Obamacare 2023 Rates for Stephens County

Obamacare > Rates > Georgia > Stephens County

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

The health insurance rates listed below are for calendar year 2023.

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

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

Obamacare Providers, 105 Plans and 2023 Rates for Stephens County, Georgia

Below, you’ll find a summary of the 105 plans for Stephens County, Georgia and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

Cigna HealthCare of Georgia, Inc

Local: | Toll Free:

Toc - Plan #1 Cigna HealthCare of Georgia, Inc

Bronze

(HMO) Cigna Connect 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$221.00
$250.83
$282.44
$394.70
$599.79

$390.06
$419.89
$451.50
$563.76

$559.12
$588.95
$620.56
$732.82

$728.18
$758.01
$789.62
$901.88

$169.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$442.00
$501.66
$564.88
$789.40
$1,199.58

$611.06
$670.72
$733.94
$958.46

$780.12
$839.78
$903.00
$1,127.52

$949.18
$1,008.84
$1,072.06
$1,296.58

$169.06

Toc - Plan #2 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 7800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,800 $15,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$228.80
$259.68
$292.40
$408.63
$620.96

$403.83
$434.71
$467.43
$583.66

$578.86
$609.74
$642.46
$758.69

$753.89
$784.77
$817.49
$933.72

$175.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$457.60
$519.36
$584.80
$817.26
$1,241.92

$632.63
$694.39
$759.83
$992.29

$807.66
$869.42
$934.86
$1,167.32

$982.69
$1,044.45
$1,109.89
$1,342.35

$175.03

Toc - Plan #3 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 6500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$229.57
$260.56
$293.39
$410.01
$623.06

$405.19
$436.18
$469.01
$585.63

$580.81
$611.80
$644.63
$761.25

$756.43
$787.42
$820.25
$936.87

$175.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$459.14
$521.12
$586.78
$820.02
$1,246.12

$634.76
$696.74
$762.40
$995.64

$810.38
$872.36
$938.02
$1,171.26

$986.00
$1,047.98
$1,113.64
$1,346.88

$175.62

Toc - Plan #4 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect HSA 7050

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,050 $14,100 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$232.05
$263.37
$296.56
$414.44
$629.78

$409.57
$440.89
$474.08
$591.96

$587.09
$618.41
$651.60
$769.48

$764.61
$795.93
$829.12
$947.00

$177.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$464.10
$526.74
$593.12
$828.88
$1,259.56

$641.62
$704.26
$770.64
$1,006.40

$819.14
$881.78
$948.16
$1,183.92

$996.66
$1,059.30
$1,125.68
$1,361.44

$177.52

Toc - Plan #5 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,800 $13,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$231.83
$263.13
$296.28
$414.05
$629.19

$409.18
$440.48
$473.63
$591.40

$586.53
$617.83
$650.98
$768.75

$763.88
$795.18
$828.33
$946.10

$177.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$463.66
$526.26
$592.56
$828.10
$1,258.38

$641.01
$703.61
$769.91
$1,005.45

$818.36
$880.96
$947.26
$1,182.80

$995.71
$1,058.31
$1,124.61
$1,360.15

$177.35

Toc - Plan #6 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 3700

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,700 $7,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$267.92
$304.08
$342.40
$478.50
$727.12

$472.88
$509.04
$547.36
$683.46

$677.84
$714.00
$752.32
$888.42

$882.80
$918.96
$957.28
$1,093.38

$204.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$535.84
$608.16
$684.80
$957.00
$1,454.24

$740.80
$813.12
$889.76
$1,161.96

$945.76
$1,018.08
$1,094.72
$1,366.92

$1,150.72
$1,223.04
$1,299.68
$1,571.88

$204.96

Toc - Plan #7 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 5000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$267.95
$304.12
$342.44
$478.55
$727.21

$472.93
$509.10
$547.42
$683.53

$677.91
$714.08
$752.40
$888.51

$882.89
$919.06
$957.38
$1,093.49

$204.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$535.90
$608.24
$684.88
$957.10
$1,454.42

$740.88
$813.22
$889.86
$1,162.08

$945.86
$1,018.20
$1,094.84
$1,367.06

$1,150.84
$1,223.18
$1,299.82
$1,572.04

$204.98

Toc - Plan #8 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 6000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$268.35
$304.58
$342.95
$479.27
$728.30

$473.64
$509.87
$548.24
$684.56

$678.93
$715.16
$753.53
$889.85

$884.22
$920.45
$958.82
$1,095.14

$205.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$536.70
$609.16
$685.90
$958.54
$1,456.60

$741.99
$814.45
$891.19
$1,163.83

$947.28
$1,019.74
$1,096.48
$1,369.12

$1,152.57
$1,225.03
$1,301.77
$1,574.41

$205.29

Toc - Plan #9 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 7200

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,200 $14,400 Annual Deductible

$7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$271.85
$308.54
$347.42
$485.52
$737.79

$479.81
$516.50
$555.38
$693.48

$687.77
$724.46
$763.34
$901.44

$895.73
$932.42
$971.30
$1,109.40

$207.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$543.70
$617.08
$694.84
$971.04
$1,475.58

$751.66
$825.04
$902.80
$1,179.00

$959.62
$1,033.00
$1,110.76
$1,386.96

$1,167.58
$1,240.96
$1,318.72
$1,594.92

$207.96

Toc - Plan #10 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$3,800 $7,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$270.55
$307.07
$345.76
$483.20
$734.26

$477.52
$514.04
$552.73
$690.17

$684.49
$721.01
$759.70
$897.14

$891.46
$927.98
$966.67
$1,104.11

$206.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$541.10
$614.14
$691.52
$966.40
$1,468.52

$748.07
$821.11
$898.49
$1,173.37

$955.04
$1,028.08
$1,105.46
$1,380.34

$1,162.01
$1,235.05
$1,312.43
$1,587.31

$206.97

Toc - Plan #11 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$4,200 $8,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$269.28
$305.63
$344.14
$480.93
$730.82

$475.28
$511.63
$550.14
$686.93

$681.28
$717.63
$756.14
$892.93

$887.28
$923.63
$962.14
$1,098.93

$206.00

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$538.56
$611.26
$688.28
$961.86
$1,461.64

$744.56
$817.26
$894.28
$1,167.86

$950.56
$1,023.26
$1,100.28
$1,373.86

$1,156.56
$1,229.26
$1,306.28
$1,579.86

$206.00

Toc - Plan #12 Cigna HealthCare of Georgia, Inc

Gold

(HMO) Cigna Connect 1600

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,600 $3,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$339.37
$385.19
$433.72
$606.12
$921.06

$598.99
$644.81
$693.34
$865.74

$858.61
$904.43
$952.96
$1,125.36

$1,118.23
$1,164.05
$1,212.58
$1,384.98

$259.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$678.74
$770.38
$867.44
$1,212.24
$1,842.12

$938.36
$1,030.00
$1,127.06
$1,471.86

$1,197.98
$1,289.62
$1,386.68
$1,731.48

$1,457.60
$1,549.24
$1,646.30
$1,991.10

$259.62

Toc - Plan #13 Cigna HealthCare of Georgia, Inc

Gold

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$341.54
$387.65
$436.49
$609.99
$926.94

$602.82
$648.93
$697.77
$871.27

$864.10
$910.21
$959.05
$1,132.55

$1,125.38
$1,171.49
$1,220.33
$1,393.83

$261.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$683.08
$775.30
$872.98
$1,219.98
$1,853.88

$944.36
$1,036.58
$1,134.26
$1,481.26

$1,205.64
$1,297.86
$1,395.54
$1,742.54

$1,466.92
$1,559.14
$1,656.82
$2,003.82

$261.28

Toc - Plan #14 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,600 $15,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$232.42
$263.79
$297.03
$415.10
$630.78

$410.22
$441.59
$474.83
$592.90

$588.02
$619.39
$652.63
$770.70

$765.82
$797.19
$830.43
$948.50

$177.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$464.84
$527.58
$594.06
$830.20
$1,261.56

$642.64
$705.38
$771.86
$1,008.00

$820.44
$883.18
$949.66
$1,185.80

$998.24
$1,060.98
$1,127.46
$1,363.60

$177.80

Toc - Plan #15 Cigna HealthCare of Georgia, Inc

Bronze

(HMO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$221.00
$250.83
$282.44
$394.70
$599.79

