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You are viewing information for Jackson County, IA

Obamacare 2023 Rates for Jackson County

Obamacare > Rates > Iowa > Jackson 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 Jackson County, IA.

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, 45 Plans and 2023 Rates for Jackson County, Iowa

Below, you’ll find a summary of the 45 plans for Jackson County, Iowa 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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Wellmark Health Plan of Iowa, Inc.

Local: 1-800-819-0893 | Toll Free: 1-800-819-0893 | TTY: 1-888-781-4262
Toc - Plan #1 Wellmark Health Plan of Iowa, Inc.
Expanded Bronze

(HMO) Wellmark Bronze HDHP HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$280.52
$318.39
$358.50
$501.00
$761.32 		$495.12
$532.99
$573.10
$715.60 		$709.72
$747.59
$787.70
$930.20 		$924.32
$962.19
$1,002.30
$1,144.80 		$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
$1,002.00
$1,522.64 		$775.64
$851.38
$931.60
$1,216.60 		$990.24
$1,065.98
$1,146.20
$1,431.20 		$1,204.84
$1,280.58
$1,360.80
$1,645.80 		$214.60
Toc - Plan #2 Wellmark Health Plan of Iowa, Inc.
Silver

(HMO) Wellmark Silver Traditional HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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 		$381.30
$432.78
$487.30
$681.01
$1,034.86 		$673.00
$724.48
$779.00
$972.71 		$964.70
$1,016.18
$1,070.70
$1,264.41 		$1,256.40
$1,307.88
$1,362.40
$1,556.11 		$291.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.60
$865.56
$974.60
$1,362.02
$2,069.72 		$1,054.30
$1,157.26
$1,266.30
$1,653.72 		$1,346.00
$1,448.96
$1,558.00
$1,945.42 		$1,637.70
$1,740.66
$1,849.70
$2,237.12 		$291.70
Toc - Plan #3 Wellmark Health Plan of Iowa, Inc.
Expanded Bronze

(HMO) Wellmark Bronze Traditional HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

Individual Family
$7,200 $14,400 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 		$278.26
$315.82
$355.61
$496.96
$755.19 		$491.13
$528.69
$568.48
$709.83 		$704.00
$741.56
$781.35
$922.70 		$916.87
$954.43
$994.22
$1,135.57 		$212.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.52
$631.64
$711.22
$993.92
$1,510.38 		$769.39
$844.51
$924.09
$1,206.79 		$982.26
$1,057.38
$1,136.96
$1,419.66 		$1,195.13
$1,270.25
$1,349.83
$1,632.53 		$212.87
Toc - Plan #4 Wellmark Health Plan of Iowa, Inc.
Gold

(HMO) Wellmark Gold Traditional HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.06
$410.94
$462.71
$646.64
$982.64 		$639.04
$687.92
$739.69
$923.62 		$916.02
$964.90
$1,016.67
$1,200.60 		$1,193.00
$1,241.88
$1,293.65
$1,477.58 		$276.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.12
$821.88
$925.42
$1,293.28
$1,965.28 		$1,001.10
$1,098.86
$1,202.40
$1,570.26 		$1,278.08
$1,375.84
$1,479.38
$1,847.24 		$1,555.06
$1,652.82
$1,756.36
$2,124.22 		$276.98
Toc - Plan #5 Wellmark Health Plan of Iowa, Inc.
Expanded Bronze

(HMO) Wellmark Bronze HDHP HMO | Farm Bureau

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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 		$280.52
$318.39
$358.50
$501.00
$761.32 		$495.12
$532.99
$573.10
$715.60 		$709.72
$747.59
$787.70
$930.20 		$924.32
$962.19
$1,002.30
$1,144.80 		$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
$1,002.00
$1,522.64 		$775.64
$851.38
$931.60
$1,216.60 		$990.24
$1,065.98
$1,146.20
$1,431.20 		$1,204.84
$1,280.58
$1,360.80
$1,645.80 		$214.60
Toc - Plan #6 Wellmark Health Plan of Iowa, Inc.
Gold

