Effingham 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 Effingham 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, 98 Plans and 2024 Rates for Effingham County, Georgia

Below, you’ll find a summary of the 98 plans for Effingham 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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Cigna HealthCare of Georgia, Inc

Local:  | Toll Free: 

Toc - Plan #1 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Connect Bronze 8500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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
$309.40
$351.17
$395.41
$552.59
$839.71
$546.09
$587.86
$632.10
$789.28
$782.78
$824.55
$868.79
$1,025.97
$1,019.47
$1,061.24
$1,105.48
$1,262.66
$236.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.80
$702.34
$790.82
$1,105.18
$1,679.42
$855.49
$939.03
$1,027.51
$1,341.87
$1,092.18
$1,175.72
$1,264.20
$1,578.56
$1,328.87
$1,412.41
$1,500.89
$1,815.25
$236.69
Toc - Plan #2 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Connect Bronze 6500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$313.20
$355.48
$400.27
$559.38
$850.03
$552.80
$595.08
$639.87
$798.98
$792.40
$834.68
$879.47
$1,038.58
$1,032.00
$1,074.28
$1,119.07
$1,278.18
$239.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.40
$710.96
$800.54
$1,118.76
$1,700.06
$866.00
$950.56
$1,040.14
$1,358.36
$1,105.60
$1,190.16
$1,279.74
$1,597.96
$1,345.20
$1,429.76
$1,519.34
$1,837.56
$239.60
Toc - Plan #3 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Connect Bronze 4500 Indiv Med Deductible Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$316.73
$359.49
$404.79
$565.69
$859.62
$559.03
$601.79
$647.09
$807.99
$801.33
$844.09
$889.39
$1,050.29
$1,043.63
$1,086.39
$1,131.69
$1,292.59
$242.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.46
$718.98
$809.58
$1,131.38
$1,719.24
$875.76
$961.28
$1,051.88
$1,373.68
$1,118.06
$1,203.58
$1,294.18
$1,615.98
$1,360.36
$1,445.88
$1,536.48
$1,858.28
$242.30
Toc - Plan #4 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Connect Silver 3700 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$3,700 $7,400 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
$377.25
$428.18
$482.13
$673.78
$1,023.87
$665.85
$716.78
$770.73
$962.38
$954.45
$1,005.38
$1,059.33
$1,250.98
$1,243.05
$1,293.98
$1,347.93
$1,539.58
$288.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.50
$856.36
$964.26
$1,347.56
$2,047.74
$1,043.10
$1,144.96
$1,252.86
$1,636.16
$1,331.70
$1,433.56
$1,541.46
$1,924.76
$1,620.30
$1,722.16
$1,830.06
$2,213.36
$288.60
Toc - Plan #5 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Connect Silver 5000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$378.15
$429.20
$483.27
$675.37
$1,026.30
$667.43
$718.48
$772.55
$964.65
$956.71
$1,007.76
$1,061.83
$1,253.93
$1,245.99
$1,297.04
$1,351.11
$1,543.21
$289.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.30
$858.40
$966.54
$1,350.74
$2,052.60
$1,045.58
$1,147.68
$1,255.82
$1,640.02
$1,334.86
$1,436.96
$1,545.10
$1,929.30
$1,624.14
$1,726.24
$1,834.38
$2,218.58
$289.28
Toc - Plan #6 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Connect Silver 7000 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$377.61
$428.59
$482.59
$674.42
$1,024.84
$666.48
$717.46
$771.46
$963.29
$955.35
$1,006.33
$1,060.33
$1,252.16
$1,244.22
$1,295.20
$1,349.20
$1,541.03
$288.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$755.22
$857.18
$965.18
$1,348.84
$2,049.68
$1,044.09
$1,146.05
$1,254.05
$1,637.71
$1,332.96
$1,434.92
$1,542.92
$1,926.58
$1,621.83
$1,723.79
$1,831.79
$2,215.45
$288.87
Toc - Plan #7 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Connect Silver 2700 Indiv Med Deductible Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.62
$434.28
$488.99
$683.36
$1,038.44
$675.33
$726.99
$781.70
$976.07
$968.04
$1,019.70
$1,074.41
$1,268.78
$1,260.75
$1,312.41
$1,367.12
$1,561.49
$292.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.24
$868.56
$977.98
$1,366.72
$2,076.88
$1,057.95
$1,161.27
$1,270.69
$1,659.43
$1,350.66
$1,453.98
$1,563.40
$1,952.14
$1,643.37
$1,746.69
$1,856.11
$2,244.85
$292.71
Toc - Plan #8 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Connect Gold 500 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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
$489.35
$555.41
$625.39
$873.98
$1,328.09
$863.70
$929.76
$999.74
$1,248.33
$1,238.05
$1,304.11
$1,374.09
$1,622.68
$1,612.40
$1,678.46
$1,748.44
$1,997.03
$374.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$978.70
$1,110.82
$1,250.78
$1,747.96
$2,656.18
$1,353.05
$1,485.17
$1,625.13
$2,122.31
$1,727.40
$1,859.52
$1,999.48
$2,496.66
$2,101.75
$2,233.87
$2,373.83
$2,871.01
$374.35
Toc - Plan #9 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Connect Bronze CMS Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

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
$311.72
$353.81
$398.38
$556.74
$846.02
$550.19
$592.28
$636.85
$795.21
$788.66
$830.75
$875.32
$1,033.68
$1,027.13
$1,069.22
$1,113.79
$1,272.15
$238.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$623.44
$707.62
$796.76
$1,113.48
$1,692.04
$861.91
$946.09
$1,035.23
$1,351.95
$1,100.38
$1,184.56
$1,273.70
$1,590.42
$1,338.85
$1,423.03
$1,512.17
$1,828.89
$238.47
Toc - Plan #10 Cigna HealthCare of Georgia, Inc
Expanded Bronze

(HMO) Connect Bronze 0 Indiv Med Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.49
$386.45
$435.14
$608.11
$924.08
$600.96
$646.92
$695.61
$868.58
$861.43
$907.39
$956.08
$1,129.05
$1,121.90
$1,167.86
$1,216.55
$1,389.52
$260.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.98
$772.90
$870.28
$1,216.22
$1,848.16
$941.45
$1,033.37
$1,130.75
$1,476.69
$1,201.92
$1,293.84
$1,391.22
$1,737.16
$1,462.39
$1,554.31
$1,651.69
$1,997.63
$260.47
Toc - Plan #11 Cigna HealthCare of Georgia, Inc
Gold

(HMO) Connect Gold CMS 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
$487.34
$553.13
$622.81
$870.38
$1,322.63
$860.15
$925.94
$995.62
$1,243.19
$1,232.96
$1,298.75
$1,368.43
$1,616.00
$1,605.77
$1,671.56
$1,741.24
$1,988.81
$372.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$974.68
$1,106.26
$1,245.62
$1,740.76
$2,645.26
$1,347.49
$1,479.07
$1,618.43
$2,113.57
$1,720.30
$1,851.88
$1,991.24
$2,486.38
$2,093.11
$2,224.69
$2,364.05
$2,859.19
$372.81
Toc - Plan #12 Cigna HealthCare of Georgia, Inc
Silver

