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Obamacare Benton County, IN

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Obamacare 2023 Rates for Benton County

Obamacare > Rates > Indiana > Benton 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 Benton County, IN.

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, 63 Plans and 2023 Rates for Benton County, Indiana

Below, you’ll find a summary of the 63 plans for Benton County, Indiana and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Anthem Blue Cross and Blue Shield

Local: 1-855-886-6152 | Toll Free: 1-855-886-6152

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

(HMO) Anthem Silver Pathway Essentials 6000 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$320.70
$363.99
$409.85
$572.77
$870.38 		$566.04
$609.33
$655.19
$818.11 		$811.38
$854.67
$900.53
$1,063.45 		$1,056.72
$1,100.01
$1,145.87
$1,308.79 		$245.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$641.40
$727.98
$819.70
$1,145.54
$1,740.76 		$886.74
$973.32
$1,065.04
$1,390.88 		$1,132.08
$1,218.66
$1,310.38
$1,636.22 		$1,377.42
$1,464.00
$1,555.72
$1,881.56 		$245.34
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway Essentials 9100 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$254.15
$288.46
$324.80
$453.91
$689.76 		$448.57
$482.88
$519.22
$648.33 		$642.99
$677.30
$713.64
$842.75 		$837.41
$871.72
$908.06
$1,037.17 		$194.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$508.30
$576.92
$649.60
$907.82
$1,379.52 		$702.72
$771.34
$844.02
$1,102.24 		$897.14
$965.76
$1,038.44
$1,296.66 		$1,091.56
$1,160.18
$1,232.86
$1,491.08 		$194.42
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway Essentials 2200 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$6,000 $12,000 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 		$458.67
$520.59
$586.18
$819.18
$1,244.83 		$809.55
$871.47
$937.06
$1,170.06 		$1,160.43
$1,222.35
$1,287.94
$1,520.94 		$1,511.31
$1,573.23
$1,638.82
$1,871.82 		$350.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.34
$1,041.18
$1,172.36
$1,638.36
$2,489.66 		$1,268.22
$1,392.06
$1,523.24
$1,989.24 		$1,619.10
$1,742.94
$1,874.12
$2,340.12 		$1,969.98
$2,093.82
$2,225.00
$2,691.00 		$350.88
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 4000 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$326.89
$371.02
$417.77
$583.83
$887.18 		$576.96
$621.09
$667.84
$833.90 		$827.03
$871.16
$917.91
$1,083.97 		$1,077.10
$1,121.23
$1,167.98
$1,334.04 		$250.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.78
$742.04
$835.54
$1,167.66
$1,774.36 		$903.85
$992.11
$1,085.61
$1,417.73 		$1,153.92
$1,242.18
$1,335.68
$1,667.80 		$1,403.99
$1,492.25
$1,585.75
$1,917.87 		$250.07
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway Essentials 5500 (3 $0 PCP Visits + $0 Virtual PCP + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$264.59
$300.31
$338.15
$472.56
$718.10 		$467.00
$502.72
$540.56
$674.97 		$669.41
$705.13
$742.97
$877.38 		$871.82
$907.54
$945.38
$1,079.79 		$202.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$529.18
$600.62
$676.30
$945.12
$1,436.20 		$731.59
$803.03
$878.71
$1,147.53 		$934.00
$1,005.44
$1,081.12
$1,349.94 		$1,136.41
$1,207.85
$1,283.53
$1,552.35 		$202.41
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway Essentials 6550 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$6,550 $13,100 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 		$252.19
$286.24
$322.30
$450.41
$684.44 		$445.12
$479.17
$515.23
$643.34 		$638.05
$672.10
$708.16
$836.27 		$830.98
$865.03
$901.09
$1,029.20 		$192.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$504.38
$572.48
$644.60
$900.82
$1,368.88 		$697.31
$765.41
$837.53
$1,093.75 		$890.24
$958.34
$1,030.46
$1,286.68 		$1,083.17
$1,151.27
$1,223.39
$1,479.61 		$192.93
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 6550 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$6,550 $13,100 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.83
$363.01
$408.74
$571.22
$868.02 		$564.50
$607.68
$653.41
$815.89 		$809.17
$852.35
$898.08
$1,060.56 		$1,053.84
$1,097.02
$1,142.75
$1,305.23 		$244.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.66
$726.02
$817.48
$1,142.44
$1,736.04 		$884.33
$970.69
$1,062.15
$1,387.11 		$1,129.00
$1,215.36
$1,306.82
$1,631.78 		$1,373.67
$1,460.03
$1,551.49
$1,876.45 		$244.67
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway Essentials 2700 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 Annual Deductible
$4,700 $9,400 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 		$455.68
$517.20
$582.36
$813.84
$1,236.72 		$804.28
$865.80
$930.96
$1,162.44 		$1,152.88
$1,214.40