(HMO) Wellmark Gold Traditional HMO | Farm Bureau

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$362.06
$410.94
$462.71
$646.64
$982.64 		$639.04
$687.92
$739.69
$923.62 		$916.02
$964.90
$1,016.67
$1,200.60 		$1,193.00
$1,241.88
$1,293.65
$1,477.58 		$276.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$724.12
$821.88
$925.42
$1,293.28
$1,965.28 		$1,001.10
$1,098.86
$1,202.40
$1,570.26 		$1,278.08
$1,375.84
$1,479.38
$1,847.24 		$1,555.06
$1,652.82
$1,756.36
$2,124.22 		$276.98
Toc - Plan #7 Wellmark Health Plan of Iowa, Inc.
Expanded Bronze

(HMO) Wellmark Bronze Primary Care | UnityPoint Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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 		$270.50
$307.01
$345.69
$483.10
$734.12 		$477.43
$513.94
$552.62
$690.03 		$684.36
$720.87
$759.55
$896.96 		$891.29
$927.80
$966.48
$1,103.89 		$206.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$541.00
$614.02
$691.38
$966.20
$1,468.24 		$747.93
$820.95
$898.31
$1,173.13 		$954.86
$1,027.88
$1,105.24
$1,380.06 		$1,161.79
$1,234.81
$1,312.17
$1,586.99 		$206.93
Toc - Plan #8 Wellmark Health Plan of Iowa, Inc.
Silver

(HMO) Wellmark Silver Primary Care | UnityPoint Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 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 		$352.89
$400.53
$450.99
$630.26
$957.75 		$622.85
$670.49
$720.95
$900.22 		$892.81
$940.45
$990.91
$1,170.18 		$1,162.77
$1,210.41
$1,260.87
$1,440.14 		$269.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$705.78
$801.06
$901.98
$1,260.52
$1,915.50 		$975.74
$1,071.02
$1,171.94
$1,530.48 		$1,245.70
$1,340.98
$1,441.90
$1,800.44 		$1,515.66
$1,610.94
$1,711.86
$2,070.40 		$269.96
Toc - Plan #9 Wellmark Health Plan of Iowa, Inc.
Gold

(HMO) Wellmark Gold Primary Care | UnityPoint Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

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 		$333.63
$378.67
$426.38
$595.86
$905.47 		$588.86
$633.90
$681.61
$851.09 		$844.09
$889.13
$936.84
$1,106.32 		$1,099.32
$1,144.36
$1,192.07
$1,361.55 		$255.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$667.26
$757.34
$852.76
$1,191.72
$1,810.94 		$922.49
$1,012.57
$1,107.99
$1,446.95 		$1,177.72
$1,267.80
$1,363.22
$1,702.18 		$1,432.95
$1,523.03
$1,618.45
$1,957.41 		$255.23
Toc - Plan #10 Wellmark Health Plan of Iowa, Inc.
Expanded Bronze

(HMO) Wellmark Standard Bronze HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

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 		$279.52
$317.26
$357.23
$499.23
$758.62 		$493.35
$531.09
$571.06
$713.06 		$707.18
$744.92
$784.89
$926.89 		$921.01
$958.75
$998.72
$1,140.72 		$213.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$559.04
$634.52
$714.46
$998.46
$1,517.24 		$772.87
$848.35
$928.29
$1,212.29 		$986.70
$1,062.18
$1,142.12
$1,426.12 		$1,200.53
$1,276.01
$1,355.95
$1,639.95 		$213.83
Toc - Plan #11 Wellmark Health Plan of Iowa, Inc.
Silver

(HMO) Wellmark Standard Silver HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

