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You are viewing information for Atchison County, KS

Obamacare 2023 Rates for Atchison County

Obamacare > Rates > Kansas > Atchison 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 Atchison County, KS.

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, 68 Plans and 2023 Rates for Atchison County, Kansas

Below, you’ll find a summary of the 68 plans for Atchison County, Kansas 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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Blue Cross and Blue Shield of Kansas, Inc.

Local: 1-785-291-4186 | Toll Free: 1-800-392-7366 | TTY: 1-800-430-1270
Toc - Plan #1 Blue Cross and Blue Shield of Kansas, Inc.
Gold

(EPO) BlueCare EPO Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$4,950 $9,900 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 		$487.54
$553.36
$623.08
$870.75
$1,323.19 		$860.51
$926.33
$996.05
$1,243.72 		$1,233.48
$1,299.30
$1,369.02
$1,616.69 		$1,606.45
$1,672.27
$1,741.99
$1,989.66 		$372.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$975.08
$1,106.72
$1,246.16
$1,741.50
$2,646.38 		$1,348.05
$1,479.69
$1,619.13
$2,114.47 		$1,721.02
$1,852.66
$1,992.10
$2,487.44 		$2,093.99
$2,225.63
$2,365.07
$2,860.41 		$372.97
Toc - Plan #2 Blue Cross and Blue Shield of Kansas, Inc.
Gold

(EPO) BlueCare EPO Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$4,950 $9,900 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 		$487.54
$553.36
$623.08
$870.75
$1,323.19 		$860.51
$926.33
$996.05
$1,243.72 		$1,233.48
$1,299.30
$1,369.02
$1,616.69 		$1,606.45
$1,672.27
$1,741.99
$1,989.66 		$372.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$975.08
$1,106.72
$1,246.16
$1,741.50
$2,646.38 		$1,348.05
$1,479.69
$1,619.13
$2,114.47 		$1,721.02
$1,852.66
$1,992.10
$2,487.44 		$2,093.99
$2,225.63
$2,365.07
$2,860.41 		$372.97
Toc - Plan #3 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$510.53
$579.45
$652.46
$911.80
$1,385.58 		$901.08
$970.00
$1,043.01
$1,302.35 		$1,291.63
$1,360.55
$1,433.56
$1,692.90 		$1,682.18
$1,751.10
$1,824.11
$2,083.45 		$390.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.06
$1,158.90
$1,304.92
$1,823.60
$2,771.16 		$1,411.61
$1,549.45
$1,695.47
$2,214.15 		$1,802.16
$1,940.00
$2,086.02
$2,604.70 		$2,192.71
$2,330.55
$2,476.57
$2,995.25 		$390.55
Toc - Plan #4 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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 		$510.53
$579.45
$652.46
$911.80
$1,385.58 		$901.08
$970.00
$1,043.01
$1,302.35 		$1,291.63
$1,360.55
$1,433.56
$1,692.90 		$1,682.18
$1,751.10
$1,824.11
$2,083.45 		$390.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.06
$1,158.90
$1,304.92
$1,823.60
$2,771.16 		$1,411.61
$1,549.45
$1,695.47
$2,214.15 		$1,802.16
$1,940.00
$2,086.02
$2,604.70 		$2,192.71
$2,330.55
$2,476.57
$2,995.25 		$390.55
Toc - Plan #5 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Simple Silver HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 Annual Deductible
$4,900 $9,800 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 		$517.02
$586.82
$660.75
$923.40
$1,403.20 		$912.54
$982.34
$1,056.27
$1,318.92 		$1,308.06
$1,377.86
$1,451.79
$1,714.44 		$1,703.58
$1,773.38
$1,847.31
$2,109.96 		$395.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,034.04
$1,173.64
$1,321.50
$1,846.80
$2,806.40 		$1,429.56
$1,569.16
$1,717.02
$2,242.32 		$1,825.08
$1,964.68
$2,112.54
$2,637.84 		$2,220.60
$2,360.20
$2,508.06
$3,033.36 		$395.52
Toc - Plan #6 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Simple Silver HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$4,900 $9,800 Annual Deductible
$4,900 $9,800 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 		$517.02
$586.82
$660.75
$923.40
$1,403.20 		$912.54
$982.34
$1,056.27
$1,318.92 		$1,308.06
$1,377.86
$1,451.79
$1,714.44 		$1,703.58
$1,773.38
$1,847.31
$2,109.96 		$395.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,034.04
$1,173.64
$1,321.50
$1,846.80
$2,806.40 		$1,429.56
$1,569.16
$1,717.02
$2,242.32 		$1,825.08
$1,964.68
$2,112.54
$2,637.84 		$2,220.60
$2,360.20
$2,508.06
$3,033.36 		$395.52
Toc - Plan #7 Blue Cross and Blue Shield of Kansas, Inc.
Expanded Bronze

(EPO) BlueCare EPO Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$387.32
$439.61
$495.00
$691.76
$1,051.19 		$683.62
$735.91
$791.30
$988.06 		$979.92
$1,032.21
$1,087.60
$1,284.36 		$1,276.22
$1,328.51
$1,383.90
$1,580.66 		$296.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.64
$879.22
$990.00
$1,383.52
$2,102.38 		$1,070.94
$1,175.52
$1,286.30
$1,679.82 		$1,367.24
$1,471.82
$1,582.60
$1,976.12 		$1,663.54
$1,768.12
$1,878.90
$2,272.42 		$296.30
Toc - Plan #8 Blue Cross and Blue Shield of Kansas, Inc.
Expanded Bronze

