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Obamacare 2023 Rates for Johnson County

Obamacare > Rates > Missouri > Johnson 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 Johnson County, MO.

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, 64 Plans and 2023 Rates for Johnson County, Missouri

Below, you’ll find a summary of the 64 plans for Johnson County, Missouri 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 City

Local: 1-816-395-3558 | Toll Free: 1-888-800-4478

Toc - Plan #1 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$472.93
$536.78
$604.41
$844.65
$1,283.53
$834.72
$898.57
$966.20
$1,206.44
$1,196.51
$1,260.36
$1,327.99
$1,568.23
$1,558.30
$1,622.15
$1,689.78
$1,930.02
$361.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$945.86
$1,073.56
$1,208.82
$1,689.30
$2,567.06
$1,307.65
$1,435.35
$1,570.61
$2,051.09
$1,669.44
$1,797.14
$1,932.40
$2,412.88
$2,031.23
$2,158.93
$2,294.19
$2,774.67
$361.79
Toc - Plan #2 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$624.06
$708.30
$797.54
$1,114.57
$1,693.69
$1,101.46
$1,185.70
$1,274.94
$1,591.97
$1,578.86
$1,663.10
$1,752.34
$2,069.37
$2,056.26
$2,140.50
$2,229.74
$2,546.77
$477.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,248.12
$1,416.60
$1,595.08
$2,229.14
$3,387.38
$1,725.52
$1,894.00
$2,072.48
$2,706.54
$2,202.92
$2,371.40
$2,549.88
$3,183.94
$2,680.32
$2,848.80
$3,027.28
$3,661.34
$477.40
Toc - Plan #3 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$506.25
$574.60
$646.99
$904.17
$1,373.97
$893.53
$961.88
$1,034.27
$1,291.45
$1,280.81
$1,349.16
$1,421.55
$1,678.73
$1,668.09
$1,736.44
$1,808.83
$2,066.01
$387.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,012.50
$1,149.20
$1,293.98
$1,808.34
$2,747.94
$1,399.78
$1,536.48
$1,681.26
$2,195.62
$1,787.06
$1,923.76
$2,068.54
$2,582.90
$2,174.34
$2,311.04
$2,455.82
$2,970.18
$387.28
Toc - Plan #4 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$542.26
$615.47
$693.01
$968.48
$1,471.70
$957.09
$1,030.30
$1,107.84
$1,383.31
$1,371.92
$1,445.13
$1,522.67
$1,798.14
$1,786.75
$1,859.96
$1,937.50
$2,212.97
$414.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,084.52
$1,230.94
$1,386.02
$1,936.96
$2,943.40
$1,499.35
$1,645.77
$1,800.85
$2,351.79
$1,914.18
$2,060.60
$2,215.68
$2,766.62
$2,329.01
$2,475.43
$2,630.51
$3,181.45
$414.83
Toc - Plan #5 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 7000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 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
$411.48
$467.03
$525.87
$734.90
$1,116.75
$726.26
$781.81
$840.65
$1,049.68
$1,041.04
$1,096.59
$1,155.43
$1,364.46
$1,355.82
$1,411.37
$1,470.21
$1,679.24
$314.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.96
$934.06
$1,051.74
$1,469.80
$2,233.50
$1,137.74
$1,248.84
$1,366.52
$1,784.58
$1,452.52
$1,563.62
$1,681.30
$2,099.36
$1,767.30
$1,878.40
$1,996.08
$2,414.14
$314.78
Toc - Plan #6 Blue Cross and Blue Shield of Kansas City
Gold

(EPO) Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$735.19
$834.44
$939.57
$1,313.05
$1,995.31
$1,297.61
$1,396.86
$1,501.99
$1,875.47
$1,860.03
$1,959.28
$2,064.41
$2,437.89
$2,422.45
$2,521.70
$2,626.83
$3,000.31
$562.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,470.38
$1,668.88
$1,879.14
$2,626.10
$3,990.62
$2,032.80
$2,231.30
$2,441.56
$3,188.52
$2,595.22
$2,793.72
$3,003.98
$3,750.94
$3,157.64
$3,356.14
$3,566.40
$4,313.36
$562.42
Toc - Plan #7 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Choice Bronze 8700 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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
$402.93
$457.33
$514.95
$719.63
$1,093.55
$711.17
$765.57
$823.19
$1,027.87
$1,019.41
$1,073.81
$1,131.43
$1,336.11
$1,327.65
$1,382.05
$1,439.67
$1,644.35
$308.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$805.86
$914.66
$1,029.90
$1,439.26
$2,187.10
$1,114.10
$1,222.90
$1,338.14
$1,747.50
$1,422.34
$1,531.14
$1,646.38
$2,055.74
$1,730.58
$1,839.38
$1,954.62
$2,363.98
$308.24
Toc - Plan #8 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Choice Silver 6000 BlueSelect EPO with Spira Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$540.23
$613.16
$690.41
$964.84
$1,466.17
$953.50
$1,026.43
$1,103.68
$1,378.11
$1,366.77
$1,439.70
$1,516.95
$1,791.38
$1,780.04
$1,852.97
$1,930.22
$2,204.65
$413.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,080.46
$1,226.32
$1,380.82
$1,929.68
$2,932.34
$1,493.73
$1,639.59
$1,794.09
$2,342.95
$1,907.00
$2,052.86
$2,207.36
$2,756.22
$2,320.27
$2,466.13
$2,620.63
$3,169.49
$413.27
Toc - Plan #9 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Saver Bronze 6500 with BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$437.24
$496.26
$558.79
$780.90
$1,186.66
$771.73
$830.75
$893.28
$1,115.39
$1,106.22
$1,165.24
$1,227.77
$1,449.88
$1,440.71
$1,499.73
$1,562.26
$1,784.37
$334.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.48
$992.52
$1,117.58
$1,561.80
$2,373.32
$1,208.97
$1,327.01
$1,452.07
$1,896.29
$1,543.46
$1,661.50
$1,786.56
$2,230.78
$1,877.95
$1,995.99
$2,121.05
$2,565.27
$334.49
Toc - Plan #10 Blue Cross and Blue Shield of Kansas City
Expanded Bronze