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 		$377.26
$428.19
$482.14
$673.79
$1,023.89 		$665.87
$716.80
$770.75
$962.40 		$954.48
$1,005.41
$1,059.36
$1,251.01 		$1,243.09
$1,294.02
$1,347.97
$1,539.62 		$288.61
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.52
$856.38
$964.28
$1,347.58
$2,047.78 		$1,043.13
$1,144.99
$1,252.89
$1,636.19 		$1,331.74
$1,433.60
$1,541.50
$1,924.80 		$1,620.35
$1,722.21
$1,830.11
$2,213.41 		$288.61
Toc - Plan #12 Wellmark Health Plan of Iowa, Inc.
Gold

(HMO) Wellmark Standard Gold HMO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-819-0893

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 		$350.56
$397.89
$448.02
$626.10
$951.42 		$618.74
$666.07
$716.20
$894.28 		$886.92
$934.25
$984.38
$1,162.46 		$1,155.10
$1,202.43
$1,252.56
$1,430.64 		$268.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.12
$795.78
$896.04
$1,252.20
$1,902.84 		$969.30
$1,063.96
$1,164.22
$1,520.38 		$1,237.48
$1,332.14
$1,432.40
$1,788.56 		$1,505.66
$1,600.32
$1,700.58
$2,056.74 		$268.18

ADVERTISEMENT

Oscar Insurance Company

Local:  | Toll Free: 

Toc - Plan #13 Oscar Insurance Company
Bronze

(EPO) Bronze Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 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 		$269.83
$306.25
$344.83
$481.90
$732.29 		$476.24
$512.66
$551.24
$688.31 		$682.65
$719.07
$757.65
$894.72 		$889.06
$925.48
$964.06
$1,101.13 		$206.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$539.66
$612.50
$689.66
$963.80
$1,464.58 		$746.07
$818.91
$896.07
$1,170.21 		$952.48
$1,025.32
$1,102.48
$1,376.62 		$1,158.89
$1,231.73
$1,308.89
$1,583.03 		$206.41
Toc - Plan #14 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Elite- $0 Ded+PCP Saver

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 		$328.78
$373.16
$420.17
$587.19
$892.29 		$580.29
$624.67
$671.68
$838.70 		$831.80
$876.18
$923.19
$1,090.21 		$1,083.31
$1,127.69
$1,174.70
$1,341.72 		$251.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.56
$746.32
$840.34
$1,174.38
$1,784.58 		$909.07
$997.83
$1,091.85
$1,425.89 		$1,160.58
$1,249.34
$1,343.36
$1,677.40 		$1,412.09
$1,500.85
$1,594.87
$1,928.91 		$251.51
Toc - Plan #15 Oscar Insurance Company
Silver

(EPO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 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 		$385.80
$437.88
$493.04
$689.03
$1,047.04 		$680.93
$733.01
$788.17
$984.16 		$976.06
$1,028.14
$1,083.30
$1,279.29 		$1,271.19
$1,323.27
$1,378.43
$1,574.42 		$295.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$771.60
$875.76
$986.08
$1,378.06
$2,094.08 		$1,066.73
$1,170.89
$1,281.21
$1,673.19 		$1,361.86
$1,466.02
$1,576.34
$1,968.32 		$1,656.99
$1,761.15
$1,871.47
$2,263.45 		$295.13
Toc - Plan #16 Oscar Insurance Company
Catastrophic