(HMO) Connect Silver CMS 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
$378.37
$429.45
$483.56
$675.77
$1,026.90
$667.83
$718.91
$773.02
$965.23
$957.29
$1,008.37
$1,062.48
$1,254.69
$1,246.75
$1,297.83
$1,351.94
$1,544.15
$289.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.74
$858.90
$967.12
$1,351.54
$2,053.80
$1,046.20
$1,148.36
$1,256.58
$1,641.00
$1,335.66
$1,437.82
$1,546.04
$1,930.46
$1,625.12
$1,727.28
$1,835.50
$2,219.92
$289.46

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UnitedHealthcare

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

Toc - Plan #13 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$457.45
$519.20
$584.62
$817.00
$1,241.52
$807.40
$869.15
$934.57
$1,166.95
$1,157.35
$1,219.10
$1,284.52
$1,516.90
$1,507.30
$1,569.05
$1,634.47
$1,866.85
$349.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$914.90
$1,038.40
$1,169.24
$1,634.00
$2,483.04
$1,264.85
$1,388.35
$1,519.19
$1,983.95
$1,614.80
$1,738.30
$1,869.14
$2,333.90
$1,964.75
$2,088.25
$2,219.09
$2,683.85
$349.95
Toc - Plan #14 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$9,450 $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
$401.51
$455.72
$513.13
$717.10
$1,089.70
$708.67
$762.88
$820.29
$1,024.26
$1,015.83
$1,070.04
$1,127.45
$1,331.42
$1,322.99
$1,377.20
$1,434.61
$1,638.58
$307.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.02
$911.44
$1,026.26
$1,434.20
$2,179.40
$1,110.18
$1,218.60
$1,333.42
$1,741.36
$1,417.34
$1,525.76
$1,640.58
$2,048.52
$1,724.50
$1,832.92
$1,947.74
$2,355.68
$307.16
Toc - Plan #15 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$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
$506.93
$575.37
$647.86
$905.38
$1,375.81
$894.73
$963.17
$1,035.66
$1,293.18
$1,282.53
$1,350.97
$1,423.46
$1,680.98
$1,670.33
$1,738.77
$1,811.26
$2,068.78
$387.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,013.86
$1,150.74
$1,295.72
$1,810.76
$2,751.62
$1,401.66
$1,538.54
$1,683.52
$2,198.56
$1,789.46
$1,926.34
$2,071.32
$2,586.36
$2,177.26
$2,314.14
$2,459.12
$2,974.16
$387.80
Toc - Plan #16 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $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
$464.72
$527.46
$593.91
$829.99
$1,261.25
$820.23
$882.97
$949.42
$1,185.50
$1,175.74
$1,238.48
$1,304.93
$1,541.01
$1,531.25
$1,593.99
$1,660.44
$1,896.52
$355.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$929.44
$1,054.92
$1,187.82
$1,659.98
$2,522.50
$1,284.95
$1,410.43
$1,543.33
$2,015.49
$1,640.46
$1,765.94
$1,898.84
$2,371.00
$1,995.97
$2,121.45
$2,254.35
$2,726.51
$355.51
Toc - Plan #17 UnitedHealthcare
Silver

(HMO) UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$458.39
$520.28
$585.83
$818.69
$1,244.08
$809.06
$870.95
$936.50
$1,169.36
$1,159.73
$1,221.62
$1,287.17
$1,520.03
$1,510.40
$1,572.29
$1,637.84
$1,870.70
$350.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$916.78
$1,040.56
$1,171.66
$1,637.38
$2,488.16
$1,267.45
$1,391.23
$1,522.33
$1,988.05
$1,618.12
$1,741.90
$1,873.00
$2,338.72
$1,968.79
$2,092.57
$2,223.67
$2,689.39
$350.67
Toc - Plan #18 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$5,900 $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
$463.38
$525.93
$592.20
$827.59
$1,257.61
$817.86
$880.41
$946.68
$1,182.07
$1,172.34
$1,234.89
$1,301.16
$1,536.55
$1,526.82
$1,589.37
$1,655.64
$1,891.03
$354.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.76
$1,051.86
$1,184.40
$1,655.18
$2,515.22
$1,281.24
$1,406.34
$1,538.88
$2,009.66
$1,635.72
$1,760.82
$1,893.36
$2,364.14
$1,990.20
$2,115.30
$2,247.84
$2,718.62
$354.48
Toc - Plan #19 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,450 $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
$399.60
$453.55
$510.69
$713.69
$1,084.52
$705.30
$759.25
$816.39
$1,019.39
$1,011.00
$1,064.95
$1,122.09
$1,325.09
$1,316.70
$1,370.65
$1,427.79
$1,630.79
$305.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.20
$907.10
$1,021.38
$1,427.38
$2,169.04
$1,104.90
$1,212.80
$1,327.08
$1,733.08
$1,410.60
$1,518.50
$1,632.78
$2,038.78
$1,716.30
$1,824.20
$1,938.48
$2,344.48
$305.70
Toc - Plan #20 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $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
$414.27
$470.20
$529.44
$739.89
$1,124.33
$731.19
$787.12
$846.36
$1,056.81
$1,048.11
$1,104.04
$1,163.28
$1,373.73
$1,365.03
$1,420.96
$1,480.20
$1,690.65
$316.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828.54
$940.40
$1,058.88
$1,479.78
$2,248.66
$1,145.46
$1,257.32
$1,375.80
$1,796.70
$1,462.38
$1,574.24
$1,692.72
$2,113.62
$1,779.30
$1,891.16
$2,009.64
$2,430.54
$316.92
Toc - Plan #21 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$407.43
$462.44
$520.70
$727.68
$1,105.77
$719.12
$774.13
$832.39
$1,039.37
$1,030.81
$1,085.82
$1,144.08
$1,351.06
$1,342.50
$1,397.51
$1,455.77
$1,662.75
$311.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.86
$924.88
$1,041.40
$1,455.36
$2,211.54
$1,126.55
$1,236.57
$1,353.09
$1,767.05
$1,438.24
$1,548.26
$1,664.78
$2,078.74
$1,749.93
$1,859.95
$1,976.47
$2,390.43
$311.69
Toc - Plan #22 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $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
$422.89
$479.98
$540.45
$755.28
$1,147.72
$746.40
$803.49
$863.96
$1,078.79
$1,069.91
$1,127.00
$1,187.47
$1,402.30
$1,393.42
$1,450.51
$1,510.98
$1,725.81
$323.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.78
$959.96
$1,080.90
$1,510.56
$2,295.44
$1,169.29
$1,283.47
$1,404.41
$1,834.07
$1,492.80
$1,606.98
$1,727.92
$2,157.58
$1,816.31
$1,930.49
$2,051.43
$2,481.09
$323.51
Toc - Plan #23 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.11
$522.22
$588.02
$821.76
$1,248.74
$812.09
$874.20
$940.00
$1,173.74
$1,164.07
$1,226.18
$1,291.98
$1,525.72
$1,516.05
$1,578.16
$1,643.96
$1,877.70
$351.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$920.22
$1,044.44
$1,176.04
$1,643.52
$2,497.48
$1,272.20
$1,396.42
$1,528.02
$1,995.50
$1,624.18
$1,748.40
$1,880.00
$2,347.48
$1,976.16
$2,100.38
$2,231.98
$2,699.46
$351.98
Toc - Plan #24 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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
$483.72
$549.02
$618.19
$863.92
$1,312.81
$853.76
$919.06
$988.23
$1,233.96
$1,223.80
$1,289.10
$1,358.27
$1,604.00
$1,593.84
$1,659.14
$1,728.31
$1,974.04
$370.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$967.44
$1,098.04
$1,236.38
$1,727.84
$2,625.62
$1,337.48
$1,468.08
$1,606.42
$2,097.88
$1,707.52
$1,838.12
$1,976.46
$2,467.92
$2,077.56
$2,208.16
$2,346.50
$2,837.96
$370.04
Toc - Plan #25 UnitedHealthcare
Gold

