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Obamacare 2023 Rates for Cleveland County

Obamacare > Rates > North Carolina > Cleveland 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 Cleveland County, NC.

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, 86 Plans and 2023 Rates for Cleveland County, North Carolina

Below, you’ll find a summary of the 86 plans for Cleveland County, North Carolina 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

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 |

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Blue Cross and Blue Shield of NC

Local: 1-800-324-4973 | Toll Free: 1-800-324-4973

Toc - Plan #1 Blue Cross and Blue Shield of NC
Gold

(POS) Blue Value Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.90
$565.12
$636.32
$889.25
$1,351.30
$878.79
$946.01
$1,017.21
$1,270.14
$1,259.68
$1,326.90
$1,398.10
$1,651.03
$1,640.57
$1,707.79
$1,778.99
$2,031.92
$380.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.80
$1,130.24
$1,272.64
$1,778.50
$2,702.60
$1,376.69
$1,511.13
$1,653.53
$2,159.39
$1,757.58
$1,892.02
$2,034.42
$2,540.28
$2,138.47
$2,272.91
$2,415.31
$2,921.17
$380.89
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$511.80
$580.89
$654.08
$914.07
$1,389.03
$903.33
$972.42
$1,045.61
$1,305.60
$1,294.86
$1,363.95
$1,437.14
$1,697.13
$1,686.39
$1,755.48
$1,828.67
$2,088.66
$391.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,023.60
$1,161.78
$1,308.16
$1,828.14
$2,778.06
$1,415.13
$1,553.31
$1,699.69
$2,219.67
$1,806.66
$1,944.84
$2,091.22
$2,611.20
$2,198.19
$2,336.37
$2,482.75
$3,002.73
$391.53
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$505.95
$574.25
$646.60
$903.63
$1,373.15
$893.00
$961.30
$1,033.65
$1,290.68
$1,280.05
$1,348.35
$1,420.70
$1,677.73
$1,667.10
$1,735.40
$1,807.75
$2,064.78
$387.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,011.90
$1,148.50
$1,293.20
$1,807.26
$2,746.30
$1,398.95
$1,535.55
$1,680.25
$2,194.31
$1,786.00
$1,922.60
$2,067.30
$2,581.36
$2,173.05
$2,309.65
$2,454.35
$2,968.41
$387.05
Toc - Plan #4 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.86
$424.33
$477.79
$667.71
$1,014.66
$659.86
$710.33
$763.79
$953.71
$945.86
$996.33
$1,049.79
$1,239.71
$1,231.86
$1,282.33
$1,335.79
$1,525.71
$286.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.72
$848.66
$955.58
$1,335.42
$2,029.32
$1,033.72
$1,134.66
$1,241.58
$1,621.42
$1,319.72
$1,420.66
$1,527.58
$1,907.42
$1,605.72
$1,706.66
$1,813.58
$2,193.42
$286.00
Toc - Plan #5 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze 7500 | HSA Eligible | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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
$371.25
$421.37
$474.46
$663.05
$1,007.57
$655.26
$705.38
$758.47
$947.06
$939.27
$989.39
$1,042.48
$1,231.07
$1,223.28
$1,273.40
$1,326.49
$1,515.08
$284.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.50
$842.74
$948.92
$1,326.10
$2,015.14
$1,026.51
$1,126.75
$1,232.93
$1,610.11
$1,310.52
$1,410.76
$1,516.94
$1,894.12
$1,594.53
$1,694.77
$1,800.95
$2,178.13
$284.01
Toc - Plan #6 Blue Cross and Blue Shield of NC
Bronze

(POS) Blue Value Bronze 9100 | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$354.41
$402.26
$452.94
$632.98
$961.87
$625.53
$673.38
$724.06
$904.10
$896.65
$944.50
$995.18
$1,175.22
$1,167.77
$1,215.62
$1,266.30
$1,446.34
$271.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.82
$804.52
$905.88
$1,265.96
$1,923.74
$979.94
$1,075.64
$1,177.00
$1,537.08
$1,251.06
$1,346.76
$1,448.12
$1,808.20
$1,522.18
$1,617.88
$1,719.24
$2,079.32
$271.12
Toc - Plan #7 Blue Cross and Blue Shield of NC
Catastrophic