(EPO) Blue KC Standard Bronze 7500 BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$405.73
$460.50
$518.52
$724.63
$1,101.15
$716.11
$770.88
$828.90
$1,035.01
$1,026.49
$1,081.26
$1,139.28
$1,345.39
$1,336.87
$1,391.64
$1,449.66
$1,655.77
$310.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.46
$921.00
$1,037.04
$1,449.26
$2,202.30
$1,121.84
$1,231.38
$1,347.42
$1,759.64
$1,432.22
$1,541.76
$1,657.80
$2,070.02
$1,742.60
$1,852.14
$1,968.18
$2,380.40
$310.38
Toc - Plan #11 Blue Cross and Blue Shield of Kansas City
Silver

(EPO) Blue KC Standard Silver 5800 BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$552.27
$626.83
$705.80
$986.35
$1,498.86
$974.76
$1,049.32
$1,128.29
$1,408.84
$1,397.25
$1,471.81
$1,550.78
$1,831.33
$1,819.74
$1,894.30
$1,973.27
$2,253.82
$422.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,104.54
$1,253.66
$1,411.60
$1,972.70
$2,997.72
$1,527.03
$1,676.15
$1,834.09
$2,395.19
$1,949.52
$2,098.64
$2,256.58
$2,817.68
$2,372.01
$2,521.13
$2,679.07
$3,240.17
$422.49
Toc - Plan #12 Blue Cross and Blue Shield of Kansas City
Catastrophic

(EPO) Blue KC Catastrophic BlueSelect EPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-800-4478

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
$335.16
$380.41
$428.34
$598.60
$909.64
$591.56
$636.81
$684.74
$855.00
$847.96
$893.21
$941.14
$1,111.40
$1,104.36
$1,149.61
$1,197.54
$1,367.80
$256.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.32
$760.82
$856.68
$1,197.20
$1,819.28
$926.72
$1,017.22
$1,113.08
$1,453.60
$1,183.12
$1,273.62
$1,369.48
$1,710.00
$1,439.52
$1,530.02
$1,625.88
$1,966.40
$256.40

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #13 Aetna CVS Health
Expanded Bronze

(EPO) Bronze: Aetna network of doctors & hospitals + Low-cost MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.59
$430.83
$485.11
$677.94
$1,030.20
$669.97
$721.21
$775.49
$968.32
$960.35
$1,011.59
$1,065.87
$1,258.70
$1,250.73
$1,301.97
$1,356.25
$1,549.08
$290.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$759.18
$861.66
$970.22
$1,355.88
$2,060.40
$1,049.56
$1,152.04
$1,260.60
$1,646.26
$1,339.94
$1,442.42
$1,550.98
$1,936.64
$1,630.32
$1,732.80
$1,841.36
$2,227.02
$290.38
Toc - Plan #14 Aetna CVS Health
Expanded Bronze

(EPO) Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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
$380.07
$431.38
$485.72
$678.80
$1,031.50
$670.82
$722.13
$776.47
$969.55
$961.57
$1,012.88
$1,067.22
$1,260.30
$1,252.32
$1,303.63
$1,357.97
$1,551.05
$290.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.14
$862.76
$971.44
$1,357.60
$2,063.00
$1,050.89
$1,153.51
$1,262.19
$1,648.35
$1,341.64
$1,444.26
$1,552.94
$1,939.10
$1,632.39
$1,735.01
$1,843.69
$2,229.85
$290.75
Toc - Plan #15 Aetna CVS Health
Gold

(EPO) Gold: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$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
$585.77
$664.85
$748.62
$1,046.19
$1,589.79
$1,033.89
$1,112.97
$1,196.74
$1,494.31
$1,482.01
$1,561.09
$1,644.86
$1,942.43
$1,930.13
$2,009.21
$2,092.98
$2,390.55
$448.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,171.54
$1,329.70
$1,497.24
$2,092.38
$3,179.58
$1,619.66
$1,777.82
$1,945.36
$2,540.50
$2,067.78
$2,225.94
$2,393.48
$2,988.62
$2,515.90
$2,674.06
$2,841.60
$3,436.74
$448.12
Toc - Plan #16 Aetna CVS Health
Silver

(EPO) Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

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
$472.02
$535.74
$603.24
$843.02
$1,281.06
$833.11
$896.83
$964.33
$1,204.11
$1,194.20
$1,257.92
$1,325.42
$1,565.20
$1,555.29
$1,619.01
$1,686.51
$1,926.29
$361.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$944.04
$1,071.48
$1,206.48
$1,686.04
$2,562.12
$1,305.13
$1,432.57
$1,567.57
$2,047.13
$1,666.22
$1,793.66
$1,928.66
$2,408.22
$2,027.31
$2,154.75
$2,289.75
$2,769.31
$361.09
Toc - Plan #17 Aetna CVS Health
Silver