(EPO) Secure

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 		$219.78
$249.44
$280.87
$392.51
$596.46 		$387.90
$417.56
$448.99
$560.63 		$556.02
$585.68
$617.11
$728.75 		$724.14
$753.80
$785.23
$896.87 		$168.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$439.56
$498.88
$561.74
$785.02
$1,192.92 		$607.68
$667.00
$729.86
$953.14 		$775.80
$835.12
$897.98
$1,121.26 		$943.92
$1,003.24
$1,066.10
$1,289.38 		$168.12
Toc - Plan #17 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Simple- HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 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 		$292.75
$332.26
$374.12
$522.83
$794.50 		$516.70
$556.21
$598.07
$746.78 		$740.65
$780.16
$822.02
$970.73 		$964.60
$1,004.11
$1,045.97
$1,194.68 		$223.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$585.50
$664.52
$748.24
$1,045.66
$1,589.00 		$809.45
$888.47
$972.19
$1,269.61 		$1,033.40
$1,112.42
$1,196.14
$1,493.56 		$1,257.35
$1,336.37
$1,420.09
$1,717.51 		$223.95
Toc - Plan #18 Oscar Insurance Company
Silver

(EPO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$378.93
$430.08
$484.27
$676.76
$1,028.40 		$668.81
$719.96
$774.15
$966.64 		$958.69
$1,009.84
$1,064.03
$1,256.52 		$1,248.57
$1,299.72
$1,353.91
$1,546.40 		$289.88
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.86
$860.16
$968.54
$1,353.52
$2,056.80 		$1,047.74
$1,150.04
$1,258.42
$1,643.40 		$1,337.62
$1,439.92
$1,548.30
$1,933.28 		$1,627.50
$1,729.80
$1,838.18
$2,223.16 		$289.88
Toc - Plan #19 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $0 PCP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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 		$290.68
$329.91
$371.48
$519.14
$788.88 		$513.04
$552.27
$593.84
$741.50 		$735.40
$774.63
$816.20
$963.86 		$957.76
$996.99
$1,038.56
$1,186.22 		$222.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.36
$659.82
$742.96
$1,038.28
$1,577.76 		$803.72
$882.18
$965.32
$1,260.64 		$1,026.08
$1,104.54
$1,187.68
$1,483.00 		$1,248.44
$1,326.90
$1,410.04
$1,705.36 		$222.36
Toc - Plan #20 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- $4700 Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 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 		$290.62
$329.85
$371.41
$519.04
$788.73 		$512.94
$552.17
$593.73
$741.36 		$735.26
$774.49
$816.05
$963.68 		$957.58
$996.81
$1,038.37
$1,186.00 		$222.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$581.24
$659.70
$742.82
$1,038.08
$1,577.46 		$803.56
$882.02
$965.14
$1,260.40 		$1,025.88
$1,104.34
$1,187.46
$1,482.72 		$1,248.20
$1,326.66
$1,409.78
$1,705.04 		$222.32
Toc - Plan #21 Oscar Insurance Company
Silver

(EPO) Silver Simple- PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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 		$369.08
$418.90
$471.68
$659.17
$1,001.67 		$651.42
$701.24
$754.02
$941.51 		$933.76
$983.58
$1,036.36
$1,223.85 		$1,216.10
$1,265.92
$1,318.70
$1,506.19 		$282.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$738.16
$837.80
$943.36
$1,318.34
$2,003.34 		$1,020.50
$1,120.14
$1,225.70
$1,600.68 		$1,302.84
$1,402.48
$1,508.04
$1,883.02 		$1,585.18
$1,684.82
$1,790.38
$2,165.36 		$282.34
Toc - Plan #22 Oscar Insurance Company
Silver

(EPO) Silver Elite- $0 Ded

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 		$392.75
$445.76
$501.92
$701.44
$1,065.90 		$693.20
$746.21
$802.37
$1,001.89 		$993.65
$1,046.66
$1,102.82
$1,302.34 		$1,294.10
$1,347.11
$1,403.27
$1,602.79 		$300.45
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$785.50
$891.52
$1,003.84
$1,402.88
$2,131.80 		$1,085.95
$1,191.97
$1,304.29
$1,703.33 		$1,386.40
$1,492.42
$1,604.74
$2,003.78 		$1,686.85
$1,792.87
$1,905.19
$2,304.23 		$300.45
Toc - Plan #23 Oscar Insurance Company
Gold