$1,279.56
$1,511.04 		$1,501.48
$1,563.00
$1,628.16
$1,859.64 		$348.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$911.36
$1,034.40
$1,164.72
$1,627.68
$2,473.44 		$1,259.96
$1,383.00
$1,513.32
$1,976.28 		$1,608.56
$1,731.60
$1,861.92
$2,324.88 		$1,957.16
$2,080.20
$2,210.52
$2,673.48 		$348.60
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.34
$368.13
$414.51
$579.27
$880.26 		$572.46
$616.25
$662.63
$827.39 		$820.58
$864.37
$910.75
$1,075.51 		$1,068.70
$1,112.49
$1,158.87
$1,323.63 		$248.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.68
$736.26
$829.02
$1,158.54
$1,760.52 		$896.80
$984.38
$1,077.14
$1,406.66 		$1,144.92
$1,232.50
$1,325.26
$1,654.78 		$1,393.04
$1,480.62
$1,573.38
$1,902.90 		$248.12
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway Essentials 6850 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$6,850 $13,700 Annual Deductible
$6,850 $13,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.43
$319.42
$359.67
$502.63
$763.80 		$496.72
$534.71
$574.96
$717.92 		$712.01
$750.00
$790.25
$933.21 		$927.30
$965.29
$1,005.54
$1,148.50 		$215.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$562.86
$638.84
$719.34
$1,005.26
$1,527.60 		$778.15
$854.13
$934.63
$1,220.55 		$993.44
$1,069.42
$1,149.92
$1,435.84 		$1,208.73
$1,284.71
$1,365.21
$1,651.13 		$215.29
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 2800 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$2,800 $5,600 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 		$329.10
$373.53
$420.59
$587.77
$893.18 		$580.86
$625.29
$672.35
$839.53 		$832.62
$877.05
$924.11
$1,091.29 		$1,084.38
$1,128.81
$1,175.87
$1,343.05 		$251.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$658.20
$747.06
$841.18
$1,175.54
$1,786.36 		$909.96
$998.82
$1,092.94
$1,427.30 		$1,161.72
$1,250.58
$1,344.70
$1,679.06 		$1,413.48
$1,502.34
$1,596.46
$1,930.82 		$251.76
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 3500 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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 		$327.70
$371.94
$418.80
$585.27
$889.38 		$578.39
$622.63
$669.49
$835.96 		$829.08
$873.32
$920.18
$1,086.65 		$1,079.77
$1,124.01
$1,170.87
$1,337.34 		$250.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$655.40
$743.88
$837.60
$1,170.54
$1,778.76 		$906.09
$994.57
$1,088.29
$1,421.23 		$1,156.78
$1,245.26
$1,338.98
$1,671.92 		$1,407.47
$1,495.95
$1,589.67
$1,922.61 		$250.69
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 5000 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$321.10
$364.45
$410.37
$573.48
$871.47 		$566.74
$610.09
$656.01
$819.12 		$812.38
$855.73
$901.65
$1,064.76 		$1,058.02
$1,101.37
$1,147.29
$1,310.40 		$245.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$642.20
$728.90
$820.74
$1,146.96
$1,742.94 		$887.84
$974.54
$1,066.38
$1,392.60 		$1,133.48
$1,220.18
$1,312.02
$1,638.24 		$1,379.12
$1,465.82
$1,557.66
$1,883.88 		$245.64
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 4500 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$5,600 $11,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.68
$368.51
$414.94
$579.88
$881.18 		$573.06
$616.89
$663.32
$828.26 		$821.44
$865.27
$911.70
$1,076.64 		$1,069.82
$1,113.65
$1,160.08
$1,325.02 		$248.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$649.36
$737.02
$829.88
$1,159.76
$1,762.36 		$897.74
$985.40
$1,078.26
$1,408.14 		$1,146.12
$1,233.78
$1,326.64
$1,656.52 		$1,394.50
$1,482.16
$1,575.02
$1,904.90 		$248.38
Toc - Plan #15 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 4000 HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$6,000 $12,000 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 		$326.46
$370.53
$417.22
$583.06
$886.01 		$576.20
$620.27
$666.96
$832.80 		$825.94
$870.01
$916.70
$1,082.54 		$1,075.68
$1,119.75
$1,166.44
$1,332.28 		$249.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$652.92
$741.06
$834.44
$1,166.12
$1,772.02 		$902.66
$990.80
$1,084.18
$1,415.86 		$1,152.40
$1,240.54
$1,333.92
$1,665.60 		$1,402.14
$1,490.28
$1,583.66
$1,915.34 		$249.74
Toc - Plan #16 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway Essentials 9100 Std

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$253.72
$287.97
$324.25
$453.14
$688.60 		$447.82
$482.07
$518.35
$647.24 		$641.92
$676.17
$712.45
$841.34 		$836.02
$870.27
$906.55
$1,035.44 		$194.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$507.44
$575.94
$648.50
$906.28
$1,377.20 		$701.54
$770.04
$842.60
$1,100.38 		$895.64
$964.14
$1,036.70
$1,294.48 		$1,089.74
$1,158.24
$1,230.80
$1,488.58 		$194.10
Toc - Plan #17 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway Essentials 7500 Std