$390.06
$419.89
$451.50
$563.76

$559.12
$588.95
$620.56
$732.82

$728.18
$758.01
$789.62
$901.88

$169.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$442.00
$501.66
$564.88
$789.40
$1,199.58

$611.06
$670.72
$733.94
$958.46

$780.12
$839.78
$903.00
$1,127.52

$949.18
$1,008.84
$1,072.06
$1,296.58

$169.06

Toc - Plan #16 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$230.28
$261.37
$294.30
$411.29
$624.99

$406.45
$437.54
$470.47
$587.46

$582.62
$613.71
$646.64
$763.63

$758.79
$789.88
$822.81
$939.80

$176.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$460.56
$522.74
$588.60
$822.58
$1,249.98

$636.73
$698.91
$764.77
$998.75

$812.90
$875.08
$940.94
$1,174.92

$989.07
$1,051.25
$1,117.11
$1,351.09

$176.17

Toc - Plan #17 Cigna HealthCare of Georgia, Inc

Expanded Bronze

(HMO) Cigna Connect 0

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$247.43
$280.83
$316.21
$441.91
$671.52

$436.71
$470.11
$505.49
$631.19

$625.99
$659.39
$694.77
$820.47

$815.27
$848.67
$884.05
$1,009.75

$189.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$494.86
$561.66
$632.42
$883.82
$1,343.04

$684.14
$750.94
$821.70
$1,073.10

$873.42
$940.22
$1,010.98
$1,262.38

$1,062.70
$1,129.50
$1,200.26
$1,451.66

$189.28

Toc - Plan #18 Cigna HealthCare of Georgia, Inc

Gold

(HMO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$337.80
$383.40
$431.70
$603.30
$916.78

$596.21
$641.81
$690.11
$861.71

$854.62
$900.22
$948.52
$1,120.12

$1,113.03
$1,158.63
$1,206.93
$1,378.53

$258.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$675.60
$766.80
$863.40
$1,206.60
$1,833.56

$934.01
$1,025.21
$1,121.81
$1,465.01

$1,192.42
$1,283.62
$1,380.22
$1,723.42

$1,450.83
$1,542.03
$1,638.63
$1,981.83

$258.41

Toc - Plan #19 Cigna HealthCare of Georgia, Inc

Silver

(HMO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$268.35
$304.58
$342.95
$479.27
$728.30

$473.64
$509.87
$548.24
$684.56

$678.93
$715.16
$753.53
$889.85

$884.22
$920.45
$958.82
$1,095.14

$205.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$536.70
$609.16
$685.90
$958.54
$1,456.60

$741.99
$814.45
$891.19
$1,163.83

$947.28
$1,019.74
$1,096.48
$1,369.12

$1,152.57
$1,225.03
$1,301.77
$1,574.41

$205.29

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

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

Toc - Plan #20 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Catastrophic

(HMO) Anthem Catastrophic Pathway X HMO 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$199.24
$226.14
$254.63
$355.84
$540.74

$351.66
$378.56
$407.05
$508.26

$504.08
$530.98
$559.47
$660.68

$656.50
$683.40
$711.89
$813.10

$152.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$398.48
$452.28
$509.26
$711.68
$1,081.48

$550.90
$604.70
$661.68
$864.10

$703.32
$757.12
$814.10
$1,016.52

$855.74
$909.54
$966.52
$1,168.94

$152.42

Toc - Plan #21 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$7,450 $14,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$289.62
$328.72
$370.13
$517.26
$786.03

$511.18
$550.28
$591.69
$738.82

$732.74
$771.84
$813.25
$960.38

$954.30
$993.40
$1,034.81
$1,181.94

$221.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$579.24
$657.44
$740.26
$1,034.52
$1,572.06

$800.80
$879.00
$961.82
$1,256.08

$1,022.36
$1,100.56
$1,183.38
$1,477.64

$1,243.92
$1,322.12
$1,404.94
$1,699.20

$221.56

Toc - Plan #22 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,600 $11,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$280.52
$318.39
$358.50
$501.01
$761.33

$495.12
$532.99
$573.10
$715.61

$709.72
$747.59
$787.70
$930.21

$924.32
$962.19
$1,002.30
$1,144.81

$214.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$561.04
$636.78
$717.00
$1,002.02
$1,522.66

$775.64
$851.38
$931.60
$1,216.62

$990.24
$1,065.98
$1,146.20
$1,431.22

$1,204.84
$1,280.58
$1,360.80
$1,645.82

$214.60

Toc - Plan #23 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$275.73
$312.95
$352.38
$492.45
$748.33

$486.66
$523.88
$563.31
$703.38

$697.59
$734.81
$774.24
$914.31

$908.52
$945.74
$985.17
$1,125.24

$210.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$551.46
$625.90
$704.76
$984.90
$1,496.66

$762.39
$836.83
$915.69
$1,195.83

$973.32
$1,047.76
$1,126.62
$1,406.76

$1,184.25
$1,258.69
$1,337.55
$1,617.69

$210.93

Toc - Plan #24 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$346.09
$392.81
$442.30
$618.12
$939.29

$610.85
$657.57
$707.06
$882.88

$875.61
$922.33
$971.82
$1,147.64

$1,140.37
$1,187.09
$1,236.58
$1,412.40

$264.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$692.18
$785.62
$884.60
$1,236.24
$1,878.58

$956.94
$1,050.38
$1,149.36
$1,501.00

$1,221.70
$1,315.14
$1,414.12
$1,765.76

$1,486.46
$1,579.90
$1,678.88
$2,030.52

$264.76

Toc - Plan #25 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$348.70
$395.77
$445.64
$622.78
$946.37

$615.46
$662.53
$712.40
$889.54

$882.22
$929.29
$979.16
$1,156.30

$1,148.98
$1,196.05
$1,245.92
$1,423.06

$266.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$697.40
$791.54
$891.28
$1,245.56
$1,892.74

$964.16
$1,058.30
$1,158.04
$1,512.32

$1,230.92
$1,325.06
$1,424.80
$1,779.08

$1,497.68
$1,591.82
$1,691.56
$2,045.84

$266.76

Toc - Plan #26 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$8,000 $16,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$264.82
$300.57
$338.44
$472.97
$718.72

$467.41
$503.16
$541.03
$675.56

$670.00
$705.75
$743.62
$878.15

$872.59
$908.34
$946.21
$1,080.74

$202.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$529.64
$601.14
$676.88
$945.94
$1,437.44

$732.23
$803.73
$879.47
$1,148.53

$934.82
$1,006.32
$1,082.06
$1,351.12

$1,137.41
$1,208.91
$1,284.65
$1,553.71

$202.59

Toc - Plan #27 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$4,950 $9,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$350.88
$398.25
$448.42
$626.67
$952.29

$619.30
$666.67
$716.84
$895.09

$887.72
$935.09
$985.26
$1,163.51

$1,156.14
$1,203.51
$1,253.68
$1,431.93

$268.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$701.76
$796.50
$896.84
$1,253.34
$1,904.58

$970.18
$1,064.92
$1,165.26
$1,521.76

$1,238.60
$1,333.34
$1,433.68
$1,790.18

$1,507.02
$1,601.76
$1,702.10
$2,058.60

$268.42

Toc - Plan #28 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$344.61
$391.13
$440.41
$615.47
$935.27

$608.24
$654.76
$704.04
$879.10

$871.87
$918.39
$967.67
$1,142.73

$1,135.50
$1,182.02
$1,231.30
$1,406.36

$263.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$689.22
$782.26
$880.82
$1,230.94
$1,870.54

$952.85
$1,045.89
$1,144.45
$1,494.57

$1,216.48
$1,309.52
$1,408.08
$1,758.20

$1,480.11
$1,573.15
$1,671.71
$2,021.83

$263.63

Toc - Plan #29 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$1,600 $3,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$385.09
$437.08
$492.15
$687.77
$1,045.13

$679.68
$731.67
$786.74
$982.36

$974.27
$1,026.26
$1,081.33
$1,276.95

$1,268.86
$1,320.85
$1,375.92
$1,571.54

$294.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$770.18
$874.16
$984.30
$1,375.54
$2,090.26