(EPO) BlueCare EPO Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 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 		$387.32
$439.61
$495.00
$691.76
$1,051.19 		$683.62
$735.91
$791.30
$988.06 		$979.92
$1,032.21
$1,087.60
$1,284.36 		$1,276.22
$1,328.51
$1,383.90
$1,580.66 		$296.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.64
$879.22
$990.00
$1,383.52
$2,102.38 		$1,070.94
$1,175.52
$1,286.30
$1,679.82 		$1,367.24
$1,471.82
$1,582.60
$1,976.12 		$1,663.54
$1,768.12
$1,878.90
$2,272.42 		$296.30
Toc - Plan #9 Blue Cross and Blue Shield of Kansas, Inc.
Expanded Bronze

(EPO) BlueCare EPO Simple Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$387.32
$439.61
$495.00
$691.76
$1,051.19 		$683.62
$735.91
$791.30
$988.06 		$979.92
$1,032.21
$1,087.60
$1,284.36 		$1,276.22
$1,328.51
$1,383.90
$1,580.66 		$296.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.64
$879.22
$990.00
$1,383.52
$2,102.38 		$1,070.94
$1,175.52
$1,286.30
$1,679.82 		$1,367.24
$1,471.82
$1,582.60
$1,976.12 		$1,663.54
$1,768.12
$1,878.90
$2,272.42 		$296.30
Toc - Plan #10 Blue Cross and Blue Shield of Kansas, Inc.
Expanded Bronze

(EPO) BlueCare EPO Simple Bronze HDHP

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$387.32
$439.61
$495.00
$691.76
$1,051.19 		$683.62
$735.91
$791.30
$988.06 		$979.92
$1,032.21
$1,087.60
$1,284.36 		$1,276.22
$1,328.51
$1,383.90
$1,580.66 		$296.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$774.64
$879.22
$990.00
$1,383.52
$2,102.38 		$1,070.94
$1,175.52
$1,286.30
$1,679.82 		$1,367.24
$1,471.82
$1,582.60
$1,976.12 		$1,663.54
$1,768.12
$1,878.90
$2,272.42 		$296.30
Toc - Plan #11 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Silver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,350 $14,700 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 		$491.67
$558.04
$628.35
$878.12
$1,334.39 		$867.80
$934.17
$1,004.48
$1,254.25 		$1,243.93
$1,310.30
$1,380.61
$1,630.38 		$1,620.06
$1,686.43
$1,756.74
$2,006.51 		$376.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.34
$1,116.08
$1,256.70
$1,756.24
$2,668.78 		$1,359.47
$1,492.21
$1,632.83
$2,132.37 		$1,735.60
$1,868.34
$2,008.96
$2,508.50 		$2,111.73
$2,244.47
$2,385.09
$2,884.63 		$376.13
Toc - Plan #12 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Silver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$7,350 $14,700 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 		$491.67
$558.04
$628.35
$878.12
$1,334.39 		$867.80
$934.17
$1,004.48
$1,254.25 		$1,243.93
$1,310.30
$1,380.61
$1,630.38 		$1,620.06
$1,686.43
$1,756.74
$2,006.51 		$376.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$983.34
$1,116.08
$1,256.70
$1,756.24
$2,668.78 		$1,359.47
$1,492.21
$1,632.83
$2,132.37 		$1,735.60
$1,868.34
$2,008.96
$2,508.50 		$2,111.73
$2,244.47
$2,385.09
$2,884.63 		$376.13
Toc - Plan #13 Blue Cross and Blue Shield of Kansas, Inc.
Bronze

(EPO) BlueCare EPO Standardized Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$357.84
$406.15
$457.32
$639.11
$971.18 		$631.59
$679.90
$731.07
$912.86 		$905.34
$953.65
$1,004.82
$1,186.61 		$1,179.09
$1,227.40
$1,278.57
$1,460.36 		$273.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.68
$812.30
$914.64
$1,278.22
$1,942.36 		$989.43
$1,086.05
$1,188.39
$1,551.97 		$1,263.18
$1,359.80
$1,462.14
$1,825.72 		$1,536.93
$1,633.55
$1,735.89
$2,099.47 		$273.75
Toc - Plan #14 Blue Cross and Blue Shield of Kansas, Inc.
Bronze

(EPO) BlueCare EPO Standardized Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$357.84
$406.15
$457.32
$639.11
$971.18 		$631.59
$679.90
$731.07
$912.86 		$905.34
$953.65
$1,004.82
$1,186.61 		$1,179.09
$1,227.40
$1,278.57
$1,460.36 		$273.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.68
$812.30
$914.64
$1,278.22
$1,942.36 		$989.43
$1,086.05
$1,188.39
$1,551.97 		$1,263.18
$1,359.80
$1,462.14
$1,825.72 		$1,536.93
$1,633.55
$1,735.89
$2,099.47 		$273.75
Toc - Plan #15 Blue Cross and Blue Shield of Kansas, Inc.
Expanded Bronze

(EPO) BlueCare EPO Standardized Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$381.43
$432.92
$487.47
$681.23
$1,035.20 		$673.22
$724.71
$779.26
$973.02 		$965.01
$1,016.50
$1,071.05
$1,264.81 		$1,256.80
$1,308.29
$1,362.84
$1,556.60 		$291.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.86
$865.84
$974.94
$1,362.46
$2,070.40 		$1,054.65
$1,157.63
$1,266.73
$1,654.25 		$1,346.44
$1,449.42
$1,558.52
$1,946.04 		$1,638.23
$1,741.21
$1,850.31
$2,237.83 		$291.79
Toc - Plan #16 Blue Cross and Blue Shield of Kansas, Inc.
Expanded Bronze