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$278.66
$316.28
$356.13
$497.69
$756.28 		$491.83
$529.45
$569.30
$710.86 		$705.00
$742.62
$782.47
$924.03 		$918.17
$955.79
$995.64
$1,137.20 		$213.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.32
$632.56
$712.26
$995.38
$1,512.56 		$770.49
$845.73
$925.43
$1,208.55 		$983.66
$1,058.90
$1,138.60
$1,421.72 		$1,196.83
$1,272.07
$1,351.77
$1,634.89 		$213.17
Toc - Plan #18 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway Essentials 5800 Std

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$318.33
$361.30
$406.83
$568.54
$863.95 		$561.85
$604.82
$650.35
$812.06 		$805.37
$848.34
$893.87
$1,055.58 		$1,048.89
$1,091.86
$1,137.39
$1,299.10 		$243.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.66
$722.60
$813.66
$1,137.08
$1,727.90 		$880.18
$966.12
$1,057.18
$1,380.60 		$1,123.70
$1,209.64
$1,300.70
$1,624.12 		$1,367.22
$1,453.16
$1,544.22
$1,867.64 		$243.52
Toc - Plan #19 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway Essentials 2000 Std

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$463.31
$525.86
$592.11
$827.47
$1,257.42 		$817.74
$880.29
$946.54
$1,181.90 		$1,172.17
$1,234.72
$1,300.97
$1,536.33 		$1,526.60
$1,589.15
$1,655.40
$1,890.76 		$354.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$926.62
$1,051.72
$1,184.22
$1,654.94
$2,514.84 		$1,281.05
$1,406.15
$1,538.65
$2,009.37 		$1,635.48
$1,760.58
$1,893.08
$2,363.80 		$1,989.91
$2,115.01
$2,247.51
$2,718.23 		$354.43
Toc - Plan #20 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Pathway Essentials POS 5000 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$269.44
$305.81
$344.34
$481.22
$731.26 		$475.56
$511.93
$550.46
$687.34 		$681.68
$718.05
$756.58
$893.46 		$887.80
$924.17
$962.70
$1,099.58 		$206.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$538.88
$611.62
$688.68
$962.44
$1,462.52 		$745.00
$817.74
$894.80
$1,168.56 		$951.12
$1,023.86
$1,100.92
$1,374.68 		$1,157.24
$1,229.98
$1,307.04
$1,580.80 		$206.12
Toc - Plan #21 Anthem Blue Cross and Blue Shield
Expanded Bronze

(POS) Anthem Bronze Pathway Essentials POS 7500 Std

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-886-6152

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 		$278.66
$316.28
$356.13
$497.69
$756.28 		$491.83
$529.45
$569.30
$710.86 		$705.00
$742.62
$782.47
$924.03 		$918.17
$955.79
$995.64
$1,137.20 		$213.17
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$557.32
$632.56
$712.26
$995.38
$1,512.56 		$770.49
$845.73
$925.43
$1,208.55 		$983.66
$1,058.90
$1,138.60
$1,421.72 		$1,196.83
$1,272.07
$1,351.77
$1,634.89 		$213.17

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-743-3333
Toc - Plan #22 CareSource
Expanded Bronze

(HMO) CareSource Marketplace HSA Eligible Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$319.65
$362.80
$408.51
$570.89
$867.52 		$564.18
$607.33
$653.04
$815.42 		$808.71
$851.86
$897.57
$1,059.95 		$1,053.24
$1,096.39
$1,142.10
$1,304.48 		$244.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$639.30
$725.60
$817.02
$1,141.78
$1,735.04 		$883.83
$970.13
$1,061.55
$1,386.31 		$1,128.36
$1,214.66
$1,306.08
$1,630.84 		$1,372.89
$1,459.19
$1,550.61
$1,875.37 		$244.53
Toc - Plan #23 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$340.78
$386.78
$435.51
$608.62
$924.86 		$601.47
$647.47
$696.20
$869.31 		$862.16
$908.16
$956.89
$1,130.00 		$1,122.85
$1,168.85
$1,217.58
$1,390.69 		$260.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$681.56
$773.56
$871.02
$1,217.24
$1,849.72 		$942.25
$1,034.25
$1,131.71
$1,477.93 		$1,202.94
$1,294.94
$1,392.40
$1,738.62 		$1,463.63
$1,555.63
$1,653.09
$1,999.31 		$260.69
Toc - Plan #24 CareSource
Gold