(POS) Blue Value Catastrophic 9100 | 3 PCP $35 | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$259.97
$295.07
$332.24
$464.31
$705.56
$458.85
$493.95
$531.12
$663.19
$657.73
$692.83
$730.00
$862.07
$856.61
$891.71
$928.88
$1,060.95
$198.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$519.94
$590.14
$664.48
$928.62
$1,411.12
$718.82
$789.02
$863.36
$1,127.50
$917.70
$987.90
$1,062.24
$1,326.38
$1,116.58
$1,186.78
$1,261.12
$1,525.26
$198.88
Toc - Plan #8 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Simple | $0 Deductible | 3 Free PCP | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$523.53
$594.21
$669.07
$935.02
$1,420.86
$924.03
$994.71
$1,069.57
$1,335.52
$1,324.53
$1,395.21
$1,470.07
$1,736.02
$1,725.03
$1,795.71
$1,870.57
$2,136.52
$400.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,047.06
$1,188.42
$1,338.14
$1,870.04
$2,841.72
$1,447.56
$1,588.92
$1,738.64
$2,270.54
$1,848.06
$1,989.42
$2,139.14
$2,671.04
$2,248.56
$2,389.92
$2,539.64
$3,071.54
$400.50
Toc - Plan #9 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 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
$484.74
$550.18
$619.50
$865.75
$1,315.58
$855.57
$921.01
$990.33
$1,236.58
$1,226.40
$1,291.84
$1,361.16
$1,607.41
$1,597.23
$1,662.67
$1,731.99
$1,978.24
$370.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$969.48
$1,100.36
$1,239.00
$1,731.50
$2,631.16
$1,340.31
$1,471.19
$1,609.83
$2,102.33
$1,711.14
$1,842.02
$1,980.66
$2,473.16
$2,081.97
$2,212.85
$2,351.49
$2,843.99
$370.83
Toc - Plan #10 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$503.97
$572.01
$644.07
$900.09
$1,367.77
$889.51
$957.55
$1,029.61
$1,285.63
$1,275.05
$1,343.09
$1,415.15
$1,671.17
$1,660.59
$1,728.63
$1,800.69
$2,056.71
$385.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,007.94
$1,144.02
$1,288.14
$1,800.18
$2,735.54
$1,393.48
$1,529.56
$1,673.68
$2,185.72
$1,779.02
$1,915.10
$2,059.22
$2,571.26
$2,164.56
$2,300.64
$2,444.76
$2,956.80
$385.54
Toc - Plan #11 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.72
$401.47
$452.05
$631.74
$960.00
$624.32
$672.07
$722.65
$902.34
$894.92
$942.67
$993.25
$1,172.94
$1,165.52
$1,213.27
$1,263.85
$1,443.54
$270.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.44
$802.94
$904.10
$1,263.48
$1,920.00
$978.04
$1,073.54
$1,174.70
$1,534.08
$1,248.64
$1,344.14
$1,445.30
$1,804.68
$1,519.24
$1,614.74
$1,715.90
$2,075.28
$270.60
Toc - Plan #12 Blue Cross and Blue Shield of NC
Gold

(POS) Blue Value Gold Standard 2000 | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$496.03
$562.99
$633.93
$885.91
$1,346.23
$875.49
$942.45
$1,013.39
$1,265.37
$1,254.95
$1,321.91
$1,392.85
$1,644.83
$1,634.41
$1,701.37
$1,772.31
$2,024.29
$379.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992.06
$1,125.98
$1,267.86
$1,771.82
$2,692.46
$1,371.52
$1,505.44
$1,647.32
$2,151.28
$1,750.98
$1,884.90
$2,026.78
$2,530.74
$2,130.44
$2,264.36
$2,406.24
$2,910.20
$379.46
Toc - Plan #13 Blue Cross and Blue Shield of NC
Silver

(POS) Blue Value Silver Standard 5800 | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$501.79
$569.53
$641.29
$896.20
$1,361.86
$885.66
$953.40
$1,025.16
$1,280.07
$1,269.53
$1,337.27
$1,409.03
$1,663.94
$1,653.40
$1,721.14
$1,792.90
$2,047.81
$383.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,003.58
$1,139.06
$1,282.58
$1,792.40
$2,723.72
$1,387.45
$1,522.93
$1,666.45
$2,176.27
$1,771.32
$1,906.80
$2,050.32
$2,560.14
$2,155.19
$2,290.67
$2,434.19
$2,944.01
$383.87
Toc - Plan #14 Blue Cross and Blue Shield of NC
Expanded Bronze