(EPO) BlueCare EPO Standardized Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$381.43
$432.92
$487.47
$681.23
$1,035.20 		$673.22
$724.71
$779.26
$973.02 		$965.01
$1,016.50
$1,071.05
$1,264.81 		$1,256.80
$1,308.29
$1,362.84
$1,556.60 		$291.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$762.86
$865.84
$974.94
$1,362.46
$2,070.40 		$1,054.65
$1,157.63
$1,266.73
$1,654.25 		$1,346.44
$1,449.42
$1,558.52
$1,946.04 		$1,638.23
$1,741.21
$1,850.31
$2,237.83 		$291.79
Toc - Plan #17 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Standardized Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$497.56
$564.73
$635.88
$888.65
$1,350.38 		$878.19
$945.36
$1,016.51
$1,269.28 		$1,258.82
$1,325.99
$1,397.14
$1,649.91 		$1,639.45
$1,706.62
$1,777.77
$2,030.54 		$380.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.12
$1,129.46
$1,271.76
$1,777.30
$2,700.76 		$1,375.75
$1,510.09
$1,652.39
$2,157.93 		$1,756.38
$1,890.72
$2,033.02
$2,538.56 		$2,137.01
$2,271.35
$2,413.65
$2,919.19 		$380.63
Toc - Plan #18 Blue Cross and Blue Shield of Kansas, Inc.
Silver

(EPO) BlueCare EPO Standardized Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$497.56
$564.73
$635.88
$888.65
$1,350.38 		$878.19
$945.36
$1,016.51
$1,269.28 		$1,258.82
$1,325.99
$1,397.14
$1,649.91 		$1,639.45
$1,706.62
$1,777.77
$2,030.54 		$380.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$995.12
$1,129.46
$1,271.76
$1,777.30
$2,700.76 		$1,375.75
$1,510.09
$1,652.39
$2,157.93 		$1,756.38
$1,890.72
$2,033.02
$2,538.56 		$2,137.01
$2,271.35
$2,413.65
$2,919.19 		$380.63
Toc - Plan #19 Blue Cross and Blue Shield of Kansas, Inc.
Gold

(EPO) BlueCare EPO Standardized Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$462.19
$524.58
$590.68
$825.47
$1,254.38 		$815.76
$878.15
$944.25
$1,179.04 		$1,169.33
$1,231.72
$1,297.82
$1,532.61 		$1,522.90
$1,585.29
$1,651.39
$1,886.18 		$353.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.38
$1,049.16
$1,181.36
$1,650.94
$2,508.76 		$1,277.95
$1,402.73
$1,534.93
$2,004.51 		$1,631.52
$1,756.30
$1,888.50
$2,358.08 		$1,985.09
$2,109.87
$2,242.07
$2,711.65 		$353.57
Toc - Plan #20 Blue Cross and Blue Shield of Kansas, Inc.
Gold

(EPO) BlueCare EPO Standardized Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-392-7366

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 		$462.19
$524.58
$590.68
$825.47
$1,254.38 		$815.76
$878.15
$944.25
$1,179.04 		$1,169.33
$1,231.72
$1,297.82
$1,532.61 		$1,522.90
$1,585.29
$1,651.39
$1,886.18 		$353.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.38
$1,049.16
$1,181.36
$1,650.94
$2,508.76 		$1,277.95
$1,402.73
$1,534.93
$2,004.51 		$1,631.52
$1,756.30
$1,888.50
$2,358.08 		$1,985.09
$2,109.87
$2,242.07
$2,711.65 		$353.57