(HMO) CareSource Marketplace Gold

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$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 		$556.29
$631.39
$710.94
$993.53
$1,509.77 		$981.85
$1,056.95
$1,136.50
$1,419.09 		$1,407.41
$1,482.51
$1,562.06
$1,844.65 		$1,832.97
$1,908.07
$1,987.62
$2,270.21 		$425.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,112.58
$1,262.78
$1,421.88
$1,987.06
$3,019.54 		$1,538.14
$1,688.34
$1,847.44
$2,412.62 		$1,963.70
$2,113.90
$2,273.00
$2,838.18 		$2,389.26
$2,539.46
$2,698.56
$3,263.74 		$425.56
Toc - Plan #25 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348.32
$395.34
$445.15
$622.09
$945.33 		$614.78
$661.80
$711.61
$888.55 		$881.24
$928.26
$978.07
$1,155.01 		$1,147.70
$1,194.72
$1,244.53
$1,421.47 		$266.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.64
$790.68
$890.30
$1,244.18
$1,890.66 		$963.10
$1,057.14
$1,156.76
$1,510.64 		$1,229.56
$1,323.60
$1,423.22
$1,777.10 		$1,496.02
$1,590.06
$1,689.68
$2,043.56 		$266.46
Toc - Plan #26 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$283.26
$321.50
$362.00
$505.90
$768.76 		$499.95
$538.19
$578.69
$722.59 		$716.64
$754.88
$795.38
$939.28 		$933.33
$971.57
$1,012.07
$1,155.97 		$216.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$566.52
$643.00
$724.00
$1,011.80
$1,537.52 		$783.21
$859.69
$940.69
$1,228.49 		$999.90
$1,076.38
$1,157.38
$1,445.18 		$1,216.59
$1,293.07
$1,374.07
$1,661.87 		$216.69
Toc - Plan #27 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276.37
$313.68
$353.20
$493.60
$750.07 		$487.79
$525.10
$564.62
$705.02 		$699.21
$736.52
$776.04
$916.44 		$910.63
$947.94
$987.46
$1,127.86 		$211.42
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$552.74
$627.36
$706.40
$987.20
$1,500.14 		$764.16
$838.78
$917.82
$1,198.62 		$975.58
$1,050.20
$1,129.24
$1,410.04 		$1,187.00
$1,261.62
$1,340.66
$1,621.46 		$211.42
Toc - Plan #28 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$389.86
$442.49
$498.24
$696.29
$1,058.08 		$688.10
$740.73
$796.48
$994.53 		$986.34
$1,038.97
$1,094.72
$1,292.77 		$1,284.58
$1,337.21
$1,392.96
$1,591.01 		$298.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.72
$884.98
$996.48
$1,392.58
$2,116.16 		$1,077.96
$1,183.22
$1,294.72
$1,690.82 		$1,376.20
$1,481.46
$1,592.96
$1,989.06 		$1,674.44
$1,779.70
$1,891.20
$2,287.30 		$298.24
Toc - Plan #29 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$348.21
$395.22
$445.01
$621.90
$945.04 		$614.59
$661.60
$711.39
$888.28 		$880.97
$927.98
$977.77
$1,154.66 		$1,147.35
$1,194.36
$1,244.15
$1,421.04 		$266.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$696.42
$790.44
$890.02
$1,243.80
$1,890.08 		$962.80
$1,056.82
$1,156.40
$1,510.18 		$1,229.18
$1,323.20
$1,422.78
$1,776.56 		$1,495.56
$1,589.58
$1,689.16
$2,042.94 		$266.38
Toc - Plan #30 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$565.35
$641.67
$722.51
$1,009.71
$1,534.35 		$997.84
$1,074.16
$1,155.00
$1,442.20 		$1,430.33
$1,506.65
$1,587.49
$1,874.69 		$1,862.82
$1,939.14
$2,019.98
$2,307.18 		$432.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,130.70
$1,283.34
$1,445.02
$2,019.42
$3,068.70 		$1,563.19
$1,715.83
$1,877.51
$2,451.91 		$1,995.68
$2,148.32
$2,310.00
$2,884.40 		$2,428.17
$2,580.81
$2,742.49
$3,316.89 		$432.49
Toc - Plan #31 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $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 		$355.75
$403.78
$454.65
$635.37
$965.50 		$627.90
$675.93
$726.80
$907.52 		$900.05
$948.08
$998.95
$1,179.67 		$1,172.20
$1,220.23
$1,271.10
$1,451.82 		$272.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$711.50
$807.56
$909.30
$1,270.74
$1,931.00 		$983.65
$1,079.71
$1,181.45
$1,542.89 		$1,255.80
$1,351.86
$1,453.60
$1,815.04 		$1,527.95
$1,624.01
$1,725.75
$2,087.19 		$272.15
Toc - Plan #32 CareSource
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$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 		$289.78
$328.90
$370.34
$517.54
$786.46 		$511.46
$550.58
$592.02
$739.22 		$733.14
$772.26
$813.70
$960.90 		$954.82
$993.94
$1,035.38
$1,182.58 		$221.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.56
$657.80
$740.68
$1,035.08
$1,572.92 		$801.24
$879.48
$962.36
$1,256.76 		$1,022.92
$1,101.16
$1,184.04
$1,478.44 		$1,244.60
$1,322.84
$1,405.72
$1,700.12 		$221.68
Toc - Plan #33 CareSource
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$282.52
$320.65
$361.05
$504.57
$766.74 		$498.64
$536.77
$577.17
$720.69 		$714.76
$752.89
$793.29
$936.81 		$930.88
$969.01
$1,009.41
$1,152.93 		$216.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$565.04
$641.30
$722.10
$1,009.14
$1,533.48 		$781.16
$857.42
$938.22
$1,225.26 		$997.28
$1,073.54
$1,154.34
$1,441.38 		$1,213.40
$1,289.66
$1,370.46
$1,657.50 		$216.12
Toc - Plan #34 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$397.08
$450.68
$507.46
$709.17
$1,077.66 		$700.84
$754.44
$811.22
$1,012.93 		$1,004.60
$1,058.20
$1,114.98
$1,316.69 		$1,308.36
$1,361.96
$1,418.74
$1,620.45 		$303.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$794.16
$901.36
$1,014.92
$1,418.34
$2,155.32 		$1,097.92
$1,205.12
$1,318.68
$1,722.10 		$1,401.68
$1,508.88
$1,622.44
$2,025.86 		$1,705.44
$1,812.64
$1,926.20
$2,329.62 		$303.76