(POS) Blue Value Bronze Standard 7500 | Statewide Doctors

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$354.15
$401.96
$452.60
$632.51
$961.16
$625.07
$672.88
$723.52
$903.43
$895.99
$943.80
$994.44
$1,174.35
$1,166.91
$1,214.72
$1,265.36
$1,445.27
$270.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$708.30
$803.92
$905.20
$1,265.02
$1,922.32
$979.22
$1,074.84
$1,176.12
$1,535.94
$1,250.14
$1,345.76
$1,447.04
$1,806.86
$1,521.06
$1,616.68
$1,717.96
$2,077.78
$270.92
Toc - Plan #15 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$1,800 $3,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$501.06
$568.70
$640.35
$894.89
$1,359.88
$884.37
$952.01
$1,023.66
$1,278.20
$1,267.68
$1,335.32
$1,406.97
$1,661.51
$1,650.99
$1,718.63
$1,790.28
$2,044.82
$383.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,002.12
$1,137.40
$1,280.70
$1,789.78
$2,719.76
$1,385.43
$1,520.71
$1,664.01
$2,173.09
$1,768.74
$1,904.02
$2,047.32
$2,556.40
$2,152.05
$2,287.33
$2,430.63
$2,939.71
$383.31
Toc - Plan #16 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold Standard 2000 | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$499.25
$566.65
$638.04
$891.66
$1,354.96
$881.18
$948.58
$1,019.97
$1,273.59
$1,263.11
$1,330.51
$1,401.90
$1,655.52
$1,645.04
$1,712.44
$1,783.83
$2,037.45
$381.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$998.50
$1,133.30
$1,276.08
$1,783.32
$2,709.92
$1,380.43
$1,515.23
$1,658.01
$2,165.25
$1,762.36
$1,897.16
$2,039.94
$2,547.18
$2,144.29
$2,279.09
$2,421.87
$2,929.11
$381.93
Toc - Plan #17 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$515.17
$584.72
$658.39
$920.09
$1,398.17
$909.28
$978.83
$1,052.50
$1,314.20
$1,303.39
$1,372.94
$1,446.61
$1,708.31
$1,697.50
$1,767.05
$1,840.72
$2,102.42
$394.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,030.34
$1,169.44
$1,316.78
$1,840.18
$2,796.34
$1,424.45
$1,563.55
$1,710.89
$2,234.29
$1,818.56
$1,957.66
$2,105.00
$2,628.40
$2,212.67
$2,351.77
$2,499.11
$3,022.51
$394.11
Toc - Plan #18 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Simple | $0 Deductible | 3 Free PCP | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$526.88
$598.01
$673.35
$941.01
$1,429.95
$929.94
$1,001.07
$1,076.41
$1,344.07
$1,333.00
$1,404.13
$1,479.47
$1,747.13
$1,736.06
$1,807.19
$1,882.53
$2,150.19
$403.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,053.76
$1,196.02
$1,346.70
$1,882.02
$2,859.90
$1,456.82
$1,599.08
$1,749.76
$2,285.08
$1,859.88
$2,002.14
$2,152.82
$2,688.14
$2,262.94
$2,405.20
$2,555.88
$3,091.20
$403.06
Toc - Plan #19 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 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
$487.80
$553.65
$623.41
$871.21
$1,323.89
$860.97
$926.82
$996.58
$1,244.38
$1,234.14
$1,299.99
$1,369.75
$1,617.55
$1,607.31
$1,673.16
$1,742.92
$1,990.72
$373.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$975.60
$1,107.30
$1,246.82
$1,742.42
$2,647.78
$1,348.77
$1,480.47
$1,619.99
$2,115.59
$1,721.94
$1,853.64
$1,993.16
$2,488.76
$2,095.11
$2,226.81
$2,366.33
$2,861.93
$373.17
Toc - Plan #20 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$507.21
$575.68
$648.21
$905.88
$1,376.57
$895.23
$963.70
$1,036.23
$1,293.90
$1,283.25
$1,351.72
$1,424.25
$1,681.92
$1,671.27
$1,739.74
$1,812.27
$2,069.94