ADVERTISEMENT

Ambetter from Sunflower Health Plan

Local: 1-844-518-9505 | Toll Free: 1-844-518-9505 | TTY: 1-844-546-9713
Toc - Plan #21 Ambetter from Sunflower Health Plan
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$421.63
$478.54
$538.83
$753.02
$1,144.28 		$744.17
$801.08
$861.37
$1,075.56 		$1,066.71
$1,123.62
$1,183.91
$1,398.10 		$1,389.25
$1,446.16
$1,506.45
$1,720.64 		$322.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.26
$957.08
$1,077.66
$1,506.04
$2,288.56 		$1,165.80
$1,279.62
$1,400.20
$1,828.58 		$1,488.34
$1,602.16
$1,722.74
$2,151.12 		$1,810.88
$1,924.70
$2,045.28
$2,473.66 		$322.54
Toc - Plan #22 Ambetter from Sunflower Health Plan
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$443.64
$503.52
$566.96
$792.32
$1,204.01 		$783.02
$842.90
$906.34
$1,131.70 		$1,122.40
$1,182.28
$1,245.72
$1,471.08 		$1,461.78
$1,521.66
$1,585.10
$1,810.46 		$339.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$887.28
$1,007.04
$1,133.92
$1,584.64
$2,408.02 		$1,226.66
$1,346.42
$1,473.30
$1,924.02 		$1,566.04
$1,685.80
$1,812.68
$2,263.40 		$1,905.42
$2,025.18
$2,152.06
$2,602.78 		$339.38
Toc - Plan #23 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$325.42
$369.34
$415.87
$581.18
$883.16 		$574.36
$618.28
$664.81
$830.12 		$823.30
$867.22
$913.75
$1,079.06 		$1,072.24
$1,116.16
$1,162.69
$1,328.00 		$248.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$650.84
$738.68
$831.74
$1,162.36
$1,766.32 		$899.78
$987.62
$1,080.68
$1,411.30 		$1,148.72
$1,236.56
$1,329.62
$1,660.24 		$1,397.66
$1,485.50
$1,578.56
$1,909.18 		$248.94
Toc - Plan #24 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$357.21
$405.42
$456.50
$637.96
$969.43 		$630.47
$678.68
$729.76
$911.22 		$903.73
$951.94
$1,003.02
$1,184.48 		$1,176.99
$1,225.20
$1,276.28
$1,457.74 		$273.26
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$714.42
$810.84
$913.00
$1,275.92
$1,938.86 		$987.68
$1,084.10
$1,186.26
$1,549.18 		$1,260.94
$1,357.36
$1,459.52
$1,822.44 		$1,534.20
$1,630.62
$1,732.78
$2,095.70 		$273.26
Toc - Plan #25 Ambetter from Sunflower Health Plan
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$424.54
$481.84
$542.55
$758.21
$1,152.18 		$749.31
$806.61
$867.32
$1,082.98 		$1,074.08
$1,131.38
$1,192.09
$1,407.75 		$1,398.85
$1,456.15
$1,516.86
$1,732.52 		$324.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.08
$963.68
$1,085.10
$1,516.42
$2,304.36 		$1,173.85
$1,288.45
$1,409.87
$1,841.19 		$1,498.62
$1,613.22
$1,734.64
$2,165.96 		$1,823.39
$1,937.99
$2,059.41
$2,490.73 		$324.77
Toc - Plan #26 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$348.94
$396.04
$445.94
$623.20
$947.01 		$615.87
$662.97
$712.87
$890.13 		$882.80
$929.90
$979.80
$1,157.06 		$1,149.73
$1,196.83
$1,246.73
$1,423.99 		$266.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$697.88
$792.08
$891.88
$1,246.40
$1,894.02 		$964.81
$1,059.01
$1,158.81
$1,513.33 		$1,231.74
$1,325.94
$1,425.74
$1,780.26 		$1,498.67
$1,592.87
$1,692.67
$2,047.19 		$266.93
Toc - Plan #27 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$393.89
$447.05
$503.38
$703.47
$1,068.99 		$695.21
$748.37
$804.70
$1,004.79 		$996.53
$1,049.69
$1,106.02
$1,306.11 		$1,297.85
$1,351.01
$1,407.34
$1,607.43 		$301.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.78
$894.10
$1,006.76
$1,406.94
$2,137.98 		$1,089.10
$1,195.42
$1,308.08
$1,708.26 		$1,390.42
$1,496.74
$1,609.40
$2,009.58 		$1,691.74
$1,798.06
$1,910.72
$2,310.90 		$301.32
Toc - Plan #28 Ambetter from Sunflower Health Plan
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$411.85
$467.44
$526.33
$735.55
$1,117.73 		$726.91
$782.50
$841.39
$1,050.61 		$1,041.97
$1,097.56
$1,156.45
$1,365.67 		$1,357.03
$1,412.62
$1,471.51
$1,680.73 		$315.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$823.70
$934.88
$1,052.66
$1,471.10
$2,235.46 		$1,138.76
$1,249.94
$1,367.72
$1,786.16 		$1,453.82
$1,565.00
$1,682.78
$2,101.22 		$1,768.88
$1,880.06
$1,997.84
$2,416.28 		$315.06
Toc - Plan #29 Ambetter from Sunflower Health Plan
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$415.94
$472.08
$531.56
$742.85
$1,128.83 		$734.13
$790.27
$849.75
$1,061.04 		$1,052.32
$1,108.46
$1,167.94
$1,379.23 		$1,370.51
$1,426.65
$1,486.13
$1,697.42 		$318.19
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$831.88
$944.16
$1,063.12
$1,485.70
$2,257.66 		$1,150.07
$1,262.35
$1,381.31
$1,803.89 		$1,468.26
$1,580.54
$1,699.50
$2,122.08 		$1,786.45
$1,898.73
$2,017.69
$2,440.27 		$318.19
Toc - Plan #30 Ambetter from Sunflower Health Plan
Silver