(EPO) Silver 1: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$4,425 $8,850 Annual Deductible
$8,850 $17,700 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
$474.74
$538.83
$606.71
$847.88
$1,288.43
$837.91
$902.00
$969.88
$1,211.05
$1,201.08
$1,265.17
$1,333.05
$1,574.22
$1,564.25
$1,628.34
$1,696.22
$1,937.39
$363.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$949.48
$1,077.66
$1,213.42
$1,695.76
$2,576.86
$1,312.65
$1,440.83
$1,576.59
$2,058.93
$1,675.82
$1,804.00
$1,939.76
$2,422.10
$2,038.99
$2,167.17
$2,302.93
$2,785.27
$363.17
Toc - Plan #18 Aetna CVS Health
Expanded Bronze

(EPO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $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
$367.56
$417.19
$469.75
$656.47
$997.57
$648.75
$698.38
$750.94
$937.66
$929.94
$979.57
$1,032.13
$1,218.85
$1,211.13
$1,260.76
$1,313.32
$1,500.04
$281.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$735.12
$834.38
$939.50
$1,312.94
$1,995.14
$1,016.31
$1,115.57
$1,220.69
$1,594.13
$1,297.50
$1,396.76
$1,501.88
$1,875.32
$1,578.69
$1,677.95
$1,783.07
$2,156.51
$281.19
Toc - Plan #19 Aetna CVS Health
Gold

(EPO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

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
$534.52
$606.68
$683.12
$954.66
$1,450.69
$943.43
$1,015.59
$1,092.03
$1,363.57
$1,352.34
$1,424.50
$1,500.94
$1,772.48
$1,761.25
$1,833.41
$1,909.85
$2,181.39
$408.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,069.04
$1,213.36
$1,366.24
$1,909.32
$2,901.38
$1,477.95
$1,622.27
$1,775.15
$2,318.23
$1,886.86
$2,031.18
$2,184.06
$2,727.14
$2,295.77
$2,440.09
$2,592.97
$3,136.05
$408.91
Toc - Plan #20 Aetna CVS Health
Silver

(EPO) Silver 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,800 $17,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.27
$509.93
$574.17
$802.40
$1,219.33
$792.96
$853.62
$917.86
$1,146.09
$1,136.65
$1,197.31
$1,261.55
$1,489.78
$1,480.34
$1,541.00
$1,605.24
$1,833.47
$343.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$898.54
$1,019.86
$1,148.34
$1,604.80
$2,438.66
$1,242.23
$1,363.55
$1,492.03
$1,948.49
$1,585.92
$1,707.24
$1,835.72
$2,292.18
$1,929.61
$2,050.93
$2,179.41
$2,635.87
$343.69
Toc - Plan #21 Aetna CVS Health
Silver

(EPO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

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

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
$440.49
$499.96
$562.95
$786.71
$1,195.49
$777.46
$836.93
$899.92
$1,123.68
$1,114.43
$1,173.90
$1,236.89
$1,460.65
$1,451.40
$1,510.87
$1,573.86
$1,797.62
$336.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$880.98
$999.92
$1,125.90
$1,573.42
$2,390.98
$1,217.95
$1,336.89
$1,462.87
$1,910.39
$1,554.92
$1,673.86
$1,799.84
$2,247.36
$1,891.89
$2,010.83
$2,136.81
$2,584.33
$336.97

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777

Toc - Plan #22 Medica
Expanded Bronze

(EPO) Select 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
$5,400 $10,800 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
$466.82
$529.82
$596.58
$833.71
$1,266.91
$823.93
$886.93
$953.69
$1,190.82
$1,181.04
$1,244.04
$1,310.80
$1,547.93
$1,538.15
$1,601.15
$1,667.91
$1,905.04
$357.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$933.64
$1,059.64
$1,193.16
$1,667.42
$2,533.82
$1,290.75
$1,416.75
$1,550.27
$2,024.53
$1,647.86
$1,773.86
$1,907.38
$2,381.64
$2,004.97
$2,130.97
$2,264.49
$2,738.75
$357.11
Toc - Plan #23 Medica
Catastrophic

(EPO) Select 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
$275.33
$312.49
$351.86
$491.72
$747.22
$485.95
$523.11
$562.48
$702.34
$696.57
$733.73
$773.10
$912.96
$907.19
$944.35
$983.72
$1,123.58
$210.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$550.66
$624.98
$703.72
$983.44
$1,494.44
$761.28
$835.60
$914.34
$1,194.06
$971.90
$1,046.22
$1,124.96
$1,404.68
$1,182.52
$1,256.84
$1,335.58
$1,615.30
$210.62
Toc - Plan #24 Medica
Expanded Bronze

(EPO) Select 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
$2,500 $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
$397.42
$451.05
$507.88
$709.77
$1,078.56
$701.43
$755.06
$811.89
$1,013.78
$1,005.44
$1,059.07
$1,115.90
$1,317.79
$1,309.45
$1,363.08
$1,419.91
$1,621.80
$304.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$794.84
$902.10
$1,015.76
$1,419.54
$2,157.12
$1,098.85
$1,206.11
$1,319.77
$1,723.55
$1,402.86
$1,510.12
$1,623.78
$2,027.56
$1,706.87
$1,814.13
$1,927.79
$2,331.57
$304.01
Toc - Plan #25 Medica
Expanded Bronze