$388.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,014.42
$1,151.36
$1,296.42
$1,811.76
$2,753.14
$1,402.44
$1,539.38
$1,684.44
$2,199.78
$1,790.46
$1,927.40
$2,072.46
$2,587.80
$2,178.48
$2,315.42
$2,460.48
$2,975.82
$388.02
Toc - Plan #21 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$509.17
$577.91
$650.72
$909.38
$1,381.89
$898.69
$967.43
$1,040.24
$1,298.90
$1,288.21
$1,356.95
$1,429.76
$1,688.42
$1,677.73
$1,746.47
$1,819.28
$2,077.94
$389.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,018.34
$1,155.82
$1,301.44
$1,818.76
$2,763.78
$1,407.86
$1,545.34
$1,690.96
$2,208.28
$1,797.38
$1,934.86
$2,080.48
$2,597.80
$2,186.90
$2,324.38
$2,470.00
$2,987.32
$389.52
Toc - Plan #22 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 5500 | $60 PCP | $20 Tier 1 Rx | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.25
$427.04
$480.85
$671.98
$1,021.14
$664.08
$714.87
$768.68
$959.81
$951.91
$1,002.70
$1,056.51
$1,247.64
$1,239.74
$1,290.53
$1,344.34
$1,535.47
$287.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.50
$854.08
$961.70
$1,343.96
$2,042.28
$1,040.33
$1,141.91
$1,249.53
$1,631.79
$1,328.16
$1,429.74
$1,537.36
$1,919.62
$1,615.99
$1,717.57
$1,825.19
$2,207.45
$287.83
Toc - Plan #23 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Standard 5800 | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$505.03
$573.21
$645.43
$901.98
$1,370.65
$891.38
$959.56
$1,031.78
$1,288.33
$1,277.73
$1,345.91
$1,418.13
$1,674.68
$1,664.08
$1,732.26
$1,804.48
$2,061.03
$386.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,010.06
$1,146.42
$1,290.86
$1,803.96
$2,741.30
$1,396.41
$1,532.77
$1,677.21
$2,190.31
$1,782.76
$1,919.12
$2,063.56
$2,576.66
$2,169.11
$2,305.47
$2,449.91
$2,963.01
$386.35
Toc - Plan #24 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.03
$404.09
$455.01
$635.87
$966.27
$628.39
$676.45
$727.37
$908.23
$900.75
$948.81
$999.73
$1,180.59
$1,173.11
$1,221.17
$1,272.09
$1,452.95
$272.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.06
$808.18
$910.02
$1,271.74
$1,932.54
$984.42
$1,080.54
$1,182.38
$1,544.10
$1,256.78
$1,352.90
$1,454.74
$1,816.46
$1,529.14
$1,625.26
$1,727.10
$2,088.82
$272.36
Toc - Plan #25 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze Standard 7500 | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$356.46
$404.58
$455.56
$636.64
$967.43
$629.15
$677.27
$728.25
$909.33
$901.84
$949.96
$1,000.94
$1,182.02
$1,174.53
$1,222.65
$1,273.63
$1,454.71
$272.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.92
$809.16
$911.12
$1,273.28
$1,934.86
$985.61
$1,081.85
$1,183.81
$1,545.97
$1,258.30
$1,354.54
$1,456.50
$1,818.66
$1,530.99
$1,627.23
$1,729.19
$2,091.35
$272.69
Toc - Plan #26 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze 7500 | HSA Eligible | Integrated | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 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
$373.58
$424.01
$477.44
$667.21
$1,013.90
$659.37
$709.80
$763.23
$953.00
$945.16
$995.59
$1,049.02
$1,238.79
$1,230.95
$1,281.38
$1,334.81
$1,524.58
$285.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$747.16
$848.02
$954.88
$1,334.42
$2,027.80
$1,032.95
$1,133.81
$1,240.67
$1,620.21
$1,318.74
$1,419.60
$1,526.46
$1,906.00
$1,604.53
$1,705.39
$1,812.25
$2,191.79
$285.79
Toc - Plan #27 Blue Cross and Blue Shield of NC
Bronze