(EPO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$426.56
$484.14
$545.14
$761.83
$1,157.67 		$752.87
$810.45
$871.45
$1,088.14 		$1,079.18
$1,136.76
$1,197.76
$1,414.45 		$1,405.49
$1,463.07
$1,524.07
$1,740.76 		$326.31
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.12
$968.28
$1,090.28
$1,523.66
$2,315.34 		$1,179.43
$1,294.59
$1,416.59
$1,849.97 		$1,505.74
$1,620.90
$1,742.90
$2,176.28 		$1,832.05
$1,947.21
$2,069.21
$2,502.59 		$326.31
Toc - Plan #31 Ambetter from Sunflower Health Plan
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$488.37
$554.29
$624.13
$872.22
$1,325.42 		$861.97
$927.89
$997.73
$1,245.82 		$1,235.57
$1,301.49
$1,371.33
$1,619.42 		$1,609.17
$1,675.09
$1,744.93
$1,993.02 		$373.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$976.74
$1,108.58
$1,248.26
$1,744.44
$2,650.84 		$1,350.34
$1,482.18
$1,621.86
$2,118.04 		$1,723.94
$1,855.78
$1,995.46
$2,491.64 		$2,097.54
$2,229.38
$2,369.06
$2,865.24 		$373.60
Toc - Plan #32 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$342.07
$388.24
$437.15
$610.92
$928.36 		$603.75
$649.92
$698.83
$872.60 		$865.43
$911.60
$960.51
$1,134.28 		$1,127.11
$1,173.28
$1,222.19
$1,395.96 		$261.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.14
$776.48
$874.30
$1,221.84
$1,856.72 		$945.82
$1,038.16
$1,135.98
$1,483.52 		$1,207.50
$1,299.84
$1,397.66
$1,745.20 		$1,469.18
$1,561.52
$1,659.34
$2,006.88 		$261.68
Toc - Plan #33 Ambetter from Sunflower Health Plan
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$412.40
$468.06
$527.03
$736.53
$1,119.22 		$727.88
$783.54
$842.51
$1,052.01 		$1,043.36
$1,099.02
$1,157.99
$1,367.49 		$1,358.84
$1,414.50
$1,473.47
$1,682.97 		$315.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$824.80
$936.12
$1,054.06
$1,473.06
$2,238.44 		$1,140.28
$1,251.60
$1,369.54
$1,788.54 		$1,455.76
$1,567.08
$1,685.02
$2,104.02 		$1,771.24
$1,882.56
$2,000.50
$2,419.50 		$315.48
Toc - Plan #34 Ambetter from Sunflower Health Plan
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$420.83
$477.63
$537.81
$751.59
$1,142.11 		$742.76
$799.56
$859.74
$1,073.52 		$1,064.69
$1,121.49
$1,181.67
$1,395.45 		$1,386.62
$1,443.42
$1,503.60
$1,717.38 		$321.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$841.66
$955.26
$1,075.62
$1,503.18
$2,284.22 		$1,163.59
$1,277.19
$1,397.55
$1,825.11 		$1,485.52
$1,599.12
$1,719.48
$2,147.04 		$1,807.45
$1,921.05
$2,041.41
$2,468.97 		$321.93
Toc - Plan #35 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$337.37
$382.91
$431.15
$602.53
$915.60 		$595.45
$640.99
$689.23
$860.61 		$853.53
$899.07
$947.31
$1,118.69 		$1,111.61
$1,157.15
$1,205.39
$1,376.77 		$258.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$674.74
$765.82
$862.30
$1,205.06
$1,831.20 		$932.82
$1,023.90
$1,120.38
$1,463.14 		$1,190.90
$1,281.98
$1,378.46
$1,721.22 		$1,448.98
$1,540.06
$1,636.54
$1,979.30 		$258.08
Toc - Plan #36 Ambetter from Sunflower Health Plan
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$459.94
$522.02
$587.79
$821.43
$1,248.24 		$811.78
$873.86
$939.63
$1,173.27 		$1,163.62
$1,225.70
$1,291.47
$1,525.11 		$1,515.46
$1,577.54
$1,643.31
$1,876.95 		$351.84
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$919.88
$1,044.04
$1,175.58
$1,642.86
$2,496.48 		$1,271.72
$1,395.88
$1,527.42
$1,994.70 		$1,623.56
$1,747.72
$1,879.26
$2,346.54 		$1,975.40
$2,099.56
$2,231.10
$2,698.38 		$351.84
Toc - Plan #37 Ambetter from Sunflower Health Plan
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$437.12
$496.12
$558.63
$780.68
$1,186.32 		$771.51
$830.51
$893.02
$1,115.07 		$1,105.90
$1,164.90
$1,227.41
$1,449.46 		$1,440.29
$1,499.29
$1,561.80
$1,783.85 		$334.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$874.24
$992.24
$1,117.26
$1,561.36
$2,372.64 		$1,208.63
$1,326.63
$1,451.65
$1,895.75 		$1,543.02
$1,661.02
$1,786.04
$2,230.14 		$1,877.41
$1,995.41
$2,120.43
$2,564.53 		$334.39
Toc - Plan #38 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$370.33
$420.31
$473.27
$661.39
$1,005.05 		$653.62
$703.60
$756.56
$944.68 		$936.91
$986.89
$1,039.85
$1,227.97 		$1,220.20
$1,270.18
$1,323.14
$1,511.26 		$283.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$740.66
$840.62
$946.54
$1,322.78
$2,010.10 		$1,023.95
$1,123.91
$1,229.83
$1,606.07 		$1,307.24
$1,407.20
$1,513.12
$1,889.36 		$1,590.53
$1,690.49
$1,796.41
$2,172.65 		$283.29
Toc - Plan #39 Ambetter from Sunflower Health Plan
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$440.14
$499.54
$562.48
$786.07
$1,194.50 		$776.84
$836.24
$899.18
$1,122.77 		$1,113.54
$1,172.94
$1,235.88
$1,459.47 		$1,450.24
$1,509.64
$1,572.58
$1,796.17 		$336.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.28
$999.08
$1,124.96
$1,572.14
$2,389.00 		$1,216.98
$1,335.78
$1,461.66
$1,908.84 		$1,553.68
$1,672.48
$1,798.36
$2,245.54 		$1,890.38
$2,009.18
$2,135.06
$2,582.24 		$336.70
Toc - Plan #40 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$361.76
$410.59
$462.32
$646.09
$981.80 		$638.50
$687.33
$739.06
$922.83 		$915.24
$964.07
$1,015.80
$1,199.57 		$1,191.98
$1,240.81
$1,292.54
$1,476.31 		$276.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$723.52
$821.18
$924.64
$1,292.18
$1,963.60 		$1,000.26
$1,097.92
$1,201.38
$1,568.92 		$1,277.00
$1,374.66
$1,478.12
$1,845.66 		$1,553.74
$1,651.40
$1,754.86
$2,122.40 		$276.74
Toc - Plan #41 Ambetter from Sunflower Health Plan
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$408.36
$463.48
$521.87
$729.31
$1,108.26 		$720.75
$775.87
$834.26
$1,041.70 		$1,033.14
$1,088.26
$1,146.65
$1,354.09 		$1,345.53
$1,400.65
$1,459.04
$1,666.48 		$312.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$816.72
$926.96
$1,043.74
$1,458.62
$2,216.52 		$1,129.11
$1,239.35
$1,356.13
$1,771.01 		$1,441.50
$1,551.74
$1,668.52
$2,083.40 		$1,753.89
$1,864.13
$1,980.91
$2,395.79 		$312.39
Toc - Plan #42 Ambetter from Sunflower Health Plan
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$431.22
$489.42
$551.09
$770.14
$1,170.30 		$761.09
$819.29
$880.96
$1,100.01 		$1,090.96
$1,149.16
$1,210.83
$1,429.88 		$1,420.83
$1,479.03
$1,540.70
$1,759.75 		$329.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.44
$978.84
$1,102.18
$1,540.28
$2,340.60 		$1,192.31
$1,308.71
$1,432.05
$1,870.15 		$1,522.18
$1,638.58
$1,761.92
$2,200.02 		$1,852.05
$1,968.45
$2,091.79
$2,529.89 		$329.87
Toc - Plan #43 Ambetter from Sunflower Health Plan
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$426.98
$484.61
$545.67
$762.57
$1,158.79 		$753.61
$811.24
$872.30
$1,089.20 		$1,080.24
$1,137.87
$1,198.93
$1,415.83 		$1,406.87
$1,464.50
$1,525.56
$1,742.46 		$326.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$853.96
$969.22
$1,091.34
$1,525.14
$2,317.58 		$1,180.59
$1,295.85
$1,417.97
$1,851.77 		$1,507.22
$1,622.48
$1,744.60
$2,178.40 		$1,833.85
$1,949.11
$2,071.23
$2,505.03 		$326.63
Toc - Plan #44 Ambetter from Sunflower Health Plan
Silver