(EPO) Select by Medica Bronze 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
$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
$386.11
$438.23
$493.44
$689.58
$1,047.89
$681.48
$733.60
$788.81
$984.95
$976.85
$1,028.97
$1,084.18
$1,280.32
$1,272.22
$1,324.34
$1,379.55
$1,575.69
$295.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$772.22
$876.46
$986.88
$1,379.16
$2,095.78
$1,067.59
$1,171.83
$1,282.25
$1,674.53
$1,362.96
$1,467.20
$1,577.62
$1,969.90
$1,658.33
$1,762.57
$1,872.99
$2,265.27
$295.37
Toc - Plan #26 Medica
Gold

(EPO) Select 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
$1,000 $2,000 Annual Deductible
$8,350 $16,700 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
$576.11
$653.88
$736.26
$1,028.92
$1,563.55
$1,016.83
$1,094.60
$1,176.98
$1,469.64
$1,457.55
$1,535.32
$1,617.70
$1,910.36
$1,898.27
$1,976.04
$2,058.42
$2,351.08
$440.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,152.22
$1,307.76
$1,472.52
$2,057.84
$3,127.10
$1,592.94
$1,748.48
$1,913.24
$2,498.56
$2,033.66
$2,189.20
$2,353.96
$2,939.28
$2,474.38
$2,629.92
$2,794.68
$3,380.00
$440.72
Toc - Plan #27 Medica
Expanded Bronze

(EPO) Select by Medica Bronze Premier ($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
$1,500 $3,000 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
$387.49
$439.79
$495.20
$692.05
$1,051.63
$683.91
$736.21
$791.62
$988.47
$980.33
$1,032.63
$1,088.04
$1,284.89
$1,276.75
$1,329.05
$1,384.46
$1,581.31
$296.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.98
$879.58
$990.40
$1,384.10
$2,103.26
$1,071.40
$1,176.00
$1,286.82
$1,680.52
$1,367.82
$1,472.42
$1,583.24
$1,976.94
$1,664.24
$1,768.84
$1,879.66
$2,273.36
$296.42
Toc - Plan #28 Medica
Gold

(EPO) Select 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
$547.94
$621.90
$700.26
$978.60
$1,487.08
$967.11
$1,041.07
$1,119.43
$1,397.77
$1,386.28
$1,460.24
$1,538.60
$1,816.94
$1,805.45
$1,879.41
$1,957.77
$2,236.11
$419.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,095.88
$1,243.80
$1,400.52
$1,957.20
$2,974.16
$1,515.05
$1,662.97
$1,819.69
$2,376.37
$1,934.22
$2,082.14
$2,238.86
$2,795.54
$2,353.39
$2,501.31
$2,658.03
$3,214.71
$419.17
Toc - Plan #29 Medica
Silver

(EPO) Select 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
$521.31
$591.67
$666.22
$931.03
$1,414.80
$920.10
$990.46
$1,065.01
$1,329.82
$1,318.89
$1,389.25
$1,463.80
$1,728.61
$1,717.68
$1,788.04
$1,862.59
$2,127.40
$398.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,042.62
$1,183.34
$1,332.44
$1,862.06
$2,829.60
$1,441.41
$1,582.13
$1,731.23
$2,260.85
$1,840.20
$1,980.92
$2,130.02
$2,659.64
$2,238.99
$2,379.71
$2,528.81
$3,058.43
$398.79
Toc - Plan #30 Medica
Bronze

(EPO) Select 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
$371.20
$421.31
$474.39
$662.95
$1,007.42
$655.16
$705.27
$758.35
$946.91
$939.12
$989.23
$1,042.31
$1,230.87
$1,223.08
$1,273.19
$1,326.27
$1,514.83
$283.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.40
$842.62
$948.78
$1,325.90
$2,014.84
$1,026.36
$1,126.58
$1,232.74
$1,609.86
$1,310.32
$1,410.54
$1,516.70
$1,893.82
$1,594.28
$1,694.50
$1,800.66
$2,177.78
$283.96

ADVERTISEMENT

Ambetter from Home State Health

Local: 1-855-650-3789 | Toll Free: 1-855-650-3789 | TTY: 1-855-650-3789

Toc - Plan #31 Ambetter from Home State Health
Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$400.01
$453.99
$511.19
$714.39
$1,085.59
$706.01
$759.99
$817.19
$1,020.39
$1,012.01
$1,065.99
$1,123.19
$1,326.39
$1,318.01
$1,371.99
$1,429.19
$1,632.39
$306.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.02
$907.98
$1,022.38
$1,428.78
$2,171.18
$1,106.02
$1,213.98
$1,328.38
$1,734.78
$1,412.02
$1,519.98
$1,634.38
$2,040.78
$1,718.02
$1,825.98
$1,940.38
$2,346.78
$306.00
Toc - Plan #32 Ambetter from Home State Health
Silver