$1,064.77
$1,168.75
$1,278.89
$1,670.13

$1,359.36
$1,463.34
$1,573.48
$1,964.72

$1,653.95
$1,757.93
$1,868.07
$2,259.31

$294.59

Toc - Plan #30 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$292.40
$331.87
$373.69
$522.23
$793.57

$516.09
$555.56
$597.38
$745.92

$739.78
$779.25
$821.07
$969.61

$963.47
$1,002.94
$1,044.76
$1,193.30

$223.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$584.80
$663.74
$747.38
$1,044.46
$1,587.14

$808.49
$887.43
$971.07
$1,268.15

$1,032.18
$1,111.12
$1,194.76
$1,491.84

$1,255.87
$1,334.81
$1,418.45
$1,715.53

$223.69

Toc - Plan #31 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$2,600 $5,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$367.60
$417.23
$469.79
$656.53
$997.67

$648.81
$698.44
$751.00
$937.74

$930.02
$979.65
$1,032.21
$1,218.95

$1,211.23
$1,260.86
$1,313.42
$1,500.16

$281.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$735.20
$834.46
$939.58
$1,313.06
$1,995.34

$1,016.41
$1,115.67
$1,220.79
$1,594.27

$1,297.62
$1,396.88
$1,502.00
$1,875.48

$1,578.83
$1,678.09
$1,783.21
$2,156.69

$281.21

Toc - Plan #32 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$272.74
$309.56
$348.56
$487.11
$740.22

$481.39
$518.21
$557.21
$695.76

$690.04
$726.86
$765.86
$904.41

$898.69
$935.51
$974.51
$1,113.06

$208.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$545.48
$619.12
$697.12
$974.22
$1,480.44

$754.13
$827.77
$905.77
$1,182.87

$962.78
$1,036.42
$1,114.42
$1,391.52

$1,171.43
$1,245.07
$1,323.07
$1,600.17

$208.65

Toc - Plan #33 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$298.34
$338.62
$381.28
$532.84
$809.69

$526.57
$566.85
$609.51
$761.07

$754.80
$795.08
$837.74
$989.30

$983.03
$1,023.31
$1,065.97
$1,217.53

$228.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$596.68
$677.24
$762.56
$1,065.68
$1,619.38

$824.91
$905.47
$990.79
$1,293.91

$1,053.14
$1,133.70
$1,219.02
$1,522.14

$1,281.37
$1,361.93
$1,447.25
$1,750.37

$228.23

Toc - Plan #34 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$349.97
$397.22
$447.26
$625.05
$949.82

$617.70
$664.95
$714.99
$892.78

$885.43
$932.68
$982.72
$1,160.51

$1,153.16
$1,200.41
$1,250.45
$1,428.24

$267.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$699.94
$794.44
$894.52
$1,250.10
$1,899.64

$967.67
$1,062.17
$1,162.25
$1,517.83

$1,235.40
$1,329.90
$1,429.98
$1,785.56

$1,503.13
$1,597.63
$1,697.71
$2,053.29

$267.73

Toc - Plan #35 Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-738-6652

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$395.74
$449.16
$505.76
$706.79
$1,074.04

$698.48
$751.90
$808.50
$1,009.53

$1,001.22
$1,054.64
$1,111.24
$1,312.27

$1,303.96
$1,357.38
$1,413.98
$1,615.01

$302.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$791.48
$898.32
$1,011.52
$1,413.58
$2,148.08

$1,094.22
$1,201.06
$1,314.26
$1,716.32

$1,396.96
$1,503.80
$1,617.00
$2,019.06

$1,699.70
$1,806.54
$1,919.74
$2,321.80

$302.74

Ambetter from Peach State Health Plan

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

Toc - Plan #36 Ambetter from Peach State Health Plan

Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$217.90
$247.31
$278.46
$389.15
$591.36

$384.59
$414.00
$445.15
$555.84

$551.28
$580.69
$611.84
$722.53

$717.97
$747.38
$778.53
$889.22

$166.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$435.80
$494.62
$556.92
$778.30
$1,182.72

$602.49
$661.31
$723.61
$944.99

$769.18
$828.00
$890.30
$1,111.68

$935.87
$994.69
$1,056.99
$1,278.37

$166.69

Toc - Plan #37 Ambetter from Peach State Health Plan

Silver

(HMO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$7,550 $15,100 Annual Deductible

$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$261.68
$296.99
$334.41
$467.34
$710.17

$461.86
$497.17
$534.59
$667.52

$662.04
$697.35
$734.77
$867.70

$862.22
$897.53
$934.95
$1,067.88

$200.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$523.36
$593.98
$668.82
$934.68
$1,420.34

$723.54
$794.16
$869.00
$1,134.86

$923.72
$994.34
$1,069.18
$1,335.04

$1,123.90
$1,194.52
$1,269.36
$1,535.22

$200.18

Toc - Plan #38 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

$258.77
$293.70
$330.70
$462.15
$702.28

$456.72
$491.65
$528.65
$660.10

$654.67
$689.60
$726.60
$858.05

$852.62
$887.55
$924.55
$1,056.00

$197.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$517.54
$587.40
$661.40
$924.30
$1,404.56

$715.49
$785.35
$859.35
$1,122.25

$913.44
$983.30
$1,057.30
$1,320.20

$1,111.39
$1,181.25
$1,255.25
$1,518.15

$197.95

Toc - Plan #39 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

$273.79
$310.74
$349.89
$488.98
$743.05

$483.23
$520.18
$559.33
$698.42

$692.67
$729.62
$768.77
$907.86

$902.11
$939.06
$978.21
$1,117.30

$209.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$547.58
$621.48
$699.78
$977.96
$1,486.10

$757.02
$830.92
$909.22
$1,187.40

$966.46
$1,040.36
$1,118.66
$1,396.84

$1,175.90
$1,249.80
$1,328.10
$1,606.28

$209.44

Toc - Plan #40 Ambetter from Peach State Health Plan

Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$256.08
$290.64
$327.26
$457.34
$694.97

$451.97
$486.53
$523.15
$653.23

$647.86
$682.42
$719.04
$849.12

$843.75
$878.31
$914.93
$1,045.01

$195.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$512.16
$581.28
$654.52
$914.68
$1,389.94

$708.05
$777.17
$850.41
$1,110.57

$903.94
$973.06
$1,046.30
$1,306.46

$1,099.83
$1,168.95
$1,242.19
$1,502.35

$195.89

Toc - Plan #41 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$239.44
$271.75
$305.99
$427.61
$649.80

$422.60
$454.91
$489.15
$610.77

$605.76
$638.07
$672.31
$793.93

$788.92
$821.23
$855.47
$977.09

$183.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$478.88
$543.50
$611.98
$855.22
$1,299.60

$662.04
$726.66
$795.14
$1,038.38

$845.20
$909.82
$978.30
$1,221.54

$1,028.36
$1,092.98
$1,161.46
$1,404.70

$183.16

Toc - Plan #42 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$234.44
$266.08
$299.60
$418.69
$636.24

$413.78
$445.42
$478.94
$598.03

$593.12
$624.76
$658.28
$777.37

$772.46
$804.10
$837.62
$956.71

$179.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$468.88
$532.16
$599.20
$837.38
$1,272.48

$648.22
$711.50
$778.54
$1,016.72

$827.56
$890.84
$957.88
$1,196.06

$1,006.90
$1,070.18
$1,137.22
$1,375.40

$179.34

Toc - Plan #43 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$265.26
$301.06
$338.99
$473.74
$719.90

$468.18
$503.98
$541.91
$676.66

$671.10
$706.90
$744.83
$879.58

$874.02
$909.82
$947.75
$1,082.50

$202.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$530.52
$602.12
$677.98
$947.48
$1,439.80

$733.44
$805.04
$880.90
$1,150.40

$936.36
$1,007.96
$1,083.82
$1,353.32

$1,139.28
$1,210.88
$1,286.74
$1,556.24

$202.92

Toc - Plan #44 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

$252.26
$286.30
$322.37
$450.51
$684.60

$445.23
$479.27
$515.34
$643.48

$638.20
$672.24
$708.31
$836.45

$831.17
$865.21
$901.28
$1,029.42

$192.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$504.52
$572.60
$644.74
$901.02
$1,369.20