(EPO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$442.23
$501.92
$565.16
$789.81
$1,200.20 		$780.53
$840.22
$903.46
$1,128.11 		$1,118.83
$1,178.52
$1,241.76
$1,466.41 		$1,457.13
$1,516.82
$1,580.06
$1,804.71 		$338.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$884.46
$1,003.84
$1,130.32
$1,579.62
$2,400.40 		$1,222.76
$1,342.14
$1,468.62
$1,917.92 		$1,561.06
$1,680.44
$1,806.92
$2,256.22 		$1,899.36
$2,018.74
$2,145.22
$2,594.52 		$338.30
Toc - Plan #45 Ambetter from Sunflower Health Plan
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$506.31
$574.66
$647.06
$904.26
$1,374.11 		$893.63
$961.98
$1,034.38
$1,291.58 		$1,280.95
$1,349.30
$1,421.70
$1,678.90 		$1,668.27
$1,736.62
$1,809.02
$2,066.22 		$387.32
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.62
$1,149.32
$1,294.12
$1,808.52
$2,748.22 		$1,399.94
$1,536.64
$1,681.44
$2,195.84 		$1,787.26
$1,923.96
$2,068.76
$2,583.16 		$2,174.58
$2,311.28
$2,456.08
$2,970.48 		$387.32
Toc - Plan #46 Ambetter from Sunflower Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$340.05
$385.94
$434.57
$607.31
$922.86 		$600.18
$646.07
$694.70
$867.44 		$860.31
$906.20
$954.83
$1,127.57 		$1,120.44
$1,166.33
$1,214.96
$1,387.70 		$260.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$680.10
$771.88
$869.14
$1,214.62
$1,845.72 		$940.23
$1,032.01
$1,129.27
$1,474.75 		$1,200.36
$1,292.14
$1,389.40
$1,734.88 		$1,460.49
$1,552.27
$1,649.53
$1,995.01 		$260.13
Toc - Plan #47 Ambetter from Sunflower Health Plan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$406.92
$461.84
$520.03
$726.74
$1,104.35 		$718.20
$773.12
$831.31
$1,038.02 		$1,029.48
$1,084.40
$1,142.59
$1,349.30 		$1,340.76
$1,395.68
$1,453.87
$1,660.58 		$311.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$813.84
$923.68
$1,040.06
$1,453.48
$2,208.70 		$1,125.12
$1,234.96
$1,351.34
$1,764.76 		$1,436.40
$1,546.24
$1,662.62
$2,076.04 		$1,747.68
$1,857.52
$1,973.90
$2,387.32 		$311.28
Toc - Plan #48 Ambetter from Sunflower Health Plan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-518-9505

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 		$430.87
$489.02
$550.63
$769.51
$1,169.34 		$760.47
$818.62
$880.23
$1,099.11 		$1,090.07
$1,148.22
$1,209.83
$1,428.71 		$1,419.67
$1,477.82
$1,539.43
$1,758.31 		$329.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.74
$978.04
$1,101.26
$1,539.02
$2,338.68 		$1,191.34
$1,307.64
$1,430.86
$1,868.62 		$1,520.94
$1,637.24
$1,760.46
$2,198.22 		$1,850.54
$1,966.84
$2,090.06
$2,527.82 		$329.60

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-866-735-2957
Toc - Plan #49 Medica
Expanded Bronze

(EPO) Medica Connect 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
$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 		$559.08
$634.54
$714.49
$998.49
$1,517.31 		$986.77
$1,062.23
$1,142.18
$1,426.18 		$1,414.46
$1,489.92
$1,569.87
$1,853.87 		$1,842.15
$1,917.61
$1,997.56
$2,281.56 		$427.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,118.16
$1,269.08
$1,428.98
$1,996.98
$3,034.62 		$1,545.85
$1,696.77
$1,856.67
$2,424.67 		$1,973.54
$2,124.46
$2,284.36
$2,852.36 		$2,401.23
$2,552.15
$2,712.05
$3,280.05 		$427.69
Toc - Plan #50 Medica
Catastrophic

(EPO) Medica Connect 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 		$423.41
$480.56
$541.11
$756.20
$1,149.11 		$747.31
$804.46
$865.01
$1,080.10 		$1,071.21
$1,128.36
$1,188.91
$1,404.00 		$1,395.11
$1,452.26
$1,512.81
$1,727.90 		$323.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$846.82
$961.12
$1,082.22
$1,512.40
$2,298.22 		$1,170.72
$1,285.02
$1,406.12
$1,836.30 		$1,494.62
$1,608.92
$1,730.02
$2,160.20 		$1,818.52
$1,932.82
$2,053.92
$2,484.10 		$323.90
Toc - Plan #51 Medica
Expanded Bronze

(EPO) Medica Connect 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
$2,500 $5,000 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 		$608.07
$690.15
$777.10
$1,085.99
$1,650.27 		$1,073.23
$1,155.31
$1,242.26
$1,551.15 		$1,538.39
$1,620.47
$1,707.42
$2,016.31 		$2,003.55
$2,085.63
$2,172.58
$2,481.47 		$465.16
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,216.14
$1,380.30
$1,554.20
$2,171.98
$3,300.54 		$1,681.30
$1,845.46
$2,019.36
$2,637.14 		$2,146.46
$2,310.62
$2,484.52
$3,102.30 		$2,611.62
$2,775.78
$2,949.68
$3,567.46 		$465.16
Toc - Plan #52 Medica
Gold