(EPO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$463.29
$525.82
$592.07
$827.42
$1,257.34
$817.70
$880.23
$946.48
$1,181.83
$1,172.11
$1,234.64
$1,300.89
$1,536.24
$1,526.52
$1,589.05
$1,655.30
$1,890.65
$354.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$926.58
$1,051.64
$1,184.14
$1,654.84
$2,514.68
$1,280.99
$1,406.05
$1,538.55
$2,009.25
$1,635.40
$1,760.46
$1,892.96
$2,363.66
$1,989.81
$2,114.87
$2,247.37
$2,718.07
$354.41
Toc - Plan #33 Ambetter from Home State Health
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$461.58
$523.88
$589.88
$824.36
$1,252.69
$814.68
$876.98
$942.98
$1,177.46
$1,167.78
$1,230.08
$1,296.08
$1,530.56
$1,520.88
$1,583.18
$1,649.18
$1,883.66
$353.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$923.16
$1,047.76
$1,179.76
$1,648.72
$2,505.38
$1,276.26
$1,400.86
$1,532.86
$2,001.82
$1,629.36
$1,753.96
$1,885.96
$2,354.92
$1,982.46
$2,107.06
$2,239.06
$2,708.02
$353.10
Toc - Plan #34 Ambetter from Home State Health
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,700 $15,400 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
$573.92
$651.39
$733.46
$1,025.00
$1,557.59
$1,012.96
$1,090.43
$1,172.50
$1,464.04
$1,452.00
$1,529.47
$1,611.54
$1,903.08
$1,891.04
$1,968.51
$2,050.58
$2,342.12
$439.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,147.84
$1,302.78
$1,466.92
$2,050.00
$3,115.18
$1,586.88
$1,741.82
$1,905.96
$2,489.04
$2,025.92
$2,180.86
$2,345.00
$2,928.08
$2,464.96
$2,619.90
$2,784.04
$3,367.12
$439.04
Toc - Plan #35 Ambetter from Home State Health
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$433.13
$491.59
$553.53
$773.55
$1,175.49
$764.47
$822.93
$884.87
$1,104.89
$1,095.81
$1,154.27
$1,216.21
$1,436.23
$1,427.15
$1,485.61
$1,547.55
$1,767.57
$331.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.26
$983.18
$1,107.06
$1,547.10
$2,350.98
$1,197.60
$1,314.52
$1,438.40
$1,878.44
$1,528.94
$1,645.86
$1,769.74
$2,209.78
$1,860.28
$1,977.20
$2,101.08
$2,541.12
$331.34
Toc - Plan #36 Ambetter from Home State Health
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$439.66
$499.01
$561.88
$785.22
$1,193.22
$775.99
$835.34
$898.21
$1,121.55
$1,112.32
$1,171.67
$1,234.54
$1,457.88
$1,448.65
$1,508.00
$1,570.87
$1,794.21
$336.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.32
$998.02
$1,123.76
$1,570.44
$2,386.44
$1,215.65
$1,334.35
$1,460.09
$1,906.77
$1,551.98
$1,670.68
$1,796.42
$2,243.10
$1,888.31
$2,007.01
$2,132.75
$2,579.43
$336.33
Toc - Plan #37 Ambetter from Home State Health
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$485.11
$550.59
$619.96
$866.39
$1,316.56
$856.21
$921.69
$991.06
$1,237.49
$1,227.31
$1,292.79
$1,362.16
$1,608.59
$1,598.41
$1,663.89
$1,733.26
$1,979.69
$371.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$970.22
$1,101.18
$1,239.92
$1,732.78
$2,633.12
$1,341.32
$1,472.28
$1,611.02
$2,103.88
$1,712.42
$1,843.38
$1,982.12
$2,474.98
$2,083.52
$2,214.48
$2,353.22
$2,846.08
$371.10
Toc - Plan #38 Ambetter from Home State Health
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$446.66
$506.95
$570.82
$797.71
$1,212.20
$788.35
$848.64
$912.51
$1,139.40
$1,130.04
$1,190.33
$1,254.20
$1,481.09
$1,471.73
$1,532.02
$1,595.89
$1,822.78
$341.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.32
$1,013.90
$1,141.64
$1,595.42
$2,424.40
$1,235.01
$1,355.59
$1,483.33
$1,937.11
$1,576.70
$1,697.28
$1,825.02
$2,278.80
$1,918.39
$2,038.97
$2,166.71
$2,620.49
$341.69
Toc - Plan #39 Ambetter from Home State Health
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$455.04
$516.46
$581.53
$812.69
$1,234.96
$803.14
$864.56
$929.63
$1,160.79
$1,151.24
$1,212.66
$1,277.73
$1,508.89
$1,499.34
$1,560.76
$1,625.83
$1,856.99
$348.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$910.08
$1,032.92
$1,163.06
$1,625.38
$2,469.92
$1,258.18
$1,381.02
$1,511.16
$1,973.48
$1,606.28
$1,729.12
$1,859.26
$2,321.58
$1,954.38
$2,077.22
$2,207.36
$2,669.68
$348.10
Toc - Plan #40 Ambetter from Home State Health
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$549.69
$623.89
$702.49
$981.73
$1,491.83
$970.20
$1,044.40
$1,123.00
$1,402.24
$1,390.71
$1,464.91
$1,543.51
$1,822.75
$1,811.22
$1,885.42
$1,964.02
$2,243.26
$420.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,099.38
$1,247.78
$1,404.98
$1,963.46
$2,983.66
$1,519.89
$1,668.29
$1,825.49
$2,383.97
$1,940.40
$2,088.80
$2,246.00
$2,804.48
$2,360.91
$2,509.31
$2,666.51
$3,224.99
$420.51
Toc - Plan #41 Ambetter from Home State Health
Gold