(EPO) Blue Local Bronze 9100 | Integrated | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$356.75
$404.91
$455.93
$637.16
$968.22
$629.66
$677.82
$728.84
$910.07
$902.57
$950.73
$1,001.75
$1,182.98
$1,175.48
$1,223.64
$1,274.66
$1,455.89
$272.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.50
$809.82
$911.86
$1,274.32
$1,936.44
$986.41
$1,082.73
$1,184.77
$1,547.23
$1,259.32
$1,355.64
$1,457.68
$1,820.14
$1,532.23
$1,628.55
$1,730.59
$2,093.05
$272.91
Toc - Plan #28 Blue Cross and Blue Shield of NC
Catastrophic

(EPO) Blue Local Catastrophic 9100 | 3 PCP $35 | Integrated | with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-324-4973

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
$261.61
$296.93
$334.34
$467.24
$710.01
$461.74
$497.06
$534.47
$667.37
$661.87
$697.19
$734.60
$867.50
$862.00
$897.32
$934.73
$1,067.63
$200.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$523.22
$593.86
$668.68
$934.48
$1,420.02
$723.35
$793.99
$868.81
$1,134.61
$923.48
$994.12
$1,068.94
$1,334.74
$1,123.61
$1,194.25
$1,269.07
$1,534.87
$200.13

ADVERTISEMENT

WellCare of North Carolina

Local: 1-833-705-2175 | Toll Free: 1-833-705-2175

Toc - Plan #29 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 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
$739.01
$838.77
$944.44
$1,319.86
$2,005.65
$1,304.35
$1,404.11
$1,509.78
$1,885.20
$1,869.69
$1,969.45
$2,075.12
$2,450.54
$2,435.03
$2,534.79
$2,640.46
$3,015.88
$565.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,478.02
$1,677.54
$1,888.88
$2,639.72
$4,011.30
$2,043.36
$2,242.88
$2,454.22
$3,205.06
$2,608.70
$2,808.22
$3,019.56
$3,770.40
$3,174.04
$3,373.56
$3,584.90
$4,335.74
$565.34
Toc - Plan #30 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,100 $16,200 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
$948.05
$1,076.03
$1,211.60
$1,693.21
$2,572.99
$1,673.30
$1,801.28
$1,936.85
$2,418.46
$2,398.55
$2,526.53
$2,662.10
$3,143.71
$3,123.80
$3,251.78
$3,387.35
$3,868.96
$725.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,896.10
$2,152.06
$2,423.20
$3,386.42
$5,145.98
$2,621.35
$2,877.31
$3,148.45
$4,111.67
$3,346.60
$3,602.56
$3,873.70
$4,836.92
$4,071.85
$4,327.81
$4,598.95
$5,562.17
$725.25
Toc - Plan #31 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 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
$980.95
$1,113.37
$1,253.64
$1,751.96
$2,662.28
$1,731.37
$1,863.79
$2,004.06
$2,502.38
$2,481.79
$2,614.21
$2,754.48
$3,252.80
$3,232.21
$3,364.63
$3,504.90
$4,003.22
$750.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,961.90
$2,226.74
$2,507.28
$3,503.92
$5,324.56
$2,712.32
$2,977.16
$3,257.70
$4,254.34
$3,462.74
$3,727.58
$4,008.12
$5,004.76
$4,213.16
$4,478.00
$4,758.54
$5,755.18
$750.42
Toc - Plan #32 WellCare of North Carolina
Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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
$740.24
$840.16
$946.02
$1,322.06
$2,008.99
$1,306.52
$1,406.44
$1,512.30
$1,888.34
$1,872.80
$1,972.72
$2,078.58
$2,454.62
$2,439.08
$2,539.00
$2,644.86
$3,020.90
$566.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,480.48
$1,680.32
$1,892.04
$2,644.12
$4,017.98
$2,046.76
$2,246.60
$2,458.32
$3,210.40
$2,613.04
$2,812.88
$3,024.60
$3,776.68
$3,179.32
$3,379.16
$3,590.88
$4,342.96
$566.28
Toc - Plan #33 WellCare of North Carolina
Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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
$936.58
$1,063.01
$1,196.94
$1,672.72
$2,541.86
$1,653.06
$1,779.49
$1,913.42
$2,389.20
$2,369.54
$2,495.97
$2,629.90
$3,105.68
$3,086.02
$3,212.45
$3,346.38
$3,822.16
$716.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,873.16
$2,126.02
$2,393.88
$3,345.44
$5,083.72
$2,589.64
$2,842.50
$3,110.36
$4,061.92
$3,306.12
$3,558.98
$3,826.84
$4,778.40
$4,022.60
$4,275.46
$4,543.32
$5,494.88
$716.48
Toc - Plan #34 WellCare of North Carolina
Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