(EPO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$400.51
$454.57
$511.84
$715.30
$1,086.96 		$706.89
$760.95
$818.22
$1,021.68 		$1,013.27
$1,067.33
$1,124.60
$1,328.06 		$1,319.65
$1,373.71
$1,430.98
$1,634.44 		$306.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$801.02
$909.14
$1,023.68
$1,430.60
$2,173.92 		$1,107.40
$1,215.52
$1,330.06
$1,736.98 		$1,413.78
$1,521.90
$1,636.44
$2,043.36 		$1,720.16
$1,828.28
$1,942.82
$2,349.74 		$306.38
Toc - Plan #24 Oscar Insurance Company
Silver

(EPO) Silver Simple- For Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone:

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 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 		$382.69
$434.34
$489.06
$683.46
$1,038.59 		$675.44
$727.09
$781.81
$976.21 		$968.19
$1,019.84
$1,074.56
$1,268.96 		$1,260.94
$1,312.59
$1,367.31
$1,561.71 		$292.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$765.38
$868.68
$978.12
$1,366.92
$2,077.18 		$1,058.13
$1,161.43
$1,270.87
$1,659.67 		$1,350.88
$1,454.18
$1,563.62
$1,952.42 		$1,643.63
$1,746.93
$1,856.37
$2,245.17 		$292.75
Toc - Plan #25 Oscar Insurance Company
Expanded Bronze

(EPO) Bronze Classic- Standard

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 		$285.13
$323.61
$364.38
$509.23
$773.82 		$503.25
$541.73
$582.50
$727.35 		$721.37
$759.85
$800.62
$945.47 		$939.49
$977.97
$1,018.74
$1,163.59 		$218.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$570.26
$647.22
$728.76
$1,018.46
$1,547.64 		$788.38
$865.34
$946.88
$1,236.58 		$1,006.50
$1,083.46
$1,165.00
$1,454.70 		$1,224.62
$1,301.58
$1,383.12
$1,672.82 		$218.12
Toc - Plan #26 Oscar Insurance Company
Bronze

(EPO) Bronze Simple- Standard

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 		$255.34
$289.80
$326.31
$456.02
$692.97 		$450.67
$485.13
$521.64
$651.35 		$646.00
$680.46
$716.97
$846.68 		$841.33
$875.79
$912.30
$1,042.01 		$195.33
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$510.68
$579.60
$652.62
$912.04
$1,385.94 		$706.01
$774.93
$847.95
$1,107.37 		$901.34
$970.26
$1,043.28
$1,302.70 		$1,096.67
$1,165.59
$1,238.61
$1,498.03 		$195.33
Toc - Plan #27 Oscar Insurance Company
Silver

(EPO) Silver Classic- Standard

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 		$372.25
$422.49
$475.72
$664.82
$1,010.26 		$657.01
$707.25
$760.48
$949.58 		$941.77
$992.01
$1,045.24
$1,234.34 		$1,226.53
$1,276.77
$1,330.00
$1,519.10 		$284.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$744.50
$844.98
$951.44
$1,329.64
$2,020.52 		$1,029.26
$1,129.74
$1,236.20
$1,614.40 		$1,314.02
$1,414.50
$1,520.96
$1,899.16 		$1,598.78
$1,699.26
$1,805.72
$2,183.92 		$284.76
Toc - Plan #28 Oscar Insurance Company
Gold

(EPO) Gold Classic- Standard

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 		$361.81
$410.64
$462.38
$646.17
$981.92 		$638.59
$687.42
$739.16
$922.95 		$915.37
$964.20
$1,015.94
$1,199.73 		$1,192.15
$1,240.98
$1,292.72
$1,476.51 		$276.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.62
$821.28
$924.76
$1,292.34
$1,963.84 		$1,000.40
$1,098.06
$1,201.54
$1,569.12 		$1,277.18
$1,374.84
$1,478.32
$1,845.90 		$1,553.96
$1,651.62
$1,755.10
$2,122.68 		$276.78