(EPO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$541.54
$614.63
$692.07
$967.17
$1,469.71
$955.81
$1,028.90
$1,106.34
$1,381.44
$1,370.08
$1,443.17
$1,520.61
$1,795.71
$1,784.35
$1,857.44
$1,934.88
$2,209.98
$414.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,083.08
$1,229.26
$1,384.14
$1,934.34
$2,939.42
$1,497.35
$1,643.53
$1,798.41
$2,348.61
$1,911.62
$2,057.80
$2,212.68
$2,762.88
$2,325.89
$2,472.07
$2,626.95
$3,177.15
$414.27
Toc - Plan #42 Ambetter from Home State Health
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,300 $10,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$628.17
$712.96
$802.79
$1,121.89
$1,704.83
$1,108.71
$1,193.50
$1,283.33
$1,602.43
$1,589.25
$1,674.04
$1,763.87
$2,082.97
$2,069.79
$2,154.58
$2,244.41
$2,563.51
$480.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,256.34
$1,425.92
$1,605.58
$2,243.78
$3,409.66
$1,736.88
$1,906.46
$2,086.12
$2,724.32
$2,217.42
$2,387.00
$2,566.66
$3,204.86
$2,697.96
$2,867.54
$3,047.20
$3,685.40
$480.54
Toc - Plan #43 Ambetter from Home State Health
Bronze

(EPO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$381.34
$432.80
$487.33
$681.05
$1,034.92
$673.05
$724.51
$779.04
$972.76
$964.76
$1,016.22
$1,070.75
$1,264.47
$1,256.47
$1,307.93
$1,362.46
$1,556.18
$291.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.68
$865.60
$974.66
$1,362.10
$2,069.84
$1,054.39
$1,157.31
$1,266.37
$1,653.81
$1,346.10
$1,449.02
$1,558.08
$1,945.52
$1,637.81
$1,740.73
$1,849.79
$2,237.23
$291.71
Toc - Plan #44 Ambetter from Home State Health
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$419.51
$476.13
$536.12
$749.23
$1,138.52
$740.43
$797.05
$857.04
$1,070.15
$1,061.35
$1,117.97
$1,177.96
$1,391.07
$1,382.27
$1,438.89
$1,498.88
$1,711.99
$320.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.02
$952.26
$1,072.24
$1,498.46
$2,277.04
$1,159.94
$1,273.18
$1,393.16
$1,819.38
$1,480.86
$1,594.10
$1,714.08
$2,140.30
$1,801.78
$1,915.02
$2,035.00
$2,461.22
$320.92
Toc - Plan #45 Ambetter from Home State Health
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$445.82
$506.00
$569.75
$796.22
$1,209.94
$786.87
$847.05
$910.80
$1,137.27
$1,127.92
$1,188.10
$1,251.85
$1,478.32
$1,468.97
$1,529.15
$1,592.90
$1,819.37
$341.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$891.64
$1,012.00
$1,139.50
$1,592.44
$2,419.88
$1,232.69
$1,353.05
$1,480.55
$1,933.49
$1,573.74
$1,694.10
$1,821.60
$2,274.54
$1,914.79
$2,035.15
$2,162.65
$2,615.59
$341.05
Toc - Plan #46 Ambetter from Home State Health
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$541.91
$615.05
$692.55
$967.83
$1,470.71
$956.46
$1,029.60
$1,107.10
$1,382.38
$1,371.01
$1,444.15
$1,521.65
$1,796.93
$1,785.56
$1,858.70
$1,936.20
$2,211.48
$414.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,083.82
$1,230.10
$1,385.10
$1,935.66
$2,941.42
$1,498.37
$1,644.65
$1,799.65
$2,350.21
$1,912.92
$2,059.20
$2,214.20
$2,764.76
$2,327.47
$2,473.75
$2,628.75
$3,179.31
$414.55
Toc - Plan #47 Ambetter from Home State Health
Expanded Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$413.03
$468.78
$527.84
$737.65
$1,120.93
$728.99
$784.74
$843.80
$1,053.61
$1,044.95
$1,100.70
$1,159.76
$1,369.57
$1,360.91
$1,416.66
$1,475.72
$1,685.53
$315.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.06
$937.56
$1,055.68
$1,475.30
$2,241.86
$1,142.02
$1,253.52
$1,371.64
$1,791.26
$1,457.98
$1,569.48
$1,687.60
$2,107.22
$1,773.94
$1,885.44
$2,003.56
$2,423.18
$315.96
Toc - Plan #48 Ambetter from Home State Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$447.23
$507.60
$571.55
$798.74
$1,213.76
$789.35
$849.72
$913.67
$1,140.86
$1,131.47
$1,191.84
$1,255.79
$1,482.98
$1,473.59
$1,533.96
$1,597.91
$1,825.10
$342.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$894.46
$1,015.20
$1,143.10
$1,597.48
$2,427.52
$1,236.58
$1,357.32
$1,485.22
$1,939.60
$1,578.70
$1,699.44
$1,827.34
$2,281.72
$1,920.82
$2,041.56
$2,169.46
$2,623.84
$342.12
Toc - Plan #49 Ambetter from Home State Health
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,700 $15,400 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
$592.60
$672.60
$757.34
$1,058.37
$1,608.30
$1,045.94
$1,125.94
$1,210.68
$1,511.71
$1,499.28
$1,579.28
$1,664.02
$1,965.05
$1,952.62
$2,032.62
$2,117.36
$2,418.39
$453.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,185.20
$1,345.20
$1,514.68
$2,116.74
$3,216.60
$1,638.54
$1,798.54
$1,968.02
$2,570.08
$2,091.88
$2,251.88
$2,421.36
$3,023.42
$2,545.22
$2,705.22
$2,874.70
$3,476.76
$453.34
Toc - Plan #50 Ambetter from Home State Health
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$476.60
$540.93
$609.08
$851.19
$1,293.47
$841.19
$905.52
$973.67
$1,215.78
$1,205.78
$1,270.11
$1,338.26
$1,580.37
$1,570.37
$1,634.70
$1,702.85
$1,944.96
$364.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$953.20
$1,081.86
$1,218.16
$1,702.38
$2,586.94
$1,317.79
$1,446.45
$1,582.75
$2,066.97
$1,682.38
$1,811.04
$1,947.34
$2,431.56
$2,046.97
$2,175.63
$2,311.93
$2,796.15
$364.59
Toc - Plan #51 Ambetter from Home State Health
Silver