(HMO) UHC Gold Virtual First (Unlimited $0 App-based Care, $3 Tier 2 Rx) (Disponible en espanol)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$486.36
$552.02
$621.57
$868.64
$1,319.98
$858.42
$924.08
$993.63
$1,240.70
$1,230.48
$1,296.14
$1,365.69
$1,612.76
$1,602.54
$1,668.20
$1,737.75
$1,984.82
$372.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.72
$1,104.04
$1,243.14
$1,737.28
$2,639.96
$1,344.78
$1,476.10
$1,615.20
$2,109.34
$1,716.84
$1,848.16
$1,987.26
$2,481.40
$2,088.90
$2,220.22
$2,359.32
$2,853.46
$372.06
Toc - Plan #26 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $3 Tier 2 Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$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
$508.79
$577.47
$650.23
$908.69
$1,380.84
$898.01
$966.69
$1,039.45
$1,297.91
$1,287.23
$1,355.91
$1,428.67
$1,687.13
$1,676.45
$1,745.13
$1,817.89
$2,076.35
$389.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,017.58
$1,154.94
$1,300.46
$1,817.38
$2,761.68
$1,406.80
$1,544.16
$1,689.68
$2,206.60
$1,796.02
$1,933.38
$2,078.90
$2,595.82
$2,185.24
$2,322.60
$2,468.12
$2,985.04
$389.22
Toc - Plan #27 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$480.09
$544.90
$613.56
$857.44
$1,302.97
$847.36
$912.17
$980.83
$1,224.71
$1,214.63
$1,279.44
$1,348.10
$1,591.98
$1,581.90
$1,646.71
$1,715.37
$1,959.25
$367.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$960.18
$1,089.80
$1,227.12
$1,714.88
$2,605.94
$1,327.45
$1,457.07
$1,594.39
$2,082.15
$1,694.72
$1,824.34
$1,961.66
$2,449.42
$2,061.99
$2,191.61
$2,328.93
$2,816.69
$367.27
Toc - Plan #28 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-609-9754

Annual Out of Pocket Expenses:

Individual Family
$1,100 $2,200 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
$519.16
$589.24
$663.48
$927.21
$1,408.99
$916.31
$986.39
$1,060.63
$1,324.36
$1,313.46
$1,383.54
$1,457.78
$1,721.51
$1,710.61
$1,780.69
$1,854.93
$2,118.66
$397.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,038.32
$1,178.48
$1,326.96
$1,854.42
$2,817.98
$1,435.47
$1,575.63
$1,724.11
$2,251.57
$1,832.62
$1,972.78
$2,121.26
$2,648.72
$2,229.77
$2,369.93
$2,518.41
$3,045.87
$397.15

ADVERTISEMENT

Anthem Blue Cross and Blue Shield

Local: 1-855-738-6652 | Toll Free: 

