.50
$1,175.60
$1,168.16
$1,216.01
$1,266.71
$1,446.81
$271.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.06
$804.76
$906.16
$1,266.36
$1,924.36
$980.27
$1,075.97
$1,177.37
$1,537.57
$1,251.48
$1,347.18
$1,448.58
$1,808.78
$1,522.69
$1,618.39
$1,719.79
$2,079.99
$271.21
Toc - Plan #92 Alliant Health Plans
Silver

(HMO) SoloCare No Referral HMO Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.19
$367.95
$414.31
$578.99
$879.83
$572.19
$615.95
$662.31
$826.99
$820.19
$863.95
$910.31
$1,074.99
$1,068.19
$1,111.95
$1,158.31
$1,322.99
$248.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.38
$735.90
$828.62
$1,157.98
$1,759.66
$896.38
$983.90
$1,076.62
$1,405.98
$1,144.38
$1,231.90
$1,324.62
$1,653.98
$1,392.38
$1,479.90
$1,572.62
$1,901.98
$248.00
Toc - Plan #93 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare No Referral HMO Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$234.59
$266.25
$299.80
$418.96
$636.66
$414.05
$445.71
$479.26
$598.42
$593.51
$625.17
$658.72
$777.88
$772.97
$804.63
$838.18
$957.34
$179.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$469.18
$532.50
$599.60
$837.92
$1,273.32
$648.64
$711.96
$779.06
$1,017.38
$828.10
$891.42
$958.52
$1,196.84
$1,007.56
$1,070.88
$1,137.98
$1,376.30
$179.46
Toc - Plan #94 Alliant Health Plans
Platinum

(HMO) SoloCare Platinum No Referral HMO - $0 PCP, $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$1,500 $3,000 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
$461.96
$524.31
$590.37
$825.04
$1,253.72
$815.35
$877.70
$943.76
$1,178.43
$1,168.74
$1,231.09
$1,297.15
$1,531.82
$1,522.13
$1,584.48
$1,650.54
$1,885.21
$353.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$923.92
$1,048.62
$1,180.74
$1,650.08
$2,507.44
$1,277.31
$1,402.01
$1,534.13
$2,003.47
$1,630.70
$1,755.40
$1,887.52
$2,356.86
$1,984.09
$2,108.79
$2,240.91
$2,710.25
$353.39
Toc - Plan #95 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Exp Bronze No Referral HMO 9450 - $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274.10
$311.09
$350.28
$489.52
$743.87
$483.78
$520.77
$559.96
$699.20
$693.46
$730.45
$769.64
$908.88
$903.14
$940.13
$979.32
$1,118.56
$209.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$548.20
$622.18
$700.56
$979.04
$1,487.74
$757.88
$831.86
$910.24
$1,188.72
$967.56
$1,041.54
$1,119.92
$1,398.40
$1,177.24
$1,251.22
$1,329.60
$1,608.08
$209.68
Toc - Plan #96 Alliant Health Plans
Platinum

(HMO) SoloCare Platinum No Referral HMO Chiro - $0 PCP, $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$1,500 $3,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$466.29
$529.22
$595.90
$832.77
$1,265.47
$822.99
$885.92
$952.60
$1,189.47
$1,179.69
$1,242.62
$1,309.30
$1,546.17
$1,536.39
$1,599.32
$1,666.00
$1,902.87
$356.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$932.58
$1,058.44
$1,191.80
$1,665.54
$2,530.94
$1,289.28
$1,415.14
$1,548.50
$2,022.24
$1,645.98
$1,771.84
$1,905.20
$2,378.94
$2,002.68
$2,128.54
$2,261.90
$2,735.64
$356.70
Toc - Plan #97 Alliant Health Plans
Gold