$697.49
$765.57
$837.71
$1,093.99

$890.46
$958.54
$1,030.68
$1,286.96

$1,083.43
$1,151.51
$1,223.65
$1,479.93

$192.97

Toc - Plan #45 Ambetter from Peach State Health Plan

Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$255.11
$289.54
$326.02
$455.61
$692.34

$450.26
$484.69
$521.17
$650.76

$645.41
$679.84
$716.32
$845.91

$840.56
$874.99
$911.47
$1,041.06

$195.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$510.22
$579.08
$652.04
$911.22
$1,384.68

$705.37
$774.23
$847.19
$1,106.37

$900.52
$969.38
$1,042.34
$1,301.52

$1,095.67
$1,164.53
$1,237.49
$1,496.67

$195.15

Toc - Plan #46 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

$261.70
$297.02
$334.44
$467.39
$710.24

$461.90
$497.22
$534.64
$667.59

$662.10
$697.42
$734.84
$867.79

$862.30
$897.62
$935.04
$1,067.99

$200.20

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$523.40
$594.04
$668.88
$934.78
$1,420.48

$723.60
$794.24
$869.08
$1,134.98

$923.80
$994.44
$1,069.28
$1,335.18

$1,124.00
$1,194.64
$1,269.48
$1,535.38

$200.20

Toc - Plan #47 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

$258.67
$293.58
$330.57
$461.96
$702.00

$456.54
$491.45
$528.44
$659.83

$654.41
$689.32
$726.31
$857.70

$852.28
$887.19
$924.18
$1,055.57

$197.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$517.34
$587.16
$661.14
$923.92
$1,404.00

$715.21
$785.03
$859.01
$1,121.79

$913.08
$982.90
$1,056.88
$1,319.66

$1,110.95
$1,180.77
$1,254.75
$1,517.53

$197.87

Toc - Plan #48 Ambetter from Peach State Health Plan

Gold

(HMO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$302.05
$342.82
$386.01
$539.45
$819.75

$533.11
$573.88
$617.07
$770.51

$764.17
$804.94
$848.13
$1,001.57

$995.23
$1,036.00
$1,079.19
$1,232.63

$231.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.10
$685.64
$772.02
$1,078.90
$1,639.50

$835.16
$916.70
$1,003.08
$1,309.96

$1,066.22
$1,147.76
$1,234.14
$1,541.02

$1,297.28
$1,378.82
$1,465.20
$1,772.08

$231.06

Toc - Plan #49 Ambetter from Peach State Health Plan

Bronze

(HMO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$207.43
$235.43
$265.09
$370.46
$562.95

$366.11
$394.11
$423.77
$529.14

$524.79
$552.79
$582.45
$687.82

$683.47
$711.47
$741.13
$846.50

$158.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$414.86
$470.86
$530.18
$740.92
$1,125.90

$573.54
$629.54
$688.86
$899.60

$732.22
$788.22
$847.54
$1,058.28

$890.90
$946.90
$1,006.22
$1,216.96

$158.68

Toc - Plan #50 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$229.52
$260.49
$293.31
$409.90
$622.89

$405.09
$436.06
$468.88
$585.47

$580.66
$611.63
$644.45
$761.04

$756.23
$787.20
$820.02
$936.61

$175.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$459.04
$520.98
$586.62
$819.80
$1,245.78

$634.61
$696.55
$762.19
$995.37

$810.18
$872.12
$937.76
$1,170.94

$985.75
$1,047.69
$1,113.33
$1,346.51

$175.57

Toc - Plan #51 Ambetter from Peach State Health Plan

Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$252.81
$286.92
$323.07
$451.50
$686.09

$446.20
$480.31
$516.46
$644.89

$639.59
$673.70
$709.85
$838.28

$832.98
$867.09
$903.24
$1,031.67

$193.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$505.62
$573.84
$646.14
$903.00
$1,372.18

$699.01
$767.23
$839.53
$1,096.39

$892.40
$960.62
$1,032.92
$1,289.78

$1,085.79
$1,154.01
$1,226.31
$1,483.17

$193.39

Toc - Plan #52 Ambetter from Peach State Health Plan

Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$259.24
$294.23
$331.30
$462.99
$703.56

$457.55
$492.54
$529.61
$661.30

$655.86
$690.85
$727.92
$859.61

$854.17
$889.16
$926.23
$1,057.92

$198.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$518.48
$588.46
$662.60
$925.98
$1,407.12

$716.79
$786.77
$860.91
$1,124.29

$915.10
$985.08
$1,059.22
$1,322.60

$1,113.41
$1,183.39
$1,257.53
$1,520.91

$198.31

Toc - Plan #53 Ambetter from Peach State Health Plan

Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$266.22
$302.15
$340.22
$475.45
$722.50

$469.87
$505.80
$543.87
$679.10

$673.52
$709.45
$747.52
$882.75

$877.17
$913.10
$951.17
$1,086.40

$203.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$532.44
$604.30
$680.44
$950.90
$1,445.00

$736.09
$807.95
$884.09
$1,154.55

$939.74
$1,011.60
$1,087.74
$1,358.20

$1,143.39
$1,215.25
$1,291.39
$1,561.85

$203.65

Toc - Plan #54 Ambetter from Peach State Health Plan

Silver

(HMO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$7,550 $15,100 Annual Deductible

$7,550 $15,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$272.04
$308.76
$347.66
$485.85
$738.30

$480.14
$516.86
$555.76
$693.95

$688.24
$724.96
$763.86
$902.05

$896.34
$933.06
$971.96
$1,110.15

$208.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$544.08
$617.52
$695.32
$971.70
$1,476.60

$752.18
$825.62
$903.42
$1,179.80

$960.28
$1,033.72
$1,111.52
$1,387.90

$1,168.38
$1,241.82
$1,319.62
$1,596.00

$208.10

Toc - Plan #55 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

$269.02
$305.33
$343.80
$480.46
$730.10

$474.81
$511.12
$549.59
$686.25

$680.60
$716.91
$755.38
$892.04

$886.39
$922.70
$961.17
$1,097.83

$205.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$538.04
$610.66
$687.60
$960.92
$1,460.20

$743.83
$816.45
$893.39
$1,166.71

$949.62
$1,022.24
$1,099.18
$1,372.50

$1,155.41
$1,228.03
$1,304.97
$1,578.29

$205.79

Toc - Plan #56 Ambetter from Peach State Health Plan

Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$226.53
$257.10
$289.49
$404.57
$614.78

$399.82
$430.39
$462.78
$577.86

$573.11
$603.68
$636.07
$751.15

$746.40
$776.97
$809.36
$924.44

$173.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$453.06
$514.20
$578.98
$809.14
$1,229.56

$626.35
$687.49
$752.27
$982.43

$799.64
$860.78
$925.56
$1,155.72

$972.93
$1,034.07
$1,098.85
$1,329.01

$173.29

Toc - Plan #57 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

$284.64
$323.05
$363.75
$508.34
$772.48

$502.38
$540.79
$581.49
$726.08

$720.12
$758.53
$799.23
$943.82

$937.86
$976.27
$1,016.97
$1,161.56

$217.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$569.28
$646.10
$727.50
$1,016.68
$1,544.96

$787.02
$863.84
$945.24
$1,234.42

$1,004.76
$1,081.58
$1,162.98
$1,452.16

$1,222.50
$1,299.32
$1,380.72
$1,669.90

$217.74

Toc - Plan #58 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$248.92
$282.51
$318.11
$444.55
$675.54

$439.34
$472.93
$508.53
$634.97

$629.76
$663.35
$698.95
$825.39

$820.18
$853.77
$889.37
$1,015.81

$190.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$497.84
$565.02
$636.22
$889.10
$1,351.08

$688.26
$755.44
$826.64
$1,079.52

$878.68
$945.86
$1,017.06
$1,269.94

$1,069.10
$1,136.28
$1,207.48
$1,460.36

$190.42

Toc - Plan #59 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$243.72
$276.62
$311.47
$435.27
$661.44

$430.16
$463.06
$497.91
$621.71

$616.60
$649.50
$684.35
$808.15

$803.04
$835.94
$870.79
$994.59

$186.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$487.44
$553.24
$622.94
$870.54
$1,322.88

$673.88
$739.68
$809.38
$1,056.98

$860.32
$926.12
$995.82
$1,243.42

$1,046.76
$1,112.56
$1,182.26
$1,429.86

$186.44

Toc - Plan #60 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$275.77
$312.99
$352.42
$492.51
$748.41