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
$953.84
$1,082.59
$1,218.99
$1,703.54
$2,588.69
$1,683.52
$1,812.27
$1,948.67
$2,433.22
$2,413.20
$2,541.95
$2,678.35
$3,162.90
$3,142.88
$3,271.63
$3,408.03
$3,892.58
$729.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,907.68
$2,165.18
$2,437.98
$3,407.08
$5,177.38
$2,637.36
$2,894.86
$3,167.66
$4,136.76
$3,367.04
$3,624.54
$3,897.34
$4,866.44
$4,096.72
$4,354.22
$4,627.02
$5,596.12
$729.68

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #35 Aetna CVS Health
Expanded Bronze

(HMO) 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
$306.70
$348.10
$391.96
$547.76
$832.38
$541.32
$582.72
$626.58
$782.38
$775.94
$817.34
$861.20
$1,017.00
$1,010.56
$1,051.96
$1,095.82
$1,251.62
$234.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$613.40
$696.20
$783.92
$1,095.52
$1,664.76
$848.02
$930.82
$1,018.54
$1,330.14
$1,082.64
$1,165.44
$1,253.16
$1,564.76
$1,317.26
$1,400.06
$1,487.78
$1,799.38
$234.62
Toc - Plan #36 Aetna CVS Health
Expanded Bronze

(HMO) 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
$8,800 $17,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.98
$313.24
$352.71
$492.91
$749.02
$487.11
$524.37
$563.84
$704.04
$698.24
$735.50
$774.97
$915.17
$909.37
$946.63
$986.10
$1,126.30
$211.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$551.96
$626.48
$705.42
$985.82
$1,498.04
$763.09
$837.61
$916.55
$1,196.95
$974.22
$1,048.74
$1,127.68
$1,408.08
$1,185.35
$1,259.87
$1,338.81
$1,619.21
$211.13
Toc - Plan #37 Aetna CVS Health
Gold

(HMO) 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
$452.62
$513.72
$578.44
$808.37
$1,228.40
$798.87
$859.97
$924.69
$1,154.62
$1,145.12
$1,206.22
$1,270.94
$1,500.87
$1,491.37
$1,552.47
$1,617.19
$1,847.12
$346.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$905.24
$1,027.44
$1,156.88
$1,616.74
$2,456.80
$1,251.49
$1,373.69
$1,503.13
$1,962.99
$1,597.74
$1,719.94
$1,849.38
$2,309.24
$1,943.99
$2,066.19
$2,195.63
$2,655.49
$346.25
Toc - Plan #38 Aetna CVS Health
Silver

(HMO) 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
$4,300 $8,600 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
$424.75
$482.09
$542.83
$758.60
$1,152.77
$749.68
$807.02
$867.76
$1,083.53
$1,074.61
$1,131.95
$1,192.69
$1,408.46
$1,399.54
$1,456.88
$1,517.62
$1,733.39
$324.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.50
$964.18
$1,085.66
$1,517.20
$2,305.54
$1,174.43
$1,289.11
$1,410.59
$1,842.13
$1,499.36
$1,614.04
$1,735.52
$2,167.06
$1,824.29
$1,938.97
$2,060.45
$2,491.99
$324.93
Toc - Plan #39 Aetna CVS Health
Silver

(HMO) 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
$8,000 $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
$403.16
$457.58
$515.23
$720.04
$1,094.17
$711.57
$765.99
$823.64
$1,028.45
$1,019.98
$1,074.40
$1,132.05
$1,336.86
$1,328.39
$1,382.81
$1,440.46
$1,645.27
$308.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.32
$915.16
$1,030.46
$1,440.08
$2,188.34
$1,114.73
$1,223.57
$1,338.87
$1,748.49
$1,423.14
$1,531.98
$1,647.28
$2,056.90
$1,731.55
$1,840.39
$1,955.69
$2,365.31
$308.41
Toc - Plan #40 Aetna CVS Health
Expanded Bronze