(HMO) SoloCare Gold No Referral HMO Chiro 2300 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.17
$398.56
$448.78
$627.17
$953.04
$619.81
$667.20
$717.42
$895.81
$888.45
$935.84
$986.06
$1,164.45
$1,157.09
$1,204.48
$1,254.70
$1,433.09
$268.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.34
$797.12
$897.56
$1,254.34
$1,906.08
$970.98
$1,065.76
$1,166.20
$1,522.98
$1,239.62
$1,334.40
$1,434.84
$1,791.62
$1,508.26
$1,603.04
$1,703.48
$2,060.26
$268.64
Toc - Plan #98 Alliant Health Plans
Gold

(HMO) SoloCare Gold No Referral HMO Chiro 1500 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$377.18
$428.09
$482.02
$673.62
$1,023.64
$665.71
$716.62
$770.55
$962.15
$954.24
$1,005.15
$1,059.08
$1,250.68
$1,242.77
$1,293.68
$1,347.61
$1,539.21
$288.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.36
$856.18
$964.04
$1,347.24
$2,047.28
$1,042.89
$1,144.71
$1,252.57
$1,635.77
$1,331.42
$1,433.24
$1,541.10
$1,924.30
$1,619.95
$1,721.77
$1,829.63
$2,212.83
$288.53
Toc - Plan #99 Alliant Health Plans
Silver

(HMO) SoloCare Silver No Referral HMO Chiro 7000 - 3 Free PCP Visits, $5 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$344.90
$391.45
$440.77
$615.98
$936.04
$608.74
$655.29
$704.61
$879.82
$872.58
$919.13
$968.45
$1,143.66
$1,136.42
$1,182.97
$1,232.29
$1,407.50
$263.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$689.80
$782.90
$881.54
$1,231.96
$1,872.08
$953.64
$1,046.74
$1,145.38
$1,495.80
$1,217.48
$1,310.58
$1,409.22
$1,759.64
$1,481.32
$1,574.42
$1,673.06
$2,023.48
$263.84
Toc - Plan #100 Alliant Health Plans
Silver

(HMO) SoloCare Silver No Referral HMO Chiro 6000/60 - 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$354.53
$402.38
$453.08
$633.18
$962.18
$625.74
$673.59
$724.29
$904.39
$896.95
$944.80
$995.50
$1,175.60
$1,168.16
$1,216.01
$1,266.71
$1,446.81
$271.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.06
$804.76
$906.16
$1,266.36
$1,924.36
$980.27
$1,075.97
$1,177.37
$1,537.57
$1,251.48
$1,347.18
$1,448.58
$1,808.78
$1,522.69
$1,618.39
$1,719.79
$2,079.99
$271.21
Toc - Plan #101 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Exp Bronze No Referral HMO Chiro 9450 - $0 Generic Rx

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$276.99
$314.37
$353.97
$494.68
$751.71
$488.88
$526.26
$565.86
$706.57
$700.77
$738.15
$777.75
$918.46
$912.66
$950.04
$989.64
$1,130.35
$211.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$553.98
$628.74
$707.94
$989.36
$1,503.42
$765.87
$840.63
$919.83
$1,201.25
$977.76
$1,052.52
$1,131.72
$1,413.14
$1,189.65
$1,264.41
$1,343.61
$1,625.03
$211.89
Toc - Plan #102 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO Chiro HDHP 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

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
$275.54
$312.72
$352.12
$492.09
$747.78
$486.32
$523.50
$562.90
$702.87
$697.10
$734.28
$773.68
$913.65
$907.88
$945.06
$984.46
$1,124.43
$210.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.08
$625.44
$704.24
$984.18
$1,495.56
$761.86
$836.22
$915.02
$1,194.96
$972.64
$1,047.00
$1,125.80
$1,405.74
$1,183.42
$1,257.78
$1,336.58
$1,616.52
$210.78
Toc - Plan #103 Alliant Health Plans
Catastrophic