(EPO) Medica Connect 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 		$830.24
$942.31
$1,061.03
$1,482.79
$2,253.24 		$1,465.36
$1,577.43
$1,696.15
$2,117.91 		$2,100.48
$2,212.55
$2,331.27
$2,753.03 		$2,735.60
$2,847.67
$2,966.39
$3,388.15 		$635.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,660.48
$1,884.62
$2,122.06
$2,965.58
$4,506.48 		$2,295.60
$2,519.74
$2,757.18
$3,600.70 		$2,930.72
$3,154.86
$3,392.30
$4,235.82 		$3,565.84
$3,789.98
$4,027.42
$4,870.94 		$635.12
Toc - Plan #53 Medica
Silver

(EPO) Medica Connect 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 		$904.19
$1,026.25
$1,155.54
$1,614.87
$2,453.95 		$1,595.89
$1,717.95
$1,847.24
$2,306.57 		$2,287.59
$2,409.65
$2,538.94
$2,998.27 		$2,979.29
$3,101.35
$3,230.64
$3,689.97 		$691.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,808.38
$2,052.50
$2,311.08
$3,229.74
$4,907.90 		$2,500.08
$2,744.20
$3,002.78
$3,921.44 		$3,191.78
$3,435.90
$3,694.48
$4,613.14 		$3,883.48
$4,127.60
$4,386.18
$5,304.84 		$691.70
Toc - Plan #54 Medica
Bronze

(EPO) Medica Connect 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 		$570.78
$647.83
$729.45
$1,019.40
$1,549.08 		$1,007.42
$1,084.47
$1,166.09
$1,456.04 		$1,444.06
$1,521.11
$1,602.73
$1,892.68 		$1,880.70
$1,957.75
$2,039.37
$2,329.32 		$436.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,141.56
$1,295.66
$1,458.90
$2,038.80
$3,098.16 		$1,578.20
$1,732.30
$1,895.54
$2,475.44 		$2,014.84
$2,168.94
$2,332.18
$2,912.08 		$2,451.48
$2,605.58
$2,768.82
$3,348.72 		$436.64

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-632-4195 | Toll Free: 1-877-632-4195 | TTY: 1-866-761-7748
Toc - Plan #55 UnitedHealthcare
Gold

(EPO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$2,200 $4,400 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$384.61
$436.53
$491.53
$686.91
$1,043.82 		$678.83
$730.75
$785.75
$981.13 		$973.05
$1,024.97
$1,079.97
$1,275.35 		$1,267.27
$1,319.19
$1,374.19
$1,569.57 		$294.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.22
$873.06
$983.06
$1,373.82
$2,087.64 		$1,063.44
$1,167.28
$1,277.28
$1,668.04 		$1,357.66
$1,461.50
$1,571.50
$1,962.26 		$1,651.88
$1,755.72
$1,865.72
$2,256.48 		$294.22
Toc - Plan #56 UnitedHealthcare
Gold

(EPO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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 		$397.52
$451.19
$508.03
$709.97
$1,078.87 		$701.62
$755.29
$812.13
$1,014.07 		$1,005.72
$1,059.39
$1,116.23
$1,318.17 		$1,309.82
$1,363.49
$1,420.33
$1,622.27 		$304.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$795.04
$902.38
$1,016.06
$1,419.94
$2,157.74 		$1,099.14
$1,206.48
$1,320.16
$1,724.04 		$1,403.24
$1,510.58
$1,624.26
$2,028.14 		$1,707.34
$1,814.68
$1,928.36
$2,332.24 		$304.10
Toc - Plan #57 UnitedHealthcare
Gold

(EPO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$389.24
$441.79
$497.45
$695.19
$1,056.40 		$687.01
$739.56
$795.22
$992.96 		$984.78
$1,037.33
$1,092.99
$1,290.73 		$1,282.55
$1,335.10
$1,390.76
$1,588.50 		$297.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$778.48
$883.58
$994.90
$1,390.38
$2,112.80 		$1,076.25
$1,181.35
$1,292.67
$1,688.15 		$1,374.02
$1,479.12
$1,590.44
$1,985.92 		$1,671.79
$1,776.89
$1,888.21
$2,283.69 		$297.77
Toc - Plan #58 UnitedHealthcare
Silver

(EPO) UHC Silver Value $4,000 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$374.93
$425.54
$479.16
$669.62
$1,017.55 		$661.75
$712.36
$765.98
$956.44 		$948.57
$999.18
$1,052.80
$1,243.26 		$1,235.39
$1,286.00
$1,339.62
$1,530.08 		$286.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$749.86
$851.08
$958.32
$1,339.24
$2,035.10 		$1,036.68
$1,137.90
$1,245.14
$1,626.06 		$1,323.50
$1,424.72
$1,531.96
$1,912.88 		$1,610.32
$1,711.54
$1,818.78
$2,199.70 		$286.82
Toc - Plan #59 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$371.06
$421.16
$474.22
$662.72
$1,007.06 		$654.92
$705.02
$758.08
$946.58 		$938.78
$988.88
$1,041.94
$1,230.44 		$1,222.64
$1,272.74
$1,325.80
$1,514.30 		$283.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$742.12
$842.32
$948.44
$1,325.44
$2,014.12 		$1,025.98
$1,126.18
$1,232.30
$1,609.30 		$1,309.84
$1,410.04
$1,516.16
$1,893.16 		$1,593.70
$1,693.90
$1,800.02
$2,177.02 		$283.86
Toc - Plan #60 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 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 		$384.60
$436.52
$491.52
$686.90
$1,043.81 		$678.82
$730.74
$785.74
$981.12 		$973.04
$1,024.96
$1,079.96
$1,275.34 		$1,267.26
$1,319.18
$1,374.18
$1,569.56 		$294.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$769.20
$873.04
$983.04
$1,373.80
$2,087.62 		$1,063.42
$1,167.26
$1,277.26
$1,668.02 		$1,357.64
$1,461.48
$1,571.48
$1,962.24 		$1,651.86
$1,755.70
$1,865.70
$2,256.46 		$294.22
Toc - Plan #61 UnitedHealthcare
Silver