$486.73
$523.95
$563.38
$703.47

$697.69
$734.91
$774.34
$914.43

$908.65
$945.87
$985.30
$1,125.39

$210.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$551.54
$625.98
$704.84
$985.02
$1,496.82

$762.50
$836.94
$915.80
$1,195.98

$973.46
$1,047.90
$1,126.76
$1,406.94

$1,184.42
$1,258.86
$1,337.72
$1,617.90

$210.96

Toc - Plan #61 Ambetter from Peach State Health Plan

Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$265.21
$301.01
$338.93
$473.65
$719.76

$468.09
$503.89
$541.81
$676.53

$670.97
$706.77
$744.69
$879.41

$873.85
$909.65
$947.57
$1,082.29

$202.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$530.42
$602.02
$677.86
$947.30
$1,439.52

$733.30
$804.90
$880.74
$1,150.18

$936.18
$1,007.78
$1,083.62
$1,353.06

$1,139.06
$1,210.66
$1,286.50
$1,555.94

$202.88

Toc - Plan #62 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

$272.07
$308.79
$347.69
$485.90
$738.37

$480.20
$516.92
$555.82
$694.03

$688.33
$725.05
$763.95
$902.16

$896.46
$933.18
$972.08
$1,110.29

$208.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$544.14
$617.58
$695.38
$971.80
$1,476.74

$752.27
$825.71
$903.51
$1,179.93

$960.40
$1,033.84
$1,111.64
$1,388.06

$1,168.53
$1,241.97
$1,319.77
$1,596.19

$208.13

Toc - Plan #63 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

$262.25
$297.64
$335.14
$468.36
$711.72

$462.86
$498.25
$535.75
$668.97

$663.47
$698.86
$736.36
$869.58

$864.08
$899.47
$936.97
$1,070.19

$200.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$524.50
$595.28
$670.28
$936.72
$1,423.44

$725.11
$795.89
$870.89
$1,137.33

$925.72
$996.50
$1,071.50
$1,337.94

$1,126.33
$1,197.11
$1,272.11
$1,538.55

$200.61

Toc - Plan #64 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

$268.91
$305.21
$343.66
$480.26
$729.81

$474.62
$510.92
$549.37
$685.97

$680.33
$716.63
$755.08
$891.68

$886.04
$922.34
$960.79
$1,097.39

$205.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$537.82
$610.42
$687.32
$960.52
$1,459.62

$743.53
$816.13
$893.03
$1,166.23

$949.24
$1,021.84
$1,098.74
$1,371.94

$1,154.95
$1,227.55
$1,304.45
$1,577.65

$205.71

Toc - Plan #65 Ambetter from Peach State Health Plan

Gold

(HMO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$5,000 $10,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$314.02
$356.40
$401.30
$560.82
$852.21

$554.24
$596.62
$641.52
$801.04

$794.46
$836.84
$881.74
$1,041.26

$1,034.68
$1,077.06
$1,121.96
$1,281.48

$240.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$628.04
$712.80
$802.60
$1,121.64
$1,704.42

$868.26
$953.02
$1,042.82
$1,361.86

$1,108.48
$1,193.24
$1,283.04
$1,602.08

$1,348.70
$1,433.46
$1,523.26
$1,842.30

$240.22

Toc - Plan #66 Ambetter from Peach State Health Plan

Expanded Bronze

(HMO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$228.13
$258.92
$291.54
$407.43
$619.12

$402.64
$433.43
$466.05
$581.94

$577.15
$607.94
$640.56
$756.45

$751.66
$782.45
$815.07
$930.96

$174.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$456.26
$517.84
$583.08
$814.86
$1,238.24

$630.77
$692.35
$757.59
$989.37

$805.28
$866.86
$932.10
$1,163.88

$979.79
$1,041.37
$1,106.61
$1,338.39

$174.51

Toc - Plan #67 Ambetter from Peach State Health Plan

Silver

(HMO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$5,700 $11,400 Annual Deductible

$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$249.61
$283.30
$319.00
$445.79
$677.43

$440.56
$474.25
$509.95
$636.74

$631.51
$665.20
$700.90
$827.69

$822.46
$856.15
$891.85
$1,018.64

$190.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$499.22
$566.60
$638.00
$891.58
$1,354.86

$690.17
$757.55
$828.95
$1,082.53

$881.12
$948.50
$1,019.90
$1,273.48

$1,072.07
$1,139.45
$1,210.85
$1,464.43

$190.95

Toc - Plan #68 Ambetter from Peach State Health Plan

Gold

(HMO) Ambetter Virtual Access Gold - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-687-1180

Annual Out of Pocket Expenses:

Individual Family

$950 $1,900 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$265.97
$301.86
$339.90
$475.00
$721.81

$469.43
$505.32
$543.36
$678.46

$672.89
$708.78
$746.82
$881.92

$876.35
$912.24
$950.28
$1,085.38

$203.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$531.94
$603.72
$679.80
$950.00
$1,443.62

$735.40
$807.18
$883.26
$1,153.46

$938.86
$1,010.64
$1,086.72
$1,356.92

$1,142.32
$1,214.10
$1,290.18
$1,560.38

$203.46

Alliant Health Plans

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

Toc - Plan #69 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$288.32
$327.23
$368.46
$514.92
$782.47

$508.88
$547.79
$589.02
$735.48

$729.44
$768.35
$809.58
$956.04

$950.00
$988.91
$1,030.14
$1,176.60

$220.56

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$576.64
$654.46
$736.92
$1,029.84
$1,564.94

$797.20
$875.02
$957.48
$1,250.40

$1,017.76
$1,095.58
$1,178.04
$1,470.96

$1,238.32
$1,316.14
$1,398.60
$1,691.52

$220.56

Toc - Plan #70 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$283.79
$322.09
$362.67
$506.83
$770.17

$500.88
$539.18
$579.76
$723.92

$717.97
$756.27
$796.85
$941.01

$935.06
$973.36
$1,013.94
$1,158.10

$217.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$567.58
$644.18
$725.34
$1,013.66
$1,540.34

$784.67
$861.27
$942.43
$1,230.75

$1,001.76
$1,078.36
$1,159.52
$1,447.84

$1,218.85
$1,295.45
$1,376.61
$1,664.93

$217.09

Toc - Plan #71 Alliant Health Plans

Platinum

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$377.37
$428.31
$482.27
$673.97
$1,024.17

$666.05
$716.99
$770.95
$962.65

$954.73
$1,005.67
$1,059.63
$1,251.33

$1,243.41
$1,294.35
$1,348.31
$1,540.01

$288.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$754.74
$856.62
$964.54
$1,347.94
$2,048.34

$1,043.42
$1,145.30
$1,253.22
$1,636.62

$1,332.10
$1,433.98
$1,541.90
$1,925.30

$1,620.78
$1,722.66
$1,830.58
$2,213.98

$288.68

Toc - Plan #72 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$299.64
$340.08
$382.93
$535.14
$813.20

$528.86
$569.30
$612.15
$764.36

$758.08
$798.52
$841.37
$993.58

$987.30
$1,027.74
$1,070.59
$1,222.80

$229.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$599.28
$680.16
$765.86
$1,070.28
$1,626.40

$828.50
$909.38
$995.08
$1,299.50

$1,057.72
$1,138.60
$1,224.30
$1,528.72

$1,286.94
$1,367.82
$1,453.52
$1,757.94

$229.22

Toc - Plan #73 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$282.28
$320.38
$360.74
$504.13
$766.08

$498.22
$536.32
$576.68
$720.07

$714.16
$752.26
$792.62
$936.01

$930.10
$968.20
$1,008.56
$1,151.95

$215.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$564.56
$640.76
$721.48
$1,008.26
$1,532.16

$780.50
$856.70
$937.42
$1,224.20

$996.44
$1,072.64
$1,153.36
$1,440.14

$1,212.38
$1,288.58
$1,369.30
$1,656.08

$215.94

Toc - Plan #74 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$290.58
$329.80
$371.35
$518.96
$788.60

$512.87
$552.09
$593.64
$741.25

$735.16
$774.38
$815.93
$963.54

$957.45
$996.67
$1,038.22
$1,185.83

$222.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$581.16
$659.60
$742.70
$1,037.92
$1,577.20