(EPO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$478.37
$542.94
$611.35
$854.35
$1,298.27
$844.32
$908.89
$977.30
$1,220.30
$1,210.27
$1,274.84
$1,343.25
$1,586.25
$1,576.22
$1,640.79
$1,709.20
$1,952.20
$365.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$956.74
$1,085.88
$1,222.70
$1,708.70
$2,596.54
$1,322.69
$1,451.83
$1,588.65
$2,074.65
$1,688.64
$1,817.78
$1,954.60
$2,440.60
$2,054.59
$2,183.73
$2,320.55
$2,806.55
$365.95
Toc - Plan #52 Ambetter from Home State Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$453.98
$515.25
$580.17
$810.78
$1,232.06
$801.26
$862.53
$927.45
$1,158.06
$1,148.54
$1,209.81
$1,274.73
$1,505.34
$1,495.82
$1,557.09
$1,622.01
$1,852.62
$347.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$907.96
$1,030.50
$1,160.34
$1,621.56
$2,464.12
$1,255.24
$1,377.78
$1,507.62
$1,968.84
$1,602.52
$1,725.06
$1,854.90
$2,316.12
$1,949.80
$2,072.34
$2,202.18
$2,663.40
$347.28
Toc - Plan #53 Ambetter from Home State Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$500.90
$568.51
$640.14
$894.59
$1,359.42
$884.08
$951.69
$1,023.32
$1,277.77
$1,267.26
$1,334.87
$1,406.50
$1,660.95
$1,650.44
$1,718.05
$1,789.68
$2,044.13
$383.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,001.80
$1,137.02
$1,280.28
$1,789.18
$2,718.84
$1,384.98
$1,520.20
$1,663.46
$2,172.36
$1,768.16
$1,903.38
$2,046.64
$2,555.54
$2,151.34
$2,286.56
$2,429.82
$2,938.72
$383.18
Toc - Plan #54 Ambetter from Home State Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$469.86
$533.28
$600.46
$839.15
$1,275.17
$829.29
$892.71
$959.89
$1,198.58
$1,188.72
$1,252.14
$1,319.32
$1,558.01
$1,548.15
$1,611.57
$1,678.75
$1,917.44
$359.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$939.72
$1,066.56
$1,200.92
$1,678.30
$2,550.34
$1,299.15
$1,425.99
$1,560.35
$2,037.73
$1,658.58
$1,785.42
$1,919.78
$2,397.16
$2,018.01
$2,144.85
$2,279.21
$2,756.59
$359.43
Toc - Plan #55 Ambetter from Home State Health
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$567.59
$644.20
$725.36
$1,013.69
$1,540.40
$1,001.79
$1,078.40
$1,159.56
$1,447.89
$1,435.99
$1,512.60
$1,593.76
$1,882.09
$1,870.19
$1,946.80
$2,027.96
$2,316.29
$434.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,135.18
$1,288.40
$1,450.72
$2,027.38
$3,080.80
$1,569.38
$1,722.60
$1,884.92
$2,461.58
$2,003.58
$2,156.80
$2,319.12
$2,895.78
$2,437.78
$2,591.00
$2,753.32
$3,329.98
$434.20
Toc - Plan #56 Ambetter from Home State Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$461.20
$523.45
$589.40
$823.68
$1,251.67
$814.01
$876.26
$942.21
$1,176.49
$1,166.82
$1,229.07
$1,295.02
$1,529.30
$1,519.63
$1,581.88
$1,647.83
$1,882.11
$352.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$922.40
$1,046.90
$1,178.80
$1,647.36
$2,503.34
$1,275.21
$1,399.71
$1,531.61
$2,000.17
$1,628.02
$1,752.52
$1,884.42
$2,352.98
$1,980.83
$2,105.33
$2,237.23
$2,705.79
$352.81
Toc - Plan #57 Ambetter from Home State Health
Gold