Toc - Plan #29 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
$365.18
$414.48
$466.70
$652.21
$991.10
$644.54
$693.84
$746.06
$931.57
$923.90
$973.20
$1,025.42
$1,210.93
$1,203.26
$1,252.56
$1,304.78
$1,490.29
$279.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.36
$828.96
$933.40
$1,304.42
$1,982.20
$1,009.72
$1,108.32
$1,212.76
$1,583.78
$1,289.08
$1,387.68
$1,492.12
$1,863.14
$1,568.44
$1,667.04
$1,771.48
$2,142.50
$279.36
Toc - Plan #30 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
$361.34
$410.12
$461.79
$645.35
$980.68
$637.77
$686.55
$738.22
$921.78
$914.20
$962.98
$1,014.65
$1,198.21
$1,190.63
$1,239.41
$1,291.08
$1,474.64
$276.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.68
$820.24
$923.58
$1,290.70
$1,961.36
$999.11
$1,096.67
$1,200.01
$1,567.13
$1,275.54
$1,373.10
$1,476.44
$1,843.56
$1,551.97
$1,649.53
$1,752.87
$2,119.99
$276.43
Toc - Plan #31 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
$356.90
$405.08
$456.12
$637.42
$968.63
$629.93
$678.11
$729.15
$910.45
$902.96
$951.14
$1,002.18
$1,183.48
$1,175.99
$1,224.17
$1,275.21
$1,456.51
$273.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.80
$810.16
$912.24
$1,274.84
$1,937.26
$986.83
$1,083.19
$1,185.27
$1,547.87
$1,259.86
$1,356.22
$1,458.30
$1,820.90
$1,532.89
$1,629.25
$1,731.33
$2,093.93
$273.03
Toc - Plan #32 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
$413.47
$469.29
$528.41
$738.46
$1,122.16
$729.77
$785.59
$844.71
$1,054.76
$1,046.07
$1,101.89
$1,161.01
$1,371.06
$1,362.37
$1,418.19
$1,477.31
$1,687.36
$316.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.94
$938.58
$1,056.82
$1,476.92
$2,244.32
$1,143.24
$1,254.88
$1,373.12
$1,793.22
$1,459.54
$1,571.18
$1,689.42
$2,109.52
$1,775.84
$1,887.48
$2,005.72
$2,425.82
$316.30
Toc - Plan #33 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
$439.28
$498.58
$561.40
$784.55
$1,192.21
$775.33
$834.63
$897.45
$1,120.60
$1,111.38
$1,170.68
$1,233.50
$1,456.65
$1,447.43
$1,506.73
$1,569.55
$1,792.70
$336.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$878.56
$997.16
$1,122.80
$1,569.10
$2,384.42
$1,214.61
$1,333.21
$1,458.85
$1,905.15
$1,550.66
$1,669.26
$1,794.90
$2,241.20
$1,886.71
$2,005.31
$2,130.95
$2,577.25
$336.05
Toc - Plan #34 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
$358.56
$406.97
$458.24
$640.39
$973.13
$632.86
$681.27
$732.54
$914.69
$907.16
$955.57
$1,006.84
$1,188.99
$1,181.46
$1,229.87
$1,281.14
$1,463.29
$274.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.12
$813.94
$916.48
$1,280.78
$1,946.26
$991.42
$1,088.24
$1,190.78
$1,555.08
$1,265.72
$1,362.54
$1,465.08
$1,829.38
$1,540.02
$1,636.84
$1,739.38
$2,103.68
$274.30
Toc - Plan #35 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
$266.91
$302.94
$341.11
$476.70
$724.39
$471.10
$507.13
$545.30
$680.89
$675.29
$711.32
$749.49
$885.08
$879.48
$915.51
$953.68
$1,089.27
$204.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$533.82
$605.88
$682.22
$953.40
$1,448.78
$738.01
$810.07
$886.41
$1,157.59
$942.20
$1,014.26
$1,090.60
$1,361.78
$1,146.39
$1,218.45
$1,294.79
$1,565.97
$204.19
Toc - Plan #36 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
$378.31
$429.38
$483.48
$675.66
$1,026.73
$667.72
$718.79
$772.89
$965.07
$957.13
$1,008.20
$1,062.30
$1,254.48
$1,246.54
$1,297.61
$1,351.71
$1,543.89
$289.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.62
$858.76
$966.96
$1,351.32
$2,053.46
$1,046.03
$1,148.17
$1,256.37
$1,640.73
$1,335.44
$1,437.58
$1,545.78
$1,930.14
$1,624.85
$1,726.99
$1,835.19
$2,219.55
$289.41
Toc - Plan #37 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
$360.06
$408.67
$460.16
$643.07
$977.20
$635.51
$684.12
$735.61
$918.52
$910.96
$959.57
$1,011.06
$1,193.97
$1,186.41
$1,235.02
$1,286.51
$1,469.42
$275.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.12
$817.34
$920.32
$1,286.14
$1,954.40
$995.57
$1,092.79
$1,195.77
$1,561.59
$1,271.02
$1,368.24
$1,471.22
$1,837.04
$1,546.47
$1,643.69
$1,746.67
$2,112.49
$275.45
Toc - Plan #38 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
$466.07
$528.99
$595.64
$832.40
$1,264.91
$822.61
$885.53
$952.18
$1,188.94
$1,179.15
$1,242.07
$1,308.72
$1,545.48
$1,535.69
$1,598.61
$1,665.26
$1,902.02
$356.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$932.14
$1,057.98
$1,191.28
$1,664.80
$2,529.82
$1,288.68
$1,414.52
$1,547.82
$2,021.34
$1,645.22
$1,771.06
$1,904.36
$2,377.88
$2,001.76
$2,127.60
$2,260.90
$2,734.42
$356.54
Toc - Plan #39 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
$443.08
$502.90
$566.26
$791.34
$1,202.52
$782.04
$841.86
$905.22
$1,130.30
$1,121.00
$1,180.82
$1,244.18
$1,469.26
$1,459.96
$1,519.78
$1,583.14
$1,808.22
$338.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.16
$1,005.80
$1,132.52
$1,582.68
$2,405.04
$1,225.12
$1,344.76
$1,471.48
$1,921.64
$1,564.08
$1,683.72
$1,810.44
$2,260.60
$1,903.04
$2,022.68
$2,149.40
$2,599.56
$338.96
Toc - Plan #40 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
$348.41
$395.45
$445.27
$622.26
$945.58
$614.94
$661.98
$711.80
$888.79
$881.47
$928.51
$978.33
$1,155.32
$1,148.00
$1,195.04
$1,244.86
$1,421.85
$266.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$696.82
$790.90
$890.54
$1,244.52
$1,891.16
$963.35
$1,057.43
$1,157.07
$1,511.05
$1,229.88
$1,323.96
$1,423.60
$1,777.58
$1,496.41
$1,590.49
$1,690.13
$2,044.11
$266.53
Toc - Plan #41 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
$446.46
$506.73
$570.58
$797.38
$1,211.69
$788.00
$848.27
$912.12
$1,138.92
$1,129.54
$1,189.81
$1,253.66
$1,480.46
$1,471.08
$1,531.35
$1,595.20
$1,822.00
$341.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.92
$1,013.46
$1,141.16
$1,594.76
$2,423.38
$1,234.46
$1,355.00
$1,482.70
$1,936.30
$1,576.00
$1,696.54
$1,824.24
$2,277.84
$1,917.54
$2,038.08
$2,165.78
$2,619.38
$341.54
Toc - Plan #42 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
$437.22
$496.24
$558.77
$780.87
$1,186.62
$771.69
$830.71
$893.24
$1,115.34
$1,106.16
$1,165.18
$1,227.71
$1,449.81
$1,440.63
$1,499.65
$1,562.18
$1,784.28
$334.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.44
$992.48
$1,117.54
$1,561.74
$2,373.24
$1,208.91
$1,326.95
$1,452.01
$1,896.21
$1,543.38
$1,661.42
$1,786.48
$2,230.68
$1,877.85
$1,995.89
$2,120.95
$2,565.15
$334.47
Toc - Plan #43 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
$505.13
$573.32
$645.56
$902.16
$1,370.92
$891.55
$959.74
$1,031.98
$1,288.58
$1,277.97
$1,346.16
$1,418.40
$1,675.00
$1,664.39
$1,732.58
$1,804.82
$2,061.42
$386.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,010.26
$1,146.64
$1,291.12
$1,804.32
$2,741.84
$1,396.68
$1,533.06
$1,677.54
$2,190.74
$1,783.10
$1,919.48
$2,063.96
$2,577.16
$2,169.52
$2,305.90
$2,450.38
$2,963.58
$386.42
Toc - Plan #44 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
$373.30
$423.70
$477.08
$666.71
$1,013.14
$658.87
$709.27
$762.65
$952.28
$944.44
$994.84
$1,048.22
$1,237.85
$1,230.01
$1,280.41
$1,333.79
$1,523.42
$285.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.60
$847.40
$954.16
$1,333.42
$2,026.28
$1,032.17
$1,132.97
$1,239.73
$1,618.99
$1,317.74
$1,418.54
$1,525.30
$1,904.56
$1,603.31
$1,704.11
$1,810.87
$2,190.13
$285.57
Toc - Plan #45 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
$366.24
$415.68
$468.05
$654.10
$993.98
$646.41
$695.85
$748.22
$934.27
$926.58
$976.02
$1,028.39
$1,214.44
$1,206.75
$1,256.19
$1,308.56
$1,494.61
$280.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$732.48
$831.36
$936.10
$1,308.20
$1,987.96
$1,012.65
$1,111.53
$1,216.27
$1,588.37
$1,292.82
$1,391.70
$1,496.44
$1,868.54
$1,572.99
$1,671.87
$1,776.61
$2,148.71
$280.17
Toc - Plan #46 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
$446.57
$506.86
$570.72
$797.57
$1,211.99
$788.20
$848.49
$912.35
$1,139.20
$1,129.83
$1,190.12
$1,253.98
$1,480.83
$1,471.46
$1,531.75
$1,595.61
$1,822.46
$341.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.14
$1,013.72
$1,141.44
$1,595.14
$2,423.98
$1,234.77
$1,355.35
$1,483.07
$1,936.77
$1,576.40
$1,696.98
$1,824.70
$2,278.40
$1,918.03
$2,038.61
$2,166.33
$2,620.03
$341.63
Toc - Plan #47 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
$525.24
$596.15
$671.26
$938.08
$1,425.50
$927.05
$997.96
$1,073.07
$1,339.89
$1,328.86
$1,399.77
$1,474.88
$1,741.70
$1,730.67
$1,801.58
$1,876.69
$2,143.51
$401.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,050.48
$1,192.30
$1,342.52
$1,876.16
$2,851.00
$1,452.29
$1,594.11
$1,744.33
$2,277.97
$1,854.10
$1,995.92
$2,146.14
$2,679.78
$2,255.91
$2,397.73
$2,547.95
$3,081.59
$401.81