$803.45
$881.89
$964.99
$1,260.21

$1,025.74
$1,104.18
$1,187.28
$1,482.50

$1,248.03
$1,326.47
$1,409.57
$1,704.79

$222.29

Toc - Plan #75 Alliant Health Plans

Platinum

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$392.47
$445.44
$501.56
$700.93
$1,065.12

$692.70
$745.67
$801.79
$1,001.16

$992.93
$1,045.90
$1,102.02
$1,301.39

$1,293.16
$1,346.13
$1,402.25
$1,601.62

$300.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$784.94
$890.88
$1,003.12
$1,401.86
$2,130.24

$1,085.17
$1,191.11
$1,303.35
$1,702.09

$1,385.40
$1,491.34
$1,603.58
$2,002.32

$1,685.63
$1,791.57
$1,903.81
$2,302.55

$300.23

Toc - Plan #76 Alliant Health Plans

Platinum

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$396.24
$449.72
$506.39
$707.67
$1,075.38

$699.36
$752.84
$809.51
$1,010.79

$1,002.48
$1,055.96
$1,112.63
$1,313.91

$1,305.60
$1,359.08
$1,415.75
$1,617.03

$303.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$792.48
$899.44
$1,012.78
$1,415.34
$2,150.76

$1,095.60
$1,202.56
$1,315.90
$1,718.46

$1,398.72
$1,505.68
$1,619.02
$2,021.58

$1,701.84
$1,808.80
$1,922.14
$2,324.70

$303.12

Toc - Plan #77 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$300.01
$340.50
$383.40
$535.81
$814.21

$529.51
$570.00
$612.90
$765.31

$759.01
$799.50
$842.40
$994.81

$988.51
$1,029.00
$1,071.90
$1,224.31

$229.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$600.02
$681.00
$766.80
$1,071.62
$1,628.42

$829.52
$910.50
$996.30
$1,301.12

$1,059.02
$1,140.00
$1,225.80
$1,530.62

$1,288.52
$1,369.50
$1,455.30
$1,760.12

$229.50

Toc - Plan #78 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$303.04
$343.94
$387.27
$541.21
$822.41

$534.86
$575.76
$619.09
$773.03

$766.68
$807.58
$850.91
$1,004.85

$998.50
$1,039.40
$1,082.73
$1,236.67

$231.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$606.08
$687.88
$774.54
$1,082.42
$1,644.82

$837.90
$919.70
$1,006.36
$1,314.24

$1,069.72
$1,151.52
$1,238.18
$1,546.06

$1,301.54
$1,383.34
$1,470.00
$1,777.88

$231.82

Toc - Plan #79 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$311.34
$353.35
$397.87
$556.03
$844.94

$549.50
$591.51
$636.03
$794.19

$787.66
$829.67
$874.19
$1,032.35

$1,025.82
$1,067.83
$1,112.35
$1,270.51

$238.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$622.68
$706.70
$795.74
$1,112.06
$1,689.88

$860.84
$944.86
$1,033.90
$1,350.22

$1,099.00
$1,183.02
$1,272.06
$1,588.38

$1,337.16
$1,421.18
$1,510.22
$1,826.54

$238.16

Toc - Plan #80 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$314.73
$357.21
$402.21
$562.09
$854.16

$555.49
$597.97
$642.97
$802.85

$796.25
$838.73
$883.73
$1,043.61

$1,037.01
$1,079.49
$1,124.49
$1,284.37

$240.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$629.46
$714.42
$804.42
$1,124.18
$1,708.32

$870.22
$955.18
$1,045.18
$1,364.94

$1,110.98
$1,195.94
$1,285.94
$1,605.70

$1,351.74
$1,436.70
$1,526.70
$1,846.46

$240.76

Toc - Plan #81 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$295.11
$334.94
$377.14
$527.05
$800.90

$520.86
$560.69
$602.89
$752.80

$746.61
$786.44
$828.64
$978.55

$972.36
$1,012.19
$1,054.39
$1,204.30

$225.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$590.22
$669.88
$754.28
$1,054.10
$1,601.80

$815.97
$895.63
$980.03
$1,279.85

$1,041.72
$1,121.38
$1,205.78
$1,505.60

$1,267.47
$1,347.13
$1,431.53
$1,731.35

$225.75

Toc - Plan #82 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$297.37
$337.50
$380.03
$531.09
$807.04

$524.85
$564.98
$607.51
$758.57

$752.33
$792.46
$834.99
$986.05

$979.81
$1,019.94
$1,062.47
$1,213.53

$227.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$594.74
$675.00
$760.06
$1,062.18
$1,614.08

$822.22
$902.48
$987.54
$1,289.66

$1,049.70
$1,129.96
$1,215.02
$1,517.14

$1,277.18
$1,357.44
$1,442.50
$1,744.62

$227.48

Toc - Plan #83 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$293.60
$333.23
$375.21
$524.36
$796.81

$518.20
$557.83
$599.81
$748.96

$742.80
$782.43
$824.41
$973.56

$967.40
$1,007.03
$1,049.01
$1,198.16

$224.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$587.20
$666.46
$750.42
$1,048.72
$1,593.62

$811.80
$891.06
$975.02
$1,273.32

$1,036.40
$1,115.66
$1,199.62
$1,497.92

$1,261.00
$1,340.26
$1,424.22
$1,722.52

$224.60

Toc - Plan #84 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$296.25
$336.23
$378.59
$529.08
$803.98

$522.87
$562.85
$605.21
$755.70

$749.49
$789.47
$831.83
$982.32

$976.11
$1,016.09
$1,058.45
$1,208.94

$226.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$592.50
$672.46
$757.18
$1,058.16
$1,607.96

$819.12
$899.08
$983.80
$1,284.78

$1,045.74
$1,125.70
$1,210.42
$1,511.40

$1,272.36
$1,352.32
$1,437.04
$1,738.02

$226.62

Toc - Plan #85 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$302.28
$343.08
$386.31
$539.86
$820.37

$533.52
$574.32
$617.55
$771.10

$764.76
$805.56
$848.79
$1,002.34

$996.00
$1,036.80
$1,080.03
$1,233.58

$231.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$604.56
$686.16
$772.62
$1,079.72
$1,640.74

$835.80
$917.40
$1,003.86
$1,310.96

$1,067.04
$1,148.64
$1,235.10
$1,542.20

$1,298.28
$1,379.88
$1,466.34
$1,773.44

$231.24

Toc - Plan #86 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$304.54
$345.65
$389.19
$543.90
$826.51

$537.51
$578.62
$622.16
$776.87

$770.48
$811.59
$855.13
$1,009.84

$1,003.45
$1,044.56
$1,088.10
$1,242.81

$232.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$609.08
$691.30
$778.38
$1,087.80
$1,653.02

$842.05
$924.27
$1,011.35
$1,320.77

$1,075.02
$1,157.24
$1,244.32
$1,553.74

$1,307.99
$1,390.21
$1,477.29
$1,786.71

$232.97

Toc - Plan #87 Alliant Health Plans

Platinum

(PPO) SoloCare PPO Platinum Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$389.82
$442.44
$498.18
$696.21
$1,057.95

$688.03
$740.65
$796.39
$994.42

$986.24
$1,038.86
$1,094.60
$1,292.63

$1,284.45
$1,337.07
$1,392.81
$1,590.84

$298.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$779.64
$884.88
$996.36
$1,392.42
$2,115.90

$1,077.85
$1,183.09
$1,294.57
$1,690.63

$1,376.06
$1,481.30
$1,592.78
$1,988.84

$1,674.27
$1,779.51
$1,890.99
$2,287.05

$298.21

Toc - Plan #88 Alliant Health Plans

Gold

(PPO) SoloCare PPO Gold Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$282.28
$320.38
$360.74
$504.13
$766.08

$498.22
$536.32
$576.68
$720.07

$714.16
$752.26
$792.62
$936.01

$930.10
$968.20
$1,008.56
$1,151.95

$215.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$564.56
$640.76
$721.48
$1,008.26
$1,532.16

$780.50
$856.70
$937.42
$1,224.20

$996.44
$1,072.64
$1,153.36
$1,440.14

$1,212.38
$1,288.58
$1,369.30
$1,656.08

$215.94

Toc - Plan #89 Alliant Health Plans

Silver

(PPO) SoloCare PPO Silver Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$267.94
$304.10
$342.42
$478.53
$727.17