ADVERTISEMENT

Ambetter from MHS

Local: 1-877-687-1182 | Toll Free: 1-877-687-1182 | TTY: 1-800-743-3333
Toc - Plan #35 Ambetter from MHS
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$326.71
$370.81
$417.53
$583.49
$886.67 		$576.64
$620.74
$667.46
$833.42 		$826.57
$870.67
$917.39
$1,083.35 		$1,076.50
$1,120.60
$1,167.32
$1,333.28 		$249.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$653.42
$741.62
$835.06
$1,166.98
$1,773.34 		$903.35
$991.55
$1,084.99
$1,416.91 		$1,153.28
$1,241.48
$1,334.92
$1,666.84 		$1,403.21
$1,491.41
$1,584.85
$1,916.77 		$249.93
Toc - Plan #36 Ambetter from MHS
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$405.19
$459.88
$517.82
$723.65
$1,099.65 		$715.15
$769.84
$827.78
$1,033.61 		$1,025.11
$1,079.80
$1,137.74
$1,343.57 		$1,335.07
$1,389.76
$1,447.70
$1,653.53 		$309.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$810.38
$919.76
$1,035.64
$1,447.30
$2,199.30 		$1,120.34
$1,229.72
$1,345.60
$1,757.26 		$1,430.30
$1,539.68
$1,655.56
$2,067.22 		$1,740.26
$1,849.64
$1,965.52
$2,377.18 		$309.96
Toc - Plan #37 Ambetter from MHS
Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$289.70
$328.80
$370.22
$517.38
$786.21 		$511.31
$550.41
$591.83
$738.99 		$732.92
$772.02
$813.44
$960.60 		$954.53
$993.63
$1,035.05
$1,182.21 		$221.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$579.40
$657.60
$740.44
$1,034.76
$1,572.42 		$801.01
$879.21
$962.05
$1,256.37 		$1,022.62
$1,100.82
$1,183.66
$1,477.98 		$1,244.23
$1,322.43
$1,405.27
$1,699.59 		$221.61
Toc - Plan #38 Ambetter from MHS
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$345.37
$391.98
$441.37
$616.81
$937.30 		$609.57
$656.18
$705.57
$881.01 		$873.77
$920.38
$969.77
$1,145.21 		$1,137.97
$1,184.58
$1,233.97
$1,409.41 		$264.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$690.74
$783.96
$882.74
$1,233.62
$1,874.60 		$954.94
$1,048.16
$1,146.94
$1,497.82 		$1,219.14
$1,312.36
$1,411.14
$1,762.02 		$1,483.34
$1,576.56
$1,675.34
$2,026.22 		$264.20
Toc - Plan #39 Ambetter from MHS
Silver