(EPO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$559.17
$634.64
$714.60
$998.66
$1,517.55
$986.93
$1,062.40
$1,142.36
$1,426.42
$1,414.69
$1,490.16
$1,570.12
$1,854.18
$1,842.45
$1,917.92
$1,997.88
$2,281.94
$427.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,118.34
$1,269.28
$1,429.20
$1,997.32
$3,035.10
$1,546.10
$1,697.04
$1,856.96
$2,425.08
$1,973.86
$2,124.80
$2,284.72
$2,852.84
$2,401.62
$2,552.56
$2,712.48
$3,280.60
$427.76
Toc - Plan #58 Ambetter from Home State Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,300 $10,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$648.62
$736.17
$828.93
$1,158.42
$1,760.33
$1,144.81
$1,232.36
$1,325.12
$1,654.61
$1,641.00
$1,728.55
$1,821.31
$2,150.80
$2,137.19
$2,224.74
$2,317.50
$2,646.99
$496.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,297.24
$1,472.34
$1,657.86
$2,316.84
$3,520.66
$1,793.43
$1,968.53
$2,154.05
$2,813.03
$2,289.62
$2,464.72
$2,650.24
$3,309.22
$2,785.81
$2,960.91
$3,146.43
$3,805.41
$496.19
Toc - Plan #59 Ambetter from Home State Health
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$421.18
$478.02
$538.25
$752.20
$1,143.05
$743.37
$800.21
$860.44
$1,074.39
$1,065.56
$1,122.40
$1,182.63
$1,396.58
$1,387.75
$1,444.59
$1,504.82
$1,718.77
$322.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$842.36
$956.04
$1,076.50
$1,504.40
$2,286.10
$1,164.55
$1,278.23
$1,398.69
$1,826.59
$1,486.74
$1,600.42
$1,720.88
$2,148.78
$1,808.93
$1,922.61
$2,043.07
$2,470.97
$322.19
Toc - Plan #60 Ambetter from Home State Health
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$444.94
$505.00
$568.63
$794.65
$1,207.55
$785.31
$845.37
$909.00
$1,135.02
$1,125.68
$1,185.74
$1,249.37
$1,475.39
$1,466.05
$1,526.11
$1,589.74
$1,815.76
$340.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$889.88
$1,010.00
$1,137.26
$1,589.30
$2,415.10
$1,230.25
$1,350.37
$1,477.63
$1,929.67
$1,570.62
$1,690.74
$1,818.00
$2,270.04
$1,910.99
$2,031.11
$2,158.37
$2,610.41
$340.37
Toc - Plan #61 Ambetter from Home State Health
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$553.91
$628.67
$707.88
$989.26
$1,503.28
$977.64
$1,052.40
$1,131.61
$1,412.99
$1,401.37
$1,476.13
$1,555.34
$1,836.72
$1,825.10
$1,899.86
$1,979.07
$2,260.45
$423.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,107.82
$1,257.34
$1,415.76
$1,978.52
$3,006.56
$1,531.55
$1,681.07
$1,839.49
$2,402.25
$1,955.28
$2,104.80
$2,263.22
$2,825.98
$2,379.01
$2,528.53
$2,686.95
$3,249.71
$423.73
Toc - Plan #62 Ambetter from Home State Health
Expanded Bronze

(EPO) CMS Standard Virtual Access Basic Bronze ? Virtual PCP Selection Required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$436.28
$495.17
$557.55
$779.18
$1,184.04
$770.03
$828.92
$891.30
$1,112.93
$1,103.78
$1,162.67
$1,225.05
$1,446.68
$1,437.53
$1,496.42
$1,558.80
$1,780.43
$333.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$872.56
$990.34
$1,115.10
$1,558.36
$2,368.08
$1,206.31
$1,324.09
$1,448.85
$1,892.11
$1,540.06
$1,657.84
$1,782.60
$2,225.86
$1,873.81
$1,991.59
$2,116.35
$2,559.61
$333.75
Toc - Plan #63 Ambetter from Home State Health
Silver

(EPO) CMS Standard Virtual Access Basic Silver ? Virtual PCP Selection Required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$463.66
$526.24
$592.54
$828.08
$1,258.35
$818.35
$880.93
$947.23
$1,182.77
$1,173.04
$1,235.62
$1,301.92
$1,537.46
$1,527.73
$1,590.31
$1,656.61
$1,892.15
$354.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$927.32
$1,052.48
$1,185.08
$1,656.16
$2,516.70
$1,282.01
$1,407.17
$1,539.77
$2,010.85
$1,636.70
$1,761.86
$1,894.46
$2,365.54
$1,991.39
$2,116.55
$2,249.15
$2,720.23
$354.69
Toc - Plan #64 Ambetter from Home State Health
Gold

(EPO) CMS Standard Virtual Access Basic Gold ? Virtual PCP Selection Required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

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
$563.59
$639.66
$720.25
$1,006.55
$1,529.55
$994.73
$1,070.80
$1,151.39
$1,437.69
$1,425.87
$1,501.94
$1,582.53
$1,868.83
$1,857.01
$1,933.08
$2,013.67
$2,299.97
$431.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,127.18
$1,279.32
$1,440.50
$2,013.10
$3,059.10
$1,558.32
$1,710.46
$1,871.64
$2,444.24
$1,989.46
$2,141.60
$2,302.78
$2,875.38
$2,420.60
$2,572.74
$2,733.92
$3,306.52
$431.14

‡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 Johnson County here.

Johnson County is in “Rating Area 4” of Missouri.

Currently, there are 64 plans offered in Rating Area 4.

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2023 Obamacare Plans for Johnson County, MO

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