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-888-516-4692
Toc - Plan #29 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Copay ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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 		$373.84
$424.30
$477.76
$667.67
$1,014.58 		$659.82
$710.28
$763.74
$953.65 		$945.80
$996.26
$1,049.72
$1,239.63 		$1,231.78
$1,282.24
$1,335.70
$1,525.61 		$285.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.68
$848.60
$955.52
$1,335.34
$2,029.16 		$1,033.66
$1,134.58
$1,241.50
$1,621.32 		$1,319.64
$1,420.56
$1,527.48
$1,907.30 		$1,605.62
$1,706.54
$1,813.46
$2,193.28 		$285.98
Toc - Plan #30 Medica
Expanded Bronze

(EPO) Medica Insure Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$433.50
$492.01
$554.00
$774.21
$1,176.49 		$765.12
$823.63
$885.62
$1,105.83 		$1,096.74
$1,155.25
$1,217.24
$1,437.45 		$1,428.36
$1,486.87
$1,548.86
$1,769.07 		$331.62
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.00
$984.02
$1,108.00
$1,548.42
$2,352.98 		$1,198.62
$1,315.64
$1,439.62
$1,880.04 		$1,530.24
$1,647.26
$1,771.24
$2,211.66 		$1,861.86
$1,978.88
$2,102.86
$2,543.28 		$331.62
Toc - Plan #31 Medica
Catastrophic

(EPO) Medica Insure Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$288.12
$327.01
$368.21
$514.57
$781.94 		$508.53
$547.42
$588.62
$734.98 		$728.94
$767.83
$809.03
$955.39 		$949.35
$988.24
$1,029.44
$1,175.80 		$220.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$576.24
$654.02
$736.42
$1,029.14
$1,563.88 		$796.65
$874.43
$956.83
$1,249.55 		$1,017.06
$1,094.84
$1,177.24
$1,469.96 		$1,237.47
$1,315.25
$1,397.65
$1,690.37 		$220.41
Toc - Plan #32 Medica
Silver

(EPO) Medica Insure Silver Share ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$525.30
$596.21
$671.33
$938.18
$1,425.65 		$927.15
$998.06
$1,073.18
$1,340.03 		$1,329.00
$1,399.91
$1,475.03
$1,741.88 		$1,730.85
$1,801.76
$1,876.88
$2,143.73 		$401.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,050.60
$1,192.42
$1,342.66
$1,876.36
$2,851.30 		$1,452.45
$1,594.27
$1,744.51
$2,278.21 		$1,854.30
$1,996.12
$2,146.36
$2,680.06 		$2,256.15
$2,397.97
$2,548.21
$3,081.91 		$401.85
Toc - Plan #33 Medica
Expanded Bronze

(EPO) Medica Insure Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 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 		$386.45
$438.61
$493.87
$690.19
$1,048.80 		$682.08
$734.24
$789.50
$985.82 		$977.71
$1,029.87
$1,085.13
$1,281.45 		$1,273.34
$1,325.50
$1,380.76
$1,577.08 		$295.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$772.90
$877.22
$987.74
$1,380.38
$2,097.60 		$1,068.53
$1,172.85
$1,283.37
$1,676.01 		$1,364.16
$1,468.48
$1,579.00
$1,971.64 		$1,659.79
$1,764.11
$1,874.63
$2,267.27 		$295.63
Toc - Plan #34 Medica
Gold

(EPO) Medica Insure Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$543.91
$617.32
$695.10
$971.40
$1,476.13 		$959.99
$1,033.40
$1,111.18
$1,387.48 		$1,376.07
$1,449.48
$1,527.26
$1,803.56 		$1,792.15
$1,865.56
$1,943.34
$2,219.64 		$416.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,087.82
$1,234.64
$1,390.20
$1,942.80
$2,952.26 		$1,503.90
$1,650.72
$1,806.28
$2,358.88 		$1,919.98
$2,066.80
$2,222.36
$2,774.96 		$2,336.06
$2,482.88
$2,638.44
$3,191.04 		$416.08
Toc - Plan #35 Medica
Silver