ADVERTISEMENT

CareSource

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

Toc - Plan #48 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
$329.31
$373.76
$420.86
$588.14
$893.74
$581.23
$625.68
$672.78
$840.06
$833.15
$877.60
$924.70
$1,091.98
$1,085.07
$1,129.52
$1,176.62
$1,343.90
$251.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$658.62
$747.52
$841.72
$1,176.28
$1,787.48
$910.54
$999.44
$1,093.64
$1,428.20
$1,162.46
$1,251.36
$1,345.56
$1,680.12
$1,414.38
$1,503.28
$1,597.48
$1,932.04
$251.92
Toc - Plan #49 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
$521.37
$591.75
$666.31
$931.17
$1,415.00
$920.22
$990.60
$1,065.16
$1,330.02
$1,319.07
$1,389.45
$1,464.01
$1,728.87
$1,717.92
$1,788.30
$1,862.86
$2,127.72
$398.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,042.74
$1,183.50
$1,332.62
$1,862.34
$2,830.00
$1,441.59
$1,582.35
$1,731.47
$2,261.19
$1,840.44
$1,981.20
$2,130.32
$2,660.04
$2,239.29
$2,380.05
$2,529.17
$3,058.89
$398.85
Toc - Plan #50 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
$433.55
$492.08
$554.08
$774.32
$1,176.66
$765.22
$823.75
$885.75
$1,105.99
$1,096.89
$1,155.42
$1,217.42
$1,437.66
$1,428.56
$1,487.09
$1,549.09
$1,769.33
$331.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.10
$984.16
$1,108.16
$1,548.64
$2,353.32
$1,198.77
$1,315.83
$1,439.83
$1,880.31
$1,530.44
$1,647.50
$1,771.50
$2,211.98
$1,862.11
$1,979.17
$2,103.17
$2,543.65
$331.67
Toc - Plan #51 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
$362.25
$411.15
$462.96
$646.98
$983.15
$639.37
$688.27
$740.08
$924.10
$916.49
$965.39
$1,017.20
$1,201.22
$1,193.61
$1,242.51
$1,294.32
$1,478.34
$277.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.50
$822.30
$925.92
$1,293.96
$1,966.30
$1,001.62
$1,099.42
$1,203.04
$1,571.08
$1,278.74
$1,376.54
$1,480.16
$1,848.20
$1,555.86
$1,653.66
$1,757.28
$2,125.32
$277.12
Toc - Plan #52 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
$431.05
$489.23
$550.87
$769.84
$1,169.85
$760.80
$818.98
$880.62
$1,099.59
$1,090.55
$1,148.73
$1,210.37
$1,429.34
$1,420.30
$1,478.48
$1,540.12
$1,759.09
$329.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$862.10
$978.46
$1,101.74
$1,539.68
$2,339.70
$1,191.85
$1,308.21
$1,431.49
$1,869.43
$1,521.60
$1,637.96
$1,761.24
$2,199.18
$1,851.35
$1,967.71
$2,090.99
$2,528.93
$329.75
Toc - Plan #53 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
$543.74
$617.14
$694.89
$971.11
$1,475.69
$959.70
$1,033.10
$1,110.85
$1,387.07
$1,375.66
$1,449.06
$1,526.81
$1,803.03
$1,791.62
$1,865.02
$1,942.77
$2,218.99
$415.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,087.48
$1,234.28
$1,389.78
$1,942.22
$2,951.38
$1,503.44
$1,650.24
$1,805.74
$2,358.18
$1,919.40
$2,066.20
$2,221.70
$2,774.14
$2,335.36
$2,482.16
$2,637.66
$3,190.10
$415.96
Toc - Plan #54 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
$558.39
$633.77
$713.62
$997.28
$1,515.46
$985.56
$1,060.94
$1,140.79
$1,424.45
$1,412.73
$1,488.11
$1,567.96
$1,851.62
$1,839.90
$1,915.28
$1,995.13
$2,278.79
$427.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,116.78
$1,267.54
$1,427.24
$1,994.56
$3,030.92
$1,543.95
$1,694.71
$1,854.41
$2,421.73
$1,971.12
$2,121.88
$2,281.58
$2,848.90
$2,398.29
$2,549.05
$2,708.75
$3,276.07
$427.17
Toc - Plan #55 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
$447.89
$508.35
$572.40
$799.93
$1,215.57
$790.52
$850.98
$915.03
$1,142.56
$1,133.15
$1,193.61
$1,257.66
$1,485.19
$1,475.78
$1,536.24
$1,600.29
$1,827.82
$342.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.78
$1,016.70
$1,144.80
$1,599.86
$2,431.14
$1,238.41
$1,359.33
$1,487.43
$1,942.49
$1,581.04
$1,701.96
$1,830.06
$2,285.12
$1,923.67
$2,044.59
$2,172.69
$2,627.75
$342.63
Toc - Plan #56 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
$336.89
$382.37
$430.54
$601.68
$914.31
$594.61
$640.09
$688.26
$859.40
$852.33
$897.81
$945.98
$1,117.12
$1,110.05
$1,155.53
$1,203.70
$1,374.84
$257.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$673.78
$764.74
$861.08
$1,203.36
$1,828.62
$931.50
$1,022.46
$1,118.80
$1,461.08
$1,189.22
$1,280.18
$1,376.52
$1,718.80
$1,446.94
$1,537.90
$1,634.24
$1,976.52
$257.72
Toc - Plan #57 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
$530.75
$602.40
$678.30
$947.92
$1,440.45
$936.77
$1,008.42
$1,084.32
$1,353.94
$1,342.79
$1,414.44
$1,490.34
$1,759.96
$1,748.81
$1,820.46
$1,896.36
$2,165.98
$406.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,061.50
$1,204.80
$1,356.60
$1,895.84
$2,880.90
$1,467.52
$1,610.82
$1,762.62
$2,301.86
$1,873.54
$2,016.84
$2,168.64
$2,707.88
$2,279.56
$2,422.86
$2,574.66
$3,113.90
$406.02
Toc - Plan #58 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
$441.18
$500.74
$563.83
$787.95
$1,197.36
$778.68
$838.24
$901.33
$1,125.45
$1,116.18
$1,175.74
$1,238.83
$1,462.95
$1,453.68
$1,513.24
$1,576.33
$1,800.45
$337.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.36
$1,001.48
$1,127.66
$1,575.90
$2,394.72
$1,219.86
$1,338.98
$1,465.16
$1,913.40
$1,557.36
$1,676.48
$1,802.66
$2,250.90
$1,894.86
$2,013.98
$2,140.16
$2,588.40
$337.50
Toc - Plan #59 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
$438.67
$497.89
$560.62
$783.47
$1,190.55
$774.25
$833.47
$896.20
$1,119.05
$1,109.83
$1,169.05
$1,231.78
$1,454.63
$1,445.41
$1,504.63
$1,567.36
$1,790.21
$335.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.34
$995.78
$1,121.24
$1,566.94
$2,381.10
$1,212.92
$1,331.36
$1,456.82
$1,902.52
$1,548.50
$1,666.94
$1,792.40
$2,238.10
$1,884.08
$2,002.52
$2,127.98
$2,573.68
$335.58
Toc - Plan #60 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
$553.12
$627.78
$706.88
$987.86
$1,501.15
$976.25
$1,050.91
$1,130.01
$1,410.99
$1,399.38
$1,474.04
$1,553.14
$1,834.12
$1,822.51
$1,897.17
$1,976.27
$2,257.25
$423.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,106.24
$1,255.56
$1,413.76
$1,975.72
$3,002.30
$1,529.37
$1,678.69
$1,836.89
$2,398.85
$1,952.50
$2,101.82
$2,260.02
$2,821.98
$2,375.63
$2,524.95
$2,683.15
$3,245.11
$423.13
Toc - Plan #61 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
$567.76
$644.40
$725.59
$1,014.01
$1,540.89
$1,002.09
$1,078.73
$1,159.92
$1,448.34
$1,436.42
$1,513.06
$1,594.25
$1,882.67
$1,870.75
$1,947.39
$2,028.58
$2,317.00
$434.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,135.52
$1,288.80
$1,451.18
$2,028.02
$3,081.78
$1,569.85
$1,723.13
$1,885.51
$2,462.35
$2,004.18
$2,157.46
$2,319.84
$2,896.68
$2,438.51
$2,591.79
$2,754.17
$3,331.01
$434.33
Toc - Plan #62 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
$455.52
$517.01
$582.15
$813.55
$1,236.27
$803.99
$865.48
$930.62
$1,162.02
$1,152.46
$1,213.95
$1,279.09
$1,510.49
$1,500.93
$1,562.42
$1,627.56
$1,858.96
$348.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$911.04
$1,034.02
$1,164.30
$1,627.10
$2,472.54
$1,259.51
$1,382.49
$1,512.77
$1,975.57
$1,607.98
$1,730.96
$1,861.24
$2,324.04
$1,956.45
$2,079.43
$2,209.71
$2,672.51
$348.47