(HMO) SoloCare Catastrophic No Referral HMO Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$205.69
$233.45
$262.86
$367.35
$558.22
$363.04
$390.80
$420.21
$524.70
$520.39
$548.15
$577.56
$682.05
$677.74
$705.50
$734.91
$839.40
$157.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$411.38
$466.90
$525.72
$734.70
$1,116.44
$568.73
$624.25
$683.07
$892.05
$726.08
$781.60
$840.42
$1,049.40
$883.43
$938.95
$997.77
$1,206.75
$157.35
Toc - Plan #104 Alliant Health Plans
Platinum

(HMO) SoloCare No Referral HMO Standard Platinum

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 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
$477.85
$542.35
$610.68
$853.42
$1,296.86
$843.40
$907.90
$976.23
$1,218.97
$1,208.95
$1,273.45
$1,341.78
$1,584.52
$1,574.50
$1,639.00
$1,707.33
$1,950.07
$365.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$955.70
$1,084.70
$1,221.36
$1,706.84
$2,593.72
$1,321.25
$1,450.25
$1,586.91
$2,072.39
$1,686.80
$1,815.80
$1,952.46
$2,437.94
$2,052.35
$2,181.35
$2,318.01
$2,803.49
$365.55
Toc - Plan #105 Alliant Health Plans
Platinum

(HMO) SoloCare No Referral HMO Standard Platinum Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 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
$482.19
$547.27
$616.23
$861.17
$1,308.64
$851.06
$916.14
$985.10
$1,230.04
$1,219.93
$1,285.01
$1,353.97
$1,598.91
$1,588.80
$1,653.88
$1,722.84
$1,967.78
$368.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$964.38
$1,094.54
$1,232.46
$1,722.34
$2,617.28
$1,333.25
$1,463.41
$1,601.33
$2,091.21
$1,702.12
$1,832.28
$1,970.20
$2,460.08
$2,070.99
$2,201.15
$2,339.07
$2,828.95
$368.87
Toc - Plan #106 Alliant Health Plans
Gold

(HMO) SoloCare No Referral HMO Standard Gold Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.39
$406.76
$458.00
$640.06
$972.63
$632.55
$680.92
$732.16
$914.22
$906.71
$955.08
$1,006.32
$1,188.38
$1,180.87
$1,229.24
$1,280.48
$1,462.54
$274.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$716.78
$813.52
$916.00
$1,280.12
$1,945.26
$990.94
$1,087.68
$1,190.16
$1,554.28
$1,265.10
$1,361.84
$1,464.32
$1,828.44
$1,539.26
$1,636.00
$1,738.48
$2,102.60
$274.16
Toc - Plan #107 Alliant Health Plans
Silver

(HMO) SoloCare No Referral HMO Standard Silver Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$327.08
$371.23
$418.00
$584.15
$887.67
$577.29
$621.44
$668.21
$834.36
$827.50
$871.65
$918.42
$1,084.57
$1,077.71
$1,121.86
$1,168.63
$1,334.78
$250.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$654.16
$742.46
$836.00
$1,168.30
$1,775.34
$904.37
$992.67
$1,086.21
$1,418.51
$1,154.58
$1,242.88
$1,336.42
$1,668.72
$1,404.79
$1,493.09
$1,586.63
$1,918.93
$250.21
Toc - Plan #108 Alliant Health Plans
Expanded Bronze

(HMO) SoloCare No Referral HMO Standard Expanded Bronze Chiro

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-866-403-2785

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$237.00
$268.99
$302.88
$423.27
$643.20
$418.30
$450.29
$484.18
$604.57
$599.60
$631.59
$665.48
$785.87
$780.90
$812.89
$846.78
$967.17
$181.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$474.00
$537.98
$605.76
$846.54
$1,286.40
$655.30
$719.28
$787.06
$1,027.84
$836.60
$900.58
$968.36
$1,209.14
$1,017.90
$1,081.88
$1,149.66
$1,390.44
$181.30

‡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 108 plans offered in Rating Area 15.

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2024 Obamacare Plans for Cook County, GA

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