(EPO) Medica Insure Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$458.82
$520.75
$586.36
$819.44
$1,245.22 		$809.81
$871.74
$937.35
$1,170.43 		$1,160.80
$1,222.73
$1,288.34
$1,521.42 		$1,511.79
$1,573.72
$1,639.33
$1,872.41 		$350.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.64
$1,041.50
$1,172.72
$1,638.88
$2,490.44 		$1,268.63
$1,392.49
$1,523.71
$1,989.87 		$1,619.62
$1,743.48
$1,874.70
$2,340.86 		$1,970.61
$2,094.47
$2,225.69
$2,691.85 		$350.99
Toc - Plan #36 Medica
Bronze

(EPO) Medica Insure Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$367.80
$417.44
$470.04
$656.87
$998.18 		$649.16
$698.80
$751.40
$938.23 		$930.52
$980.16
$1,032.76
$1,219.59 		$1,211.88
$1,261.52
$1,314.12
$1,500.95 		$281.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$735.60
$834.88
$940.08
$1,313.74
$1,996.36 		$1,016.96
$1,116.24
$1,221.44
$1,595.10 		$1,298.32
$1,397.60
$1,502.80
$1,876.46 		$1,579.68
$1,678.96
$1,784.16
$2,157.82 		$281.36
Toc - Plan #37 Medica
Expanded Bronze

(EPO) Inspire by Medica Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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 		$347.91
$394.86
$444.61
$621.35
$944.20 		$614.05
$661.00
$710.75
$887.49 		$880.19
$927.14
$976.89
$1,153.63 		$1,146.33
$1,193.28
$1,243.03
$1,419.77 		$266.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$695.82
$789.72
$889.22
$1,242.70
$1,888.40 		$961.96
$1,055.86
$1,155.36
$1,508.84 		$1,228.10
$1,322.00
$1,421.50
$1,774.98 		$1,494.24
$1,588.14
$1,687.64
$2,041.12 		$266.14
Toc - Plan #38 Medica
Catastrophic

(EPO) Inspire by Medica Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$231.23
$262.44
$295.51
$412.97
$627.54 		$408.12
$439.33
$472.40
$589.86 		$585.01
$616.22
$649.29
$766.75 		$761.90
$793.11
$826.18
$943.64 		$176.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$462.46
$524.88
$591.02
$825.94
$1,255.08 		$639.35
$701.77
$767.91
$1,002.83 		$816.24
$878.66
$944.80
$1,179.72 		$993.13
$1,055.55
$1,121.69
$1,356.61 		$176.89
Toc - Plan #39 Medica
Silver

(EPO) Inspire by Medica Silver Share ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$421.59
$478.49
$538.77
$752.93
$1,144.16 		$744.10
$801.00
$861.28
$1,075.44 		$1,066.61
$1,123.51
$1,183.79
$1,397.95 		$1,389.12
$1,446.02
$1,506.30
$1,720.46 		$322.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.18
$956.98
$1,077.54
$1,505.86
$2,288.32 		$1,165.69
$1,279.49
$1,400.05
$1,828.37 		$1,488.20
$1,602.00
$1,722.56
$2,150.88 		$1,810.71
$1,924.51
$2,045.07
$2,473.39 		$322.51
Toc - Plan #40 Medica
Expanded Bronze

(EPO) Inspire by Medica Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,700 $5,400 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 		$310.15
$352.01
$396.36
$553.91
$841.72 		$547.41
$589.27
$633.62
$791.17 		$784.67
$826.53
$870.88
$1,028.43 		$1,021.93
$1,063.79
$1,108.14
$1,265.69 		$237.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$620.30
$704.02
$792.72
$1,107.82
$1,683.44 		$857.56
$941.28
$1,029.98
$1,345.08 		$1,094.82
$1,178.54
$1,267.24
$1,582.34 		$1,332.08
$1,415.80
$1,504.50
$1,819.60 		$237.26
Toc - Plan #41 Medica
Expanded Bronze