(EPO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$330.96
$375.63
$422.96
$591.08
$898.20 		$584.14
$628.81
$676.14
$844.26 		$837.32
$881.99
$929.32
$1,097.44 		$1,090.50
$1,135.17
$1,182.50
$1,350.62 		$253.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$661.92
$751.26
$845.92
$1,182.16
$1,796.40 		$915.10
$1,004.44
$1,099.10
$1,435.34 		$1,168.28
$1,257.62
$1,352.28
$1,688.52 		$1,421.46
$1,510.80
$1,605.46
$1,941.70 		$253.18
Toc - Plan #40 Ambetter from MHS
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$444.20
$504.15
$567.67
$793.32
$1,205.52 		$784.00
$843.95
$907.47
$1,133.12 		$1,123.80
$1,183.75
$1,247.27
$1,472.92 		$1,463.60
$1,523.55
$1,587.07
$1,812.72 		$339.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$888.40
$1,008.30
$1,135.34
$1,586.64
$2,411.04 		$1,228.20
$1,348.10
$1,475.14
$1,926.44 		$1,568.00
$1,687.90
$1,814.94
$2,266.24 		$1,907.80
$2,027.70
$2,154.74
$2,606.04 		$339.80
Toc - Plan #41 Ambetter from MHS
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$318.02
$360.95
$406.42
$567.97
$863.09 		$561.30
$604.23
$649.70
$811.25 		$804.58
$847.51
$892.98
$1,054.53 		$1,047.86
$1,090.79
$1,136.26
$1,297.81 		$243.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$636.04
$721.90
$812.84
$1,135.94
$1,726.18 		$879.32
$965.18
$1,056.12
$1,379.22 		$1,122.60
$1,208.46
$1,299.40
$1,622.50 		$1,365.88
$1,451.74
$1,542.68
$1,865.78 		$243.28
Toc - Plan #42 Ambetter from MHS
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$307.99
$349.56
$393.60
$550.06
$835.87 		$543.60
$585.17
$629.21
$785.67 		$779.21
$820.78
$864.82
$1,021.28 		$1,014.82
$1,056.39
$1,100.43
$1,256.89 		$235.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$615.98
$699.12
$787.20
$1,100.12
$1,671.74 		$851.59
$934.73
$1,022.81
$1,335.73 		$1,087.20
$1,170.34
$1,258.42
$1,571.34 		$1,322.81
$1,405.95
$1,494.03
$1,806.95 		$235.61
Toc - Plan #43 Ambetter from MHS
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$321.88
$365.32
$411.35
$574.86
$873.55 		$568.11
$611.55
$657.58
$821.09 		$814.34
$857.78
$903.81
$1,067.32 		$1,060.57
$1,104.01
$1,150.04
$1,313.55 		$246.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$643.76
$730.64
$822.70
$1,149.72
$1,747.10 		$889.99
$976.87
$1,068.93
$1,395.95 		$1,136.22
$1,223.10
$1,315.16
$1,642.18 		$1,382.45
$1,469.33
$1,561.39
$1,888.41 		$246.23
Toc - Plan #44 Ambetter from MHS
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$323.09
$366.69
$412.89
$577.02
$876.83 		$570.24
$613.84
$660.04
$824.17 		$817.39
$860.99
$907.19
$1,071.32 		$1,064.54
$1,108.14
$1,154.34
$1,318.47 		$247.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$646.18
$733.38
$825.78
$1,154.04
$1,753.66 		$893.33
$980.53
$1,072.93
$1,401.19 		$1,140.48
$1,227.68
$1,320.08
$1,648.34 		$1,387.63
$1,474.83
$1,567.23
$1,895.49 		$247.15
Toc - Plan #45 Ambetter from MHS
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$388.79
$441.26
$496.86
$694.36
$1,055.14 		$686.20
$738.67
$794.27
$991.77 		$983.61
$1,036.08
$1,091.68
$1,289.18 		$1,281.02
$1,333.49
$1,389.09
$1,586.59 		$297.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.58
$882.52
$993.72
$1,388.72
$2,110.28 		$1,074.99
$1,179.93
$1,291.13
$1,686.13 		$1,372.40
$1,477.34
$1,588.54
$1,983.54 		$1,669.81
$1,774.75
$1,885.95
$2,280.95 		$297.41
Toc - Plan #46 Ambetter from MHS
Bronze