(EPO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$375.05
$425.68
$479.32
$669.84
$1,017.89 		$661.96
$712.59
$766.23
$956.75 		$948.87
$999.50
$1,053.14
$1,243.66 		$1,235.78
$1,286.41
$1,340.05
$1,530.57 		$286.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$750.10
$851.36
$958.64
$1,339.68
$2,035.78 		$1,037.01
$1,138.27
$1,245.55
$1,626.59 		$1,323.92
$1,425.18
$1,532.46
$1,913.50 		$1,610.83
$1,712.09
$1,819.37
$2,200.41 		$286.91
Toc - Plan #62 UnitedHealthcare
Silver

(EPO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$377.38
$428.33
$482.30
$674.01
$1,024.22 		$666.08
$717.03
$771.00
$962.71 		$954.78
$1,005.73
$1,059.70
$1,251.41 		$1,243.48
$1,294.43
$1,348.40
$1,540.11 		$288.70
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$754.76
$856.66
$964.60
$1,348.02
$2,048.44 		$1,043.46
$1,145.36
$1,253.30
$1,636.72 		$1,332.16
$1,434.06
$1,542.00
$1,925.42 		$1,620.86
$1,722.76
$1,830.70
$2,214.12 		$288.70
Toc - Plan #63 UnitedHealthcare
Silver

(EPO) UHC Silver Value HSA $5,400 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$378.74
$429.87
$484.03
$676.43
$1,027.90 		$668.48
$719.61
$773.77
$966.17 		$958.22
$1,009.35
$1,063.51
$1,255.91 		$1,247.96
$1,299.09
$1,353.25
$1,545.65 		$289.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.48
$859.74
$968.06
$1,352.86
$2,055.80 		$1,047.22
$1,149.48
$1,257.80
$1,642.60 		$1,336.96
$1,439.22
$1,547.54
$1,932.34 		$1,626.70
$1,728.96
$1,837.28
$2,222.08 		$289.74
Toc - Plan #64 UnitedHealthcare
Bronze

(EPO) UHC Bronze Essential ($3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$272.01
$308.73
$347.63
$485.81
$738.23 		$480.10
$516.82
$555.72
$693.90 		$688.19
$724.91
$763.81
$901.99 		$896.28
$933.00
$971.90
$1,110.08 		$208.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$544.02
$617.46
$695.26
$971.62
$1,476.46 		$752.11
$825.55
$903.35
$1,179.71 		$960.20
$1,033.64
$1,111.44
$1,387.80 		$1,168.29
$1,241.73
$1,319.53
$1,595.89 		$208.09
Toc - Plan #65 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value $6,500 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$278.43
$316.02
$355.84
$497.28
$755.67 		$491.43
$529.02
$568.84
$710.28 		$704.43
$742.02
$781.84
$923.28 		$917.43
$955.02
$994.84
$1,136.28 		$213.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$556.86
$632.04
$711.68
$994.56
$1,511.34 		$769.86
$845.04
$924.68
$1,207.56 		$982.86
$1,058.04
$1,137.68
$1,420.56 		$1,195.86
$1,271.04
$1,350.68
$1,633.56 		$213.00
Toc - Plan #66 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Value HSA $6,700 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$276.99
$314.39
$354.00
$494.71
$751.76 		$488.89
$526.29
$565.90
$706.61 		$700.79
$738.19
$777.80
$918.51 		$912.69
$950.09
$989.70
$1,130.41 		$211.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$553.98
$628.78
$708.00
$989.42
$1,503.52 		$765.88
$840.68
$919.90
$1,201.32 		$977.78
$1,052.58
$1,131.80
$1,413.22 		$1,189.68
$1,264.48
$1,343.70
$1,625.12 		$211.90
Toc - Plan #67 UnitedHealthcare
Expanded Bronze

(EPO) UHC Bronze Standard $7,500 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$273.98
$310.97
$350.15
$489.33
$743.58 		$483.57
$520.56
$559.74
$698.92 		$693.16
$730.15
$769.33
$908.51 		$902.75
$939.74
$978.92
$1,118.10 		$209.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.96
$621.94
$700.30
$978.66
$1,487.16 		$757.55
$831.53
$909.89
$1,188.25 		$967.14
$1,041.12
$1,119.48
$1,397.84 		$1,176.73
$1,250.71
$1,329.07
$1,607.43 		$209.59
Toc - Plan #68 UnitedHealthcare
Bronze

(EPO) UHC Bronze Standard $9,100 Indiv Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-632-4195

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 		$264.55
$300.26
$338.09
$472.48
$717.98 		$466.93
$502.64
$540.47
$674.86 		$669.31
$705.02
$742.85
$877.24 		$871.69
$907.40
$945.23
$1,079.62 		$202.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$529.10
$600.52
$676.18
$944.96
$1,435.96 		$731.48
$802.90
$878.56
$1,147.34 		$933.86
$1,005.28
$1,080.94
$1,349.72 		$1,136.24
$1,207.66
$1,283.32
$1,552.10 		$202.38

‡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 Atchison County here.

Atchison County is in “Rating Area 2” of Kansas.

Currently, there are 68 plans offered in Rating Area 2.

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2023 Obamacare Plans for Atchison County, KS

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