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 #63 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
$320.73
$364.02
$409.88
$572.81
$870.44
$566.08
$609.37
$655.23
$818.16
$811.43
$854.72
$900.58
$1,063.51
$1,056.78
$1,100.07
$1,145.93
$1,308.86
$245.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.46
$728.04
$819.76
$1,145.62
$1,740.88
$886.81
$973.39
$1,065.11
$1,390.97
$1,132.16
$1,218.74
$1,310.46
$1,636.32
$1,377.51
$1,464.09
$1,555.81
$1,881.67
$245.35
Toc - Plan #64 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
$380.74
$432.12
$486.57
$679.98
$1,033.29
$672.00
$723.38
$777.83
$971.24
$963.26
$1,014.64
$1,069.09
$1,262.50
$1,254.52
$1,305.90
$1,360.35
$1,553.76
$291.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.48
$864.24
$973.14
$1,359.96
$2,066.58
$1,052.74
$1,155.50
$1,264.40
$1,651.22
$1,344.00
$1,446.76
$1,555.66
$1,942.48
$1,635.26
$1,738.02
$1,846.92
$2,233.74
$291.26
Toc - Plan #65 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
$401.22
$455.37
$512.74
$716.55
$1,088.87
$708.14
$762.29
$819.66
$1,023.47
$1,015.06
$1,069.21
$1,126.58
$1,330.39
$1,321.98
$1,376.13
$1,433.50
$1,637.31
$306.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.44
$910.74
$1,025.48
$1,433.10
$2,177.74
$1,109.36
$1,217.66
$1,332.40
$1,740.02
$1,416.28
$1,524.58
$1,639.32
$2,046.94
$1,723.20
$1,831.50
$1,946.24
$2,353.86
$306.92
Toc - Plan #66 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
$354.19
$402.00
$452.64
$632.57
$961.25
$625.14
$672.95
$723.59
$903.52
$896.09
$943.90
$994.54
$1,174.47
$1,167.04
$1,214.85
$1,265.49
$1,445.42
$270.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.38
$804.00
$905.28
$1,265.14
$1,922.50
$979.33
$1,074.95
$1,176.23
$1,536.09
$1,250.28
$1,345.90
$1,447.18
$1,807.04
$1,521.23
$1,616.85
$1,718.13
$2,077.99
$270.95
Toc - Plan #67 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
$347.02
$393.86
$443.48
$619.76
$941.79
$612.48
$659.32
$708.94
$885.22
$877.94
$924.78
$974.40
$1,150.68
$1,143.40
$1,190.24
$1,239.86
$1,416.14
$265.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$694.04
$787.72
$886.96
$1,239.52
$1,883.58
$959.50
$1,053.18
$1,152.42
$1,504.98
$1,224.96
$1,318.64
$1,417.88
$1,770.44
$1,490.42
$1,584.10
$1,683.34
$2,035.90
$265.46
Toc - Plan #68 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
$369.34
$419.19
$472.00
$659.62
$1,002.36
$651.88
$701.73
$754.54
$942.16
$934.42
$984.27
$1,037.08
$1,224.70
$1,216.96
$1,266.81
$1,319.62
$1,507.24
$282.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$738.68
$838.38
$944.00
$1,319.24
$2,004.72
$1,021.22
$1,120.92
$1,226.54
$1,601.78
$1,303.76
$1,403.46
$1,509.08
$1,884.32
$1,586.30
$1,686.00
$1,791.62
$2,166.86
$282.54
Toc - Plan #69 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
$374.85
$425.45
$479.05
$669.47
$1,017.33
$661.61
$712.21
$765.81
$956.23
$948.37
$998.97
$1,052.57
$1,242.99
$1,235.13
$1,285.73
$1,339.33
$1,529.75
$286.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.70
$850.90
$958.10
$1,338.94
$2,034.66
$1,036.46
$1,137.66
$1,244.86
$1,625.70
$1,323.22
$1,424.42
$1,531.62
$1,912.46
$1,609.98
$1,711.18
$1,818.38
$2,199.22
$286.76
Toc - Plan #70 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
$384.16
$436.01
$490.94
$686.08
$1,042.57
$678.03
$729.88
$784.81
$979.95
$971.90
$1,023.75
$1,078.68
$1,273.82
$1,265.77
$1,317.62
$1,372.55
$1,567.69
$293.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.32
$872.02
$981.88
$1,372.16
$2,085.14
$1,062.19
$1,165.89
$1,275.75
$1,666.03
$1,356.06
$1,459.76
$1,569.62
$1,959.90
$1,649.93
$1,753.63
$1,863.49
$2,253.77
$293.87
Toc - Plan #71 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
$378.71
$429.83
$483.98
$676.37
$1,027.80
$668.42
$719.54
$773.69
$966.08
$958.13
$1,009.25
$1,063.40
$1,255.79
$1,247.84
$1,298.96
$1,353.11
$1,545.50
$289.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.42
$859.66
$967.96
$1,352.74
$2,055.60
$1,047.13
$1,149.37
$1,257.67
$1,642.45
$1,336.84
$1,439.08
$1,547.38
$1,932.16
$1,626.55
$1,728.79
$1,837.09
$2,221.87
$289.71
Toc - Plan #72 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
$438.35
$497.52
$560.20
$782.88
$1,189.66
$773.68
$832.85
$895.53
$1,118.21
$1,109.01
$1,168.18
$1,230.86
$1,453.54
$1,444.34
$1,503.51
$1,566.19
$1,788.87
$335.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$876.70
$995.04
$1,120.40
$1,565.76
$2,379.32
$1,212.03
$1,330.37
$1,455.73
$1,901.09
$1,547.36
$1,665.70
$1,791.06
$2,236.42
$1,882.69
$2,001.03
$2,126.39
$2,571.75
$335.33
Toc - Plan #73 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
$341.17
$387.22
$436.01
$609.32
$925.92
$602.16
$648.21
$697.00
$870.31
$863.15
$909.20
$957.99
$1,131.30
$1,124.14
$1,170.19
$1,218.98
$1,392.29
$260.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$682.34
$774.44
$872.02
$1,218.64
$1,851.84
$943.33
$1,035.43
$1,133.01
$1,479.63
$1,204.32
$1,296.42
$1,394.00
$1,740.62
$1,465.31
$1,557.41
$1,654.99
$2,001.61
$260.99
Toc - Plan #74 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
$367.68
$417.31
$469.89
$656.67
$997.87
$648.95
$698.58
$751.16
$937.94
$930.22
$979.85
$1,032.43
$1,219.21
$1,211.49
$1,261.12
$1,313.70
$1,500.48
$281.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.36
$834.62
$939.78
$1,313.34
$1,995.74
$1,016.63
$1,115.89
$1,221.05
$1,594.61
$1,297.90
$1,397.16
$1,502.32
$1,875.88
$1,579.17
$1,678.43
$1,783.59
$2,157.15
$281.27
Toc - Plan #75 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
$385.74
$437.80
$492.96
$688.91
$1,046.86
$680.82
$732.88
$788.04
$983.99
$975.90
$1,027.96
$1,083.12
$1,279.07
$1,270.98
$1,323.04
$1,378.20
$1,574.15
$295.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.48
$875.60
$985.92
$1,377.82
$2,093.72
$1,066.56
$1,170.68
$1,281.00
$1,672.90
$1,361.64
$1,465.76
$1,576.08
$1,967.98
$1,656.72
$1,760.84
$1,871.16
$2,263.06