(EPO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$276.96
$314.33
$353.94
$494.63
$751.63 		$488.82
$526.19
$565.80
$706.49 		$700.68
$738.05
$777.66
$918.35 		$912.54
$949.91
$989.52
$1,130.21 		$211.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.92
$628.66
$707.88
$989.26
$1,503.26 		$765.78
$840.52
$919.74
$1,201.12 		$977.64
$1,052.38
$1,131.60
$1,412.98 		$1,189.50
$1,264.24
$1,343.46
$1,624.84 		$211.86
Toc - Plan #47 Ambetter from MHS
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$302.21
$343.00
$386.21
$539.73
$820.17 		$533.39
$574.18
$617.39
$770.91 		$764.57
$805.36
$848.57
$1,002.09 		$995.75
$1,036.54
$1,079.75
$1,233.27 		$231.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$604.42
$686.00
$772.42
$1,079.46
$1,640.34 		$835.60
$917.18
$1,003.60
$1,310.64 		$1,066.78
$1,148.36
$1,234.78
$1,541.82 		$1,297.96
$1,379.54
$1,465.96
$1,773.00 		$231.18
Toc - Plan #48 Ambetter from MHS
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$320.21
$363.43
$409.22
$571.88
$869.03 		$565.16
$608.38
$654.17
$816.83 		$810.11
$853.33
$899.12
$1,061.78 		$1,055.06
$1,098.28
$1,144.07
$1,306.73 		$244.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.42
$726.86
$818.44
$1,143.76
$1,738.06 		$885.37
$971.81
$1,063.39
$1,388.71 		$1,130.32
$1,216.76
$1,308.34
$1,633.66 		$1,375.27
$1,461.71
$1,553.29
$1,878.61 		$244.95
Toc - Plan #49 Ambetter from MHS
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$386.60
$438.78
$494.06
$690.45
$1,049.20 		$682.34
$734.52
$789.80
$986.19 		$978.08
$1,030.26
$1,085.54
$1,281.93 		$1,273.82
$1,326.00
$1,381.28
$1,577.67 		$295.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$773.20
$877.56
$988.12
$1,380.90
$2,098.40 		$1,068.94
$1,173.30
$1,283.86
$1,676.64 		$1,364.68
$1,469.04
$1,579.60
$1,972.38 		$1,660.42
$1,764.78
$1,875.34
$2,268.12 		$295.74
Toc - Plan #50 Ambetter from MHS
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$339.87
$385.74
$434.34
$606.98
$922.37 		$599.86
$645.73
$694.33
$866.97 		$859.85
$905.72
$954.32
$1,126.96 		$1,119.84
$1,165.71
$1,214.31
$1,386.95 		$259.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$679.74
$771.48
$868.68
$1,213.96
$1,844.74 		$939.73
$1,031.47
$1,128.67
$1,473.95 		$1,199.72
$1,291.46
$1,388.66
$1,733.94 		$1,459.71
$1,551.45
$1,648.65
$1,993.93 		$259.99
Toc - Plan #51 Ambetter from MHS
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$421.50
$478.39
$538.66
$752.78
$1,143.92 		$743.94
$800.83
$861.10
$1,075.22 		$1,066.38
$1,123.27
$1,183.54
$1,397.66 		$1,388.82
$1,445.71
$1,505.98
$1,720.10 		$322.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.00
$956.78
$1,077.32
$1,505.56
$2,287.84 		$1,165.44
$1,279.22
$1,399.76
$1,828.00 		$1,487.88
$1,601.66
$1,722.20
$2,150.44 		$1,810.32
$1,924.10
$2,044.64
$2,472.88 		$322.44
Toc - Plan #52 Ambetter from MHS
Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$301.36
$342.03
$385.13
$538.21
$817.86 		$531.89
$572.56
$615.66
$768.74 		$762.42
$803.09
$846.19
$999.27 		$992.95
$1,033.62
$1,076.72
$1,229.80 		$230.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$602.72
$684.06
$770.26
$1,076.42
$1,635.72 		$833.25
$914.59
$1,000.79
$1,306.95 		$1,063.78
$1,145.12
$1,231.32
$1,537.48 		$1,294.31
$1,375.65
$1,461.85
$1,768.01 		$230.53
Toc - Plan #53 Ambetter from MHS
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$330.83
$375.48
$422.78
$590.84
$897.83 		$583.90
$628.55
$675.85
$843.91 		$836.97
$881.62
$928.92
$1,096.98 		$1,090.04
$1,134.69
$1,181.99
$1,350.05 		$253.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$661.66
$750.96
$845.56
$1,181.68
$1,795.66 		$914.73
$1,004.03
$1,098.63
$1,434.75 		$1,167.80
$1,257.10
$1,351.70
$1,687.82 		$1,420.87
$1,510.17
$1,604.77
$1,940.89 		$253.07
Toc - Plan #54 Ambetter from MHS
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$320.39
$363.63
$409.45
$572.20
$869.52 		$565.48
$608.72
$654.54
$817.29 		$810.57
$853.81
$899.63
$1,062.38 		$1,055.66
$1,098.90
$1,144.72
$1,307.47 		$245.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$640.78
$727.26
$818.90
$1,144.40
$1,739.04 		$885.87
$972.35
$1,063.99
$1,389.49 		$1,130.96
$1,217.44
$1,309.08
$1,634.58 		$1,376.05
$1,462.53
$1,554.17
$1,879.67 		$245.09
Toc - Plan #55 Ambetter from MHS
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$334.84
$380.03
$427.91
$598.00
$908.72 		$590.98
$636.17
$684.05
$854.14 		$847.12
$892.31
$940.19
$1,110.28 		$1,103.26
$1,148.45
$1,196.33
$1,366.42 		$256.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$669.68
$760.06
$855.82
$1,196.00
$1,817.44 		$925.82
$1,016.20
$1,111.96
$1,452.14 		$1,181.96
$1,272.34
$1,368.10
$1,708.28 		$1,438.10
$1,528.48
$1,624.24
$1,964.42 		$256.14
Toc - Plan #56 Ambetter from MHS
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$336.09
$381.45
$429.51
$600.24
$912.13 		$593.19
$638.55
$686.61
$857.34 		$850.29
$895.65
$943.71
$1,114.44 		$1,107.39
$1,152.75
$1,200.81
$1,371.54 		$257.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$672.18
$762.90
$859.02
$1,200.48
$1,824.26 		$929.28
$1,020.00
$1,116.12
$1,457.58 		$1,186.38
$1,277.10
$1,373.22
$1,714.68 		$1,443.48
$1,534.20
$1,630.32
$1,971.78 		$257.10
Toc - Plan #57 Ambetter from MHS
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$404.44
$459.03
$516.86
$722.31
$1,097.62 		$713.83
$768.42
$826.25
$1,031.70 		$1,023.22
$1,077.81
$1,135.64
$1,341.09 		$1,332.61
$1,387.20
$1,445.03
$1,650.48 		$309.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$808.88
$918.06
$1,033.72
$1,444.62
$2,195.24 		$1,118.27
$1,227.45
$1,343.11
$1,754.01 		$1,427.66
$1,536.84
$1,652.50
$2,063.40 		$1,737.05
$1,846.23
$1,961.89
$2,372.79 		$309.39
Toc - Plan #58 Ambetter from MHS
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$359.27
$407.76
$459.14
$641.64
$975.04 		$634.11
$682.60
$733.98
$916.48 		$908.95
$957.44
$1,008.82
$1,191.32 		$1,183.79
$1,232.28
$1,283.66
$1,466.16 		$274.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$718.54
$815.52
$918.28
$1,283.28
$1,950.08 		$993.38
$1,090.36
$1,193.12
$1,558.12 		$1,268.22
$1,365.20
$1,467.96
$1,832.96 		$1,543.06
$1,640.04
$1,742.80
$2,107.80 		$274.84
Toc - Plan #59 Ambetter from MHS
Silver