(EPO) Inspire by Medica Bronze Copay $5 Preferred Primary Care ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,700 $15,400 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 		$309.69
$351.49
$395.77
$553.09
$840.47 		$546.59
$588.39
$632.67
$789.99 		$783.49
$825.29
$869.57
$1,026.89 		$1,020.39
$1,062.19
$1,106.47
$1,263.79 		$236.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$619.38
$702.98
$791.54
$1,106.18
$1,680.94 		$856.28
$939.88
$1,028.44
$1,343.08 		$1,093.18
$1,176.78
$1,265.34
$1,579.98 		$1,330.08
$1,413.68
$1,502.24
$1,816.88 		$236.90
Toc - Plan #42 Medica
Gold

(EPO) Inspire by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,750 $3,500 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 		$433.34
$491.82
$553.79
$773.92
$1,176.05 		$764.83
$823.31
$885.28
$1,105.41 		$1,096.32
$1,154.80
$1,216.77
$1,436.90 		$1,427.81
$1,486.29
$1,548.26
$1,768.39 		$331.49
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.68
$983.64
$1,107.58
$1,547.84
$2,352.10 		$1,198.17
$1,315.13
$1,439.07
$1,879.33 		$1,529.66
$1,646.62
$1,770.56
$2,210.82 		$1,861.15
$1,978.11
$2,102.05
$2,542.31 		$331.49
Toc - Plan #43 Medica
Gold

(EPO) Inspire by Medica Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$436.51
$495.43
$557.85
$779.60
$1,184.67 		$770.44
$829.36
$891.78
$1,113.53 		$1,104.37
$1,163.29
$1,225.71
$1,447.46 		$1,438.30
$1,497.22
$1,559.64
$1,781.39 		$333.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$873.02
$990.86
$1,115.70
$1,559.20
$2,369.34 		$1,206.95
$1,324.79
$1,449.63
$1,893.13 		$1,540.88
$1,658.72
$1,783.56
$2,227.06 		$1,874.81
$1,992.65
$2,117.49
$2,560.99 		$333.93
Toc - Plan #44 Medica
Silver

(EPO) Inspire by Medica Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$368.23
$417.93
$470.59
$657.64
$999.35 		$649.92
$699.62
$752.28
$939.33 		$931.61
$981.31
$1,033.97
$1,221.02 		$1,213.30
$1,263.00
$1,315.66
$1,502.71 		$281.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$736.46
$835.86
$941.18
$1,315.28
$1,998.70 		$1,018.15
$1,117.55
$1,222.87
$1,596.97 		$1,299.84
$1,399.24
$1,504.56
$1,878.66 		$1,581.53
$1,680.93
$1,786.25
$2,160.35 		$281.69
Toc - Plan #45 Medica
Bronze

(EPO) Inspire by Medica Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

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 		$295.18
$335.02
$377.23
$527.17
$801.09 		$520.99
$560.83
$603.04
$752.98 		$746.80
$786.64
$828.85
$978.79 		$972.61
$1,012.45
$1,054.66
$1,204.60 		$225.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$590.36
$670.04
$754.46
$1,054.34
$1,602.18 		$816.17
$895.85
$980.27
$1,280.15 		$1,041.98
$1,121.66
$1,206.08
$1,505.96 		$1,267.79
$1,347.47
$1,431.89
$1,731.77 		$225.81

‡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 Jackson County here.

Jackson County is in “Rating Area 6” of Iowa.

Currently, there are 45 plans offered in Rating Area 6.

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2023 Obamacare Plans for Jackson County, IA

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