$295.08
Toc - Plan #76 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
$394.36
$447.59
$503.98
$704.31
$1,070.27
$696.04
$749.27
$805.66
$1,005.99
$997.72
$1,050.95
$1,107.34
$1,307.67
$1,299.40
$1,352.63
$1,409.02
$1,609.35
$301.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.72
$895.18
$1,007.96
$1,408.62
$2,140.54
$1,090.40
$1,196.86
$1,309.64
$1,710.30
$1,392.08
$1,498.54
$1,611.32
$2,011.98
$1,693.76
$1,800.22
$1,913.00
$2,313.66
$301.68
Toc - Plan #77 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
$332.21
$377.05
$424.55
$593.31
$901.59
$586.34
$631.18
$678.68
$847.44
$840.47
$885.31
$932.81
$1,101.57
$1,094.60
$1,139.44
$1,186.94
$1,355.70
$254.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.42
$754.10
$849.10
$1,186.62
$1,803.18
$918.55
$1,008.23
$1,103.23
$1,440.75
$1,172.68
$1,262.36
$1,357.36
$1,694.88
$1,426.81
$1,516.49
$1,611.49
$1,949.01
$254.13
Toc - Plan #78 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
$415.57
$471.66
$531.09
$742.19
$1,127.84
$733.48
$789.57
$849.00
$1,060.10
$1,051.39
$1,107.48
$1,166.91
$1,378.01
$1,369.30
$1,425.39
$1,484.82
$1,695.92
$317.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$831.14
$943.32
$1,062.18
$1,484.38
$2,255.68
$1,149.05
$1,261.23
$1,380.09
$1,802.29
$1,466.96
$1,579.14
$1,698.00
$2,120.20
$1,784.87
$1,897.05
$2,015.91
$2,438.11
$317.91
Toc - Plan #79 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
$366.86
$416.38
$468.84
$655.20
$995.64
$647.50
$697.02
$749.48
$935.84
$928.14
$977.66
$1,030.12
$1,216.48
$1,208.78
$1,258.30
$1,310.76
$1,497.12
$280.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.72
$832.76
$937.68
$1,310.40
$1,991.28
$1,014.36
$1,113.40
$1,218.32
$1,591.04
$1,295.00
$1,394.04
$1,498.96
$1,871.68
$1,575.64
$1,674.68
$1,779.60
$2,152.32
$280.64
Toc - Plan #80 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
$359.44
$407.95
$459.35
$641.94
$975.49
$634.40
$682.91
$734.31
$916.90
$909.36
$957.87
$1,009.27
$1,191.86
$1,184.32
$1,232.83
$1,284.23
$1,466.82
$274.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.88
$815.90
$918.70
$1,283.88
$1,950.98
$993.84
$1,090.86
$1,193.66
$1,558.84
$1,268.80
$1,365.82
$1,468.62
$1,833.80
$1,543.76
$1,640.78
$1,743.58
$2,108.76
$274.96
Toc - Plan #81 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
$388.27
$440.67
$496.19
$693.43
$1,053.73
$685.29
$737.69
$793.21
$990.45
$982.31
$1,034.71
$1,090.23
$1,287.47
$1,279.33
$1,331.73
$1,387.25
$1,584.49
$297.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$776.54
$881.34
$992.38
$1,386.86
$2,107.46
$1,073.56
$1,178.36
$1,289.40
$1,683.88
$1,370.58
$1,475.38
$1,586.42
$1,980.90
$1,667.60
$1,772.40
$1,883.44
$2,277.92
$297.02
Toc - Plan #82 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
$397.90
$451.61
$508.51
$710.63
$1,079.88
$702.29
$756.00
$812.90
$1,015.02
$1,006.68
$1,060.39
$1,117.29
$1,319.41
$1,311.07
$1,364.78
$1,421.68
$1,623.80
$304.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.80
$903.22
$1,017.02
$1,421.26
$2,159.76
$1,100.19
$1,207.61
$1,321.41
$1,725.65
$1,404.58
$1,512.00
$1,625.80
$2,030.04
$1,708.97
$1,816.39
$1,930.19
$2,334.43
$304.39
Toc - Plan #83 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
$382.55
$434.19
$488.89
$683.22
$1,038.22
$675.20
$726.84
$781.54
$975.87
$967.85
$1,019.49
$1,074.19
$1,268.52
$1,260.50
$1,312.14
$1,366.84
$1,561.17
$292.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.10
$868.38
$977.78
$1,366.44
$2,076.44
$1,057.75
$1,161.03
$1,270.43
$1,659.09
$1,350.40
$1,453.68
$1,563.08
$1,951.74
$1,643.05
$1,746.33
$1,855.73
$2,244.39
$292.65
Toc - Plan #84 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
$392.27
$445.21
$501.30
$700.57
$1,064.58
$692.35
$745.29
$801.38
$1,000.65
$992.43
$1,045.37
$1,101.46
$1,300.73
$1,292.51
$1,345.45
$1,401.54
$1,600.81
$300.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.54
$890.42
$1,002.60
$1,401.14
$2,129.16
$1,084.62
$1,190.50
$1,302.68
$1,701.22
$1,384.70
$1,490.58
$1,602.76
$2,001.30
$1,684.78
$1,790.66
$1,902.84
$2,301.38
$300.08
Toc - Plan #85 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
$454.04
$515.32
$580.25
$810.89
$1,232.23
$801.37
$862.65
$927.58
$1,158.22
$1,148.70
$1,209.98
$1,274.91
$1,505.55
$1,496.03
$1,557.31
$1,622.24
$1,852.88
$347.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$908.08
$1,030.64
$1,160.50
$1,621.78
$2,464.46
$1,255.41
$1,377.97
$1,507.83
$1,969.11
$1,602.74
$1,725.30
$1,855.16
$2,316.44
$1,950.07
$2,072.63
$2,202.49
$2,663.77
$347.33
Toc - Plan #86 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
$353.38
$401.08
$451.61
$631.12
$959.05
$623.71
$671.41
$721.94
$901.45
$894.04
$941.74
$992.27
$1,171.78
$1,164.37
$1,212.07
$1,262.60
$1,442.11
$270.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.76
$802.16
$903.22
$1,262.24
$1,918.10
$977.09
$1,072.49
$1,173.55
$1,532.57
$1,247.42
$1,342.82
$1,443.88
$1,802.90
$1,517.75
$1,613.15
$1,714.21
$2,073.23
$270.33
Toc - Plan #87 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
$380.84
$432.24
$486.70
$680.16
$1,033.57
$672.18
$723.58
$778.04
$971.50
$963.52
$1,014.92
$1,069.38
$1,262.84
$1,254.86
$1,306.26
$1,360.72
$1,554.18
$291.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.68
$864.48
$973.40
$1,360.32
$2,067.14
$1,053.02
$1,155.82
$1,264.74
$1,651.66
$1,344.36
$1,447.16
$1,556.08
$1,943.00
$1,635.70
$1,738.50
$1,847.42
$2,234.34
$291.34
Toc - Plan #88 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
$399.54
$453.47
$510.60
$713.56
$1,084.32
$705.18
$759.11
$816.24
$1,019.20
$1,010.82
$1,064.75
$1,121.88
$1,324.84
$1,316.46
$1,370.39
$1,427.52
$1,630.48
$305.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.08
$906.94
$1,021.20
$1,427.12
$2,168.64
$1,104.72
$1,212.58
$1,326.84
$1,732.76
$1,410.36
$1,518.22
$1,632.48
$2,038.40
$1,716.00
$1,823.86
$1,938.12
$2,344.04
$305.64