(EPO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$344.28
$390.75
$439.98
$614.87
$934.36 		$607.65
$654.12
$703.35
$878.24 		$871.02
$917.49
$966.72
$1,141.61 		$1,134.39
$1,180.86
$1,230.09
$1,404.98 		$263.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$688.56
$781.50
$879.96
$1,229.74
$1,868.72 		$951.93
$1,044.87
$1,143.33
$1,493.11 		$1,215.30
$1,308.24
$1,406.70
$1,756.48 		$1,478.67
$1,571.61
$1,670.07
$2,019.85 		$263.37
Toc - Plan #60 Ambetter from MHS
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$462.08
$524.45
$590.52
$825.25
$1,254.05 		$815.56
$877.93
$944.00
$1,178.73 		$1,169.04
$1,231.41
$1,297.48
$1,532.21 		$1,522.52
$1,584.89
$1,650.96
$1,885.69 		$353.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.16
$1,048.90
$1,181.04
$1,650.50
$2,508.10 		$1,277.64
$1,402.38
$1,534.52
$2,003.98 		$1,631.12
$1,755.86
$1,888.00
$2,357.46 		$1,984.60
$2,109.34
$2,241.48
$2,710.94 		$353.48
Toc - Plan #61 Ambetter from MHS
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$301.92
$342.66
$385.84
$539.21
$819.38 		$532.88
$573.62
$616.80
$770.17 		$763.84
$804.58
$847.76
$1,001.13 		$994.80
$1,035.54
$1,078.72
$1,232.09 		$230.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$603.84
$685.32
$771.68
$1,078.42
$1,638.76 		$834.80
$916.28
$1,002.64
$1,309.38 		$1,065.76
$1,147.24
$1,233.60
$1,540.34 		$1,296.72
$1,378.20
$1,464.56
$1,771.30 		$230.96
Toc - Plan #62 Ambetter from MHS
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$317.21
$360.02
$405.38
$566.51
$860.87 		$559.87
$602.68
$648.04
$809.17 		$802.53
$845.34
$890.70
$1,051.83 		$1,045.19
$1,088.00
$1,133.36
$1,294.49 		$242.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$634.42
$720.04
$810.76
$1,133.02
$1,721.74 		$877.08
$962.70
$1,053.42
$1,375.68 		$1,119.74
$1,205.36
$1,296.08
$1,618.34 		$1,362.40
$1,448.02
$1,538.74
$1,861.00 		$242.66
Toc - Plan #63 Ambetter from MHS
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1182

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 		$389.77
$442.37
$498.11
$696.11
$1,057.80 		$687.93
$740.53
$796.27
$994.27 		$986.09
$1,038.69
$1,094.43
$1,292.43 		$1,284.25
$1,336.85
$1,392.59
$1,590.59 		$298.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$779.54
$884.74
$996.22
$1,392.22
$2,115.60 		$1,077.70
$1,182.90
$1,294.38
$1,690.38 		$1,375.86
$1,481.06
$1,592.54
$1,988.54 		$1,674.02
$1,779.22
$1,890.70
$2,286.70 		$298.16

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

Benton County is in “Rating Area 5” of Indiana.

Currently, there are 63 plans offered in Rating Area 5.

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2023 Obamacare Plans for Benton County, IN

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