$472.91
$509.07
$547.39
$683.50

$677.88
$714.04
$752.36
$888.47

$882.85
$919.01
$957.33
$1,093.44

$204.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$535.88
$608.20
$684.84
$957.06
$1,454.34

$740.85
$813.17
$889.81
$1,162.03

$945.82
$1,018.14
$1,094.78
$1,367.00

$1,150.79
$1,223.11
$1,299.75
$1,571.97

$204.97

Toc - Plan #90 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$286.81
$325.52
$366.53
$512.23
$778.38

$506.21
$544.92
$585.93
$731.63

$725.61
$764.32
$805.33
$951.03

$945.01
$983.72
$1,024.73
$1,170.43

$219.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$573.62
$651.04
$733.06
$1,024.46
$1,556.76

$793.02
$870.44
$952.46
$1,243.86

$1,012.42
$1,089.84
$1,171.86
$1,463.26

$1,231.82
$1,309.24
$1,391.26
$1,682.66

$219.40

Toc - Plan #91 Alliant Health Plans

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$298.51
$338.79
$381.48
$533.11
$810.12

$526.86
$567.14
$609.83
$761.46

$755.21
$795.49
$838.18
$989.81

$983.56
$1,023.84
$1,066.53
$1,218.16

$228.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$597.02
$677.58
$762.96
$1,066.22
$1,620.24

$825.37
$905.93
$991.31
$1,294.57

$1,053.72
$1,134.28
$1,219.66
$1,522.92

$1,282.07
$1,362.63
$1,448.01
$1,751.27

$228.35

Toc - Plan #92 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$280.02
$317.81
$357.85
$500.10
$759.94

$494.23
$532.02
$572.06
$714.31

$708.44
$746.23
$786.27
$928.52

$922.65
$960.44
$1,000.48
$1,142.73

$214.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$560.04
$635.62
$715.70
$1,000.20
$1,519.88

$774.25
$849.83
$929.91
$1,214.41

$988.46
$1,064.04
$1,144.12
$1,428.62

$1,202.67
$1,278.25
$1,358.33
$1,642.83

$214.21

Toc - Plan #93 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$278.50
$316.09
$355.91
$497.39
$755.83

$491.55
$529.14
$568.96
$710.44

$704.60
$742.19
$782.01
$923.49

$917.65
$955.24
$995.06
$1,136.54

$213.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$557.00
$632.18
$711.82
$994.78
$1,511.66

$770.05
$845.23
$924.87
$1,207.83

$983.10
$1,058.28
$1,137.92
$1,420.88

$1,196.15
$1,271.33
$1,350.97
$1,633.93

$213.05

Toc - Plan #94 Alliant Health Plans

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$286.81
$325.52
$366.53
$512.23
$778.38

$506.21
$544.92
$585.93
$731.63

$725.61
$764.32
$805.33
$951.03

$945.01
$983.72
$1,024.73
$1,170.43

$219.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$573.62
$651.04
$733.06
$1,024.46
$1,556.76

$793.02
$870.44
$952.46
$1,243.86

$1,012.42
$1,089.84
$1,171.86
$1,463.26

$1,231.82
$1,309.24
$1,391.26
$1,682.66

$219.40

Toc - Plan #95 Alliant Health Plans

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$217.38
$246.71
$277.79
$388.22
$589.93

$383.67
$413.00
$444.08
$554.51

$549.96
$579.29
$610.37
$720.80

$716.25
$745.58
$776.66
$887.09

$166.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$434.76
$493.42
$555.58
$776.44
$1,179.86

$601.05
$659.71
$721.87
$942.73

$767.34
$826.00
$888.16
$1,109.02

$933.63
$992.29
$1,054.45
$1,275.31

$166.29

Toc - Plan #96 Alliant Health Plans

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$226.05
$256.55
$288.88
$403.70
$613.47

$398.97
$429.47
$461.80
$576.62

$571.89
$602.39
$634.72
$749.54

$744.81
$775.31
$807.64
$922.46

$172.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$452.10
$513.10
$577.76
$807.40
$1,226.94

$625.02
$686.02
$750.68
$980.32

$797.94
$858.94
$923.60
$1,153.24

$970.86
$1,031.86
$1,096.52
$1,326.16

$172.92

Toc - Plan #97 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO 110015

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$216.99
$246.28
$277.31
$387.53
$588.90

$382.98
$412.27
$443.30
$553.52

$548.97
$578.26
$609.29
$719.51

$714.96
$744.25
$775.28
$885.50

$165.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$433.98
$492.56
$554.62
$775.06
$1,177.80

$599.97
$658.55
$720.61
$941.05

$765.96
$824.54
$886.60
$1,107.04

$931.95
$990.53
$1,052.59
$1,273.03

$165.99

Toc - Plan #98 Alliant Health Plans

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$8,500 $17,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$225.68
$256.13
$288.40
$403.04
$612.46

$398.31
$428.76
$461.03
$575.67

$570.94
$601.39
$633.66
$748.30

$743.57
$774.02
$806.29
$920.93

$172.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$451.36
$512.26
$576.80
$806.08
$1,224.92

$623.99
$684.89
$749.43
$978.71

$796.62
$857.52
$922.06
$1,151.34

$969.25
$1,030.15
$1,094.69
$1,323.97

$172.63

Toc - Plan #99 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare Bronze No Referral HMO HDHP 110019

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,050 $14,100 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$222.65
$252.70
$284.54
$397.64
$604.25

$392.97
$423.02
$454.86
$567.96

$563.29
$593.34
$625.18
$738.28

$733.61
$763.66
$795.50
$908.60

$170.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$445.30
$505.40
$569.08
$795.28
$1,208.50

$615.62
$675.72
$739.40
$965.60

$785.94
$846.04
$909.72
$1,135.92

$956.26
$1,016.36
$1,080.04
$1,306.24

$170.32

Toc - Plan #100 Alliant Health Plans

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,050 $14,100 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$231.33
$262.55
$295.63
$413.14
$627.81

$408.29
$439.51
$472.59
$590.10

$585.25
$616.47
$649.55
$767.06

$762.21
$793.43
$826.51
$944.02

$176.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$462.66
$525.10
$591.26
$826.28
$1,255.62

$639.62
$702.06
$768.22
$1,003.24

$816.58
$879.02
$945.18
$1,180.20

$993.54
$1,055.98
$1,122.14
$1,357.16

$176.96

Toc - Plan #101 Alliant Health Plans

Catastrophic

(HMO) SoloCare Catastropic No Referral HMO 110023

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$162.28
$184.17
$207.38
$289.81
$440.40

$286.42
$308.31
$331.52
$413.95

$410.56
$432.45
$455.66
$538.09

$534.70
$556.59
$579.80
$662.23

$124.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$324.56
$368.34
$414.76
$579.62
$880.80

$448.70
$492.48
$538.90
$703.76

$572.84
$616.62
$663.04
$827.90

$696.98
$740.76
$787.18
$952.04

$124.14

Toc - Plan #102 Alliant Health Plans

Gold

(HMO) SoloCare HMO Gold Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$280.77
$318.67
$358.81
$501.44
$761.99

$495.55
$533.45
$573.59
$716.22

$710.33
$748.23
$788.37
$931.00

$925.11
$963.01
$1,003.15
$1,145.78

$214.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$561.54
$637.34
$717.62
$1,002.88
$1,523.98

$776.32
$852.12
$932.40
$1,217.66

$991.10
$1,066.90
$1,147.18
$1,432.44

$1,205.88
$1,281.68
$1,361.96
$1,647.22

$214.78

Toc - Plan #103 Alliant Health Plans

Silver

(HMO) SoloCare HMO Silver Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$264.92
$300.67
$338.55
$473.13
$718.96

$467.58
$503.33
$541.21
$675.79

$670.24
$705.99
$743.87
$878.45

$872.90
$908.65
$946.53
$1,081.11

$202.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$529.84
$601.34
$677.10
$946.26
$1,437.92

$732.50
$804.00
$879.76
$1,148.92

$935.16
$1,006.66
$1,082.42
$1,351.58

$1,137.82
$1,209.32
$1,285.08
$1,554.24

$202.66

Toc - Plan #104 Alliant Health Plans

Bronze

(HMO) SoloCare HMO Bronze Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$200.77
$227.86
$256.57
$358.56
$544.86

$354.35
$381.44
$410.15
$512.14

$507.93
$535.02
$563.73
$665.72

$661.51
$688.60
$717.31
$819.30

$153.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$401.54
$455.72
$513.14
$717.12
$1,089.72

$555.12
$609.30
$666.72
$870.70

$708.70
$762.88
$820.30
$1,024.28

$862.28
$916.46
$973.88
$1,177.86

$153.58

Toc - Plan #105 Alliant Health Plans

Expanded Bronze

(HMO) SoloCare HMO Expanded Bronze Standardized

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-811-4793

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$201.90
$229.15
$258.02
$360.58
$547.94

$356.35
$383.60
$412.47
$515.03

$510.80
$538.05
$566.92
$669.48

$665.25
$692.50
$721.37
$823.93

$154.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$403.80
$458.30
$516.04
$721.16
$1,095.88

$558.25
$612.75
$670.49
$875.61

$712.70
$767.20
$824.94
$1,030.06

$867.15
$921.65
$979.39
$1,184.51

$154.45

‡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 Stephens County here.