ADVERTISEMENT

Aetna CVS Health

Local: 1-877-336-3915 | Toll Free: 1-877-336-3915

Toc - Plan #89 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$8,395 $16,790 Annual Deductible
$8,885 $17,770 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.97
$458.50
$516.27
$721.48
$1,096.36
$713.01
$767.54
$825.31
$1,030.52
$1,022.05
$1,076.58
$1,134.35
$1,339.56
$1,331.09
$1,385.62
$1,443.39
$1,648.60
$309.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$807.94
$917.00
$1,032.54
$1,442.96
$2,192.72
$1,116.98
$1,226.04
$1,341.58
$1,752.00
$1,426.02
$1,535.08
$1,650.62
$2,061.04
$1,735.06
$1,844.12
$1,959.66
$2,370.08
$309.04
Toc - Plan #90 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $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
$335.78
$381.11
$429.12
$599.70
$911.29
$592.65
$637.98
$685.99
$856.57
$849.52
$894.85
$942.86
$1,113.44
$1,106.39
$1,151.72
$1,199.73
$1,370.31
$256.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$671.56
$762.22
$858.24
$1,199.40
$1,822.58
$928.43
$1,019.09
$1,115.11
$1,456.27
$1,185.30
$1,275.96
$1,371.98
$1,713.14
$1,442.17
$1,532.83
$1,628.85
$1,970.01
$256.87
Toc - Plan #91 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$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
$449.53
$510.21
$574.50
$802.85
$1,220.01
$793.42
$854.10
$918.39
$1,146.74
$1,137.31
$1,197.99
$1,262.28
$1,490.63
$1,481.20
$1,541.88
$1,606.17
$1,834.52
$343.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$899.06
$1,020.42
$1,149.00
$1,605.70
$2,440.02
$1,242.95
$1,364.31
$1,492.89
$1,949.59
$1,586.84
$1,708.20
$1,836.78
$2,293.48
$1,930.73
$2,052.09
$2,180.67
$2,637.37
$343.89
Toc - Plan #92 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.21
$467.86
$526.80
$736.20
$1,118.73
$727.55
$783.20
$842.14
$1,051.54
$1,042.89
$1,098.54
$1,157.48
$1,366.88
$1,358.23
$1,413.88
$1,472.82
$1,682.22
$315.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$824.42
$935.72
$1,053.60
$1,472.40
$2,237.46
$1,139.76
$1,251.06
$1,368.94
$1,787.74
$1,455.10
$1,566.40
$1,684.28
$2,103.08
$1,770.44
$1,881.74
$1,999.62
$2,418.42
$315.34
Toc - Plan #93 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

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
$404.01
$458.55
$516.32
$721.56
$1,096.47
$713.08
$767.62
$825.39
$1,030.63
$1,022.15
$1,076.69
$1,134.46
$1,339.70
$1,331.22
$1,385.76
$1,443.53
$1,648.77
$309.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.02
$917.10
$1,032.64
$1,443.12
$2,192.94
$1,117.09
$1,226.17
$1,341.71
$1,752.19
$1,426.16
$1,535.24
$1,650.78
$2,061.26
$1,735.23
$1,844.31
$1,959.85
$2,370.33
$309.07
Toc - Plan #94 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 2 HSA: Aetna network of doctors & hospitals + walk-in clinic + Virtual Care 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.80
$374.32
$421.48
$589.02
$895.07
$582.10
$626.62
$673.78
$841.32
$834.40
$878.92
$926.08
$1,093.62
$1,086.70
$1,131.22
$1,178.38
$1,345.92
$252.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.60
$748.64
$842.96
$1,178.04
$1,790.14
$911.90
$1,000.94
$1,095.26
$1,430.34
$1,164.20
$1,253.24
$1,347.56
$1,682.64
$1,416.50
$1,505.54
$1,599.86
$1,934.94
$252.30
Toc - Plan #95 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$0 $0 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
$368.54
$418.29
$470.99
$658.20
$1,000.20
$650.47
$700.22
$752.92
$940.13
$932.40
$982.15
$1,034.85
$1,222.06
$1,214.33
$1,264.08
$1,316.78
$1,503.99
$281.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$737.08
$836.58
$941.98
$1,316.40
$2,000.40
$1,019.01
$1,118.51
$1,223.91
$1,598.33
$1,300.94
$1,400.44
$1,505.84
$1,880.26
$1,582.87
$1,682.37
$1,787.77
$2,162.19
$281.93
Toc - Plan #96 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.79
$507.10
$570.99
$797.96
$1,212.58
$788.58
$848.89
$912.78
$1,139.75
$1,130.37
$1,190.68
$1,254.57
$1,481.54
$1,472.16
$1,532.47
$1,596.36
$1,823.33
$341.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.58
$1,014.20
$1,141.98
$1,595.92
$2,425.16
$1,235.37
$1,355.99
$1,483.77
$1,937.71
$1,577.16
$1,697.78
$1,825.56
$2,279.50
$1,918.95
$2,039.57
$2,167.35
$2,621.29
$341.79
Toc - Plan #97 Aetna CVS Health
Gold

(HMO) Gold 4: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$452.68
$513.79
$578.52
$808.47
$1,228.55
$798.98
$860.09
$924.82
$1,154.77
$1,145.28
$1,206.39
$1,271.12
$1,501.07
$1,491.58
$1,552.69
$1,617.42
$1,847.37
$346.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$905.36
$1,027.58
$1,157.04
$1,616.94
$2,457.10
$1,251.66
$1,373.88
$1,503.34
$1,963.24
$1,597.96
$1,720.18
$1,849.64
$2,309.54
$1,944.26
$2,066.48
$2,195.94
$2,655.84
$346.30
Toc - Plan #98 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors & hospitals + $0 walk-in clinic + $0 Virtual Care options 24/7

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$411.97
$467.58
$526.50
$735.77
$1,118.08
$727.13
$782.74
$841.66
$1,050.93
$1,042.29
$1,097.90
$1,156.82
$1,366.09
$1,357.45
$1,413.06
$1,471.98
$1,681.25
$315.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$823.94
$935.16
$1,053.00
$1,471.54
$2,236.16
$1,139.10
$1,250.32
$1,368.16
$1,786.70
$1,454.26
$1,565.48
$1,683.32
$2,101.86
$1,769.42
$1,880.64
$1,998.48
$2,417.02
$315.16

‡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 Effingham County here.

Effingham County is in “Rating Area 14” of Georgia.

Currently, there are 98 plans offered in Rating Area 14.

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2024 Obamacare Plans for Effingham County, GA

Plan Browser: 98 Plans
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