Stephens County is in “Rating Area 10” of Georgia.

Currently, there are 105 plans offered in Rating Area 10.

Top

2023 Obamacare Plans for Stephens County, GA

Plan Browser: 105 Plans

Cigna HealthCare of Georgia, Inc

Local: | Toll Free:

1. Bronze Cigna Connect 9100

2. Expanded Bronze Cigna Connect 7800

3. Expanded Bronze Cigna Connect 6500

4. Expanded Bronze Cigna Connect HSA 7050

5. Expanded Bronze Cigna Connect 6800 Enhanced Diabetes Care

6. Silver Cigna Connect 3700

7. Silver Cigna Connect 5000

8. Silver Cigna Connect 6000

9. Silver Cigna Connect 7200

10. Silver Cigna Connect 3800 Enhanced Diabetes Care

11. Silver Cigna Connect 4200 Enhanced Asthma COPD Care

12. Gold Cigna Connect 1600

13. Gold Cigna Connect 1900 Enhanced Diabetes Care

14. Expanded Bronze Cigna Connect 7600 Enhanced Asthma COPD Care

15. Bronze Cigna Simple Choice 9100

16. Expanded Bronze Cigna Simple Choice 7500

17. Expanded Bronze Cigna Connect 0

18. Gold Cigna Simple Choice 2000

19. Silver Cigna Simple Choice 5800

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc

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

20. Catastrophic Anthem Catastrophic Pathway X HMO 9100

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ambetter from Peach State Health Plan

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

36. Bronze Clear Bronze

37. Silver Premier Silver

38. Silver Complete Silver

39. Gold Complete Gold

40. Silver Everyday Silver

41. Expanded Bronze Choice Bronze HSA

42. Expanded Bronze Everyday Bronze

43. Expanded Bronze Elite Bronze

44. Silver Clear Silver

45. Silver Focused Silver

46. Gold Everyday Gold

47. Gold Clear Gold

48. Gold Elite Gold

49. Bronze CMS Standard Bronze

50. Expanded Bronze CMS Standard Expanded Bronze

51. Silver CMS Standard Silver

52. Gold CMS Standard Gold

53. Silver Everyday Silver + Vision + Adult Dental

54. Silver Premier Silver + Vision + Adult Dental

55. Silver Complete Silver + Vision + Adult Dental

56. Bronze Clear Bronze + Vision + Adult Dental

57. Gold Complete Gold + Vision + Adult Dental

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

59. Expanded Bronze Everyday Bronze + Vision + Adult Dental

60. Expanded Bronze Elite Bronze + Vision + Adult Dental

61. Silver Focused Silver + Vision + Adult Dental

62. Gold Everyday Gold + Vision + Adult Dental

63. Silver Clear Silver + Vision + Adult Dental

64. Gold Clear Gold + Vision + Adult Dental

65. Gold Elite Gold + Vision + Adult Dental

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

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

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

Alliant Health Plans

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

87. Platinum SoloCare PPO Platinum Standardized

88. Gold SoloCare PPO Gold Standardized

89. Silver SoloCare PPO Silver Standardized

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

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

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

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

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

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

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

97. Expanded Bronze SoloCare Bronze No Referral HMO 110015

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

99. Expanded Bronze SoloCare Bronze No Referral HMO HDHP 110019

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

101. Catastrophic SoloCare Catastropic No Referral HMO 110023

102. Gold SoloCare HMO Gold Standardized

103. Silver SoloCare HMO Silver Standardized

104. Bronze SoloCare HMO Bronze Standardized

105. Expanded Bronze SoloCare HMO Expanded Bronze Standardized

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

Obamacare Providers, 105 Plans and 2023 Rates for Stephens County, Georgia

You may also be interested in:

Do I Qualify For a Tax Credit to Pay My Premiums?

How do I sign up in Georgia?

Using a Broker to Help You Sign Up

Obamacare Rates and Providers for Other Years

How to Sign Up for Obamacare in Georgia

Where's the Georgia Health Care Exchange?

Georgia Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

Georgia Has Not Expanded Medicaid

The Medicaid Coverage Gap

Get Help Finding a Health Insurance Plan in Georgia

Get Help From Georgia's Health Insurance Exchange

Get Help From a Licensed Insurance Broker

More Information

Cigna HealthCare of Georgia, Inc

(HMO) Cigna Connect 9100

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Cigna Connect 7800

Annual Out of Pocket Expenses:

Individual Family $7,800 $15,600 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 6500

Annual Out of Pocket Expenses:

Individual Family $6,500 $13,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect HSA 7050

Annual Out of Pocket Expenses:

Individual Family $7,050 $14,100 Annual Deductible $7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Annual Out of Pocket Expenses:

Individual Family $6,800 $13,600 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 3700

Annual Out of Pocket Expenses:

Individual Family $3,700 $7,400 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 5000

Annual Out of Pocket Expenses:

Individual Family $5,000 $10,000 Annual Deductible $9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 6000

Annual Out of Pocket Expenses:

Individual Family $6,000 $12,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 7200

Annual Out of Pocket Expenses:

Individual Family $7,200 $14,400 Annual Deductible $7,200 $14,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Annual Out of Pocket Expenses:

Individual Family $4,200 $8,400 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 1600

Annual Out of Pocket Expenses:

Individual Family $1,600 $3,200 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 1900 Enhanced Diabetes Care

Annual Out of Pocket Expenses:

Individual Family $1,900 $3,800 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Connect 7600 Enhanced Asthma COPD Care

Annual Out of Pocket Expenses:

Individual Family $7,600 $15,200 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) Cigna Simple Choice 9100

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) Cigna Simple Choice 7500

Annual Out of Pocket Expenses:

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,800 $15,600 Annual Deductible

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

Individual Family

$6,500 $13,000 Annual Deductible

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

Individual Family

$7,050 $14,100 Annual Deductible

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

Individual Family

$6,800 $13,600 Annual Deductible

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

Individual Family

$3,700 $7,400 Annual Deductible

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

Individual Family

$5,000 $10,000 Annual Deductible

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

Individual Family

$6,000 $12,000 Annual Deductible

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

Individual Family

$7,200 $14,400 Annual Deductible

$7,200 $14,400 Maximum Out of Pocket Per Year

Individual Family

$3,800 $7,600 Annual Deductible

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

Individual Family

$4,200 $8,400 Annual Deductible

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

Individual Family

$1,600 $3,200 Annual Deductible

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

Individual Family

$1,900 $3,800 Annual Deductible

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

Individual Family

$7,600 $15,200 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

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

Individual Family

$5,800 $11,600 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$7,450 $14,900 Annual Deductible

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

Individual Family

$5,600 $11,200 Annual Deductible

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

Individual Family

$6,000 $12,000 Annual Deductible

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

Individual Family

$3,000 $6,000 Annual Deductible

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

Individual Family

$5,500 $11,000 Annual Deductible

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

Individual Family

$8,000 $16,000 Annual Deductible

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

Individual Family

$4,950 $9,900 Annual Deductible

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

Individual Family

$6,500 $13,000 Annual Deductible

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

Individual Family

$1,600 $3,200 Annual Deductible

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

Individual Family

$5,000 $10,000 Annual Deductible

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

Individual Family

$2,600 $5,200 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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