(HMO) 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
$286.04
$324.65
$365.56
$510.86
$776.31
$504.86
$543.47
$584.38
$729.68
$723.68
$762.29
$803.20
$948.50
$942.50
$981.11
$1,022.02
$1,167.32
$218.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$572.08
$649.30
$731.12
$1,021.72
$1,552.62
$790.90
$868.12
$949.94
$1,240.54
$1,009.72
$1,086.94
$1,168.76
$1,459.36
$1,228.54
$1,305.76
$1,387.58
$1,678.18
$218.82
Toc - Plan #41 Aetna CVS Health
Gold

(HMO) 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
$444.28
$504.26
$567.79
$793.48
$1,205.78
$784.15
$844.13
$907.66
$1,133.35
$1,124.02
$1,184.00
$1,247.53
$1,473.22
$1,463.89
$1,523.87
$1,587.40
$1,813.09
$339.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.56
$1,008.52
$1,135.58
$1,586.96
$2,411.56
$1,228.43
$1,348.39
$1,475.45
$1,926.83
$1,568.30
$1,688.26
$1,815.32
$2,266.70
$1,908.17
$2,028.13
$2,155.19
$2,606.57
$339.87
Toc - Plan #42 Aetna CVS Health
Silver

(HMO) 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
$6,500 $13,000 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
$417.01
$473.31
$532.94
$744.79
$1,131.78
$736.03
$792.33
$851.96
$1,063.81
$1,055.05
$1,111.35
$1,170.98
$1,382.83
$1,374.07
$1,430.37
$1,490.00
$1,701.85
$319.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.02
$946.62
$1,065.88
$1,489.58
$2,263.56
$1,153.04
$1,265.64
$1,384.90
$1,808.60
$1,472.06
$1,584.66
$1,703.92
$2,127.62
$1,791.08
$1,903.68
$2,022.94
$2,446.64
$319.02
Toc - Plan #43 Aetna CVS Health
Silver

(HMO) 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
$393.73
$446.88
$503.19
$703.20
$1,068.58
$694.93
$748.08
$804.39
$1,004.40
$996.13
$1,049.28
$1,105.59
$1,305.60
$1,297.33
$1,350.48
$1,406.79
$1,606.80
$301.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.46
$893.76
$1,006.38
$1,406.40
$2,137.16
$1,088.66
$1,194.96
$1,307.58
$1,707.60
$1,389.86
$1,496.16
$1,608.78
$2,008.80
$1,691.06
$1,797.36
$1,909.98
$2,310.00
$301.20

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310 | TTY: 1-833-863-1310

Toc - Plan #44 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$296.73
$336.77
$379.20
$529.93
$805.29
$523.72
$563.76
$606.19
$756.92
$750.71
$790.75
$833.18
$983.91
$977.70
$1,017.74
$1,060.17
$1,210.90
$226.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$593.46
$673.54
$758.40
$1,059.86
$1,610.58
$820.45
$900.53
$985.39
$1,286.85
$1,047.44
$1,127.52
$1,212.38
$1,513.84
$1,274.43
$1,354.51
$1,439.37
$1,740.83
$226.99
Toc - Plan #45 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$326.30
$370.34
$417.00
$582.75
$885.55
$575.91
$619.95
$666.61
$832.36
$825.52
$869.56
$916.22
$1,081.97
$1,075.13
$1,119.17
$1,165.83
$1,331.58
$249.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$652.60
$740.68
$834.00
$1,165.50
$1,771.10
$902.21
$990.29
$1,083.61
$1,415.11
$1,151.82
$1,239.90
$1,333.22
$1,664.72
$1,401.43
$1,489.51
$1,582.83
$1,914.33
$249.61
Toc - Plan #46 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$316.60
$359.33
$404.61
$565.44
$859.23
$558.79
$601.52
$646.80
$807.63
$800.98
$843.71
$888.99
$1,049.82
$1,043.17
$1,085.90
$1,131.18
$1,292.01
$242.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$633.20
$718.66
$809.22
$1,130.88
$1,718.46
$875.39
$960.85
$1,051.41
$1,373.07
$1,117.58
$1,203.04
$1,293.60
$1,615.26
$1,359.77
$1,445.23
$1,535.79
$1,857.45
$242.19
Toc - Plan #47 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$356.28
$404.36
$455.31
$636.29
$966.91
$628.82
$676.90
$727.85
$908.83
$901.36
$949.44
$1,000.39
$1,181.37
$1,173.90
$1,221.98
$1,272.93
$1,453.91
$272.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$712.56
$808.72
$910.62
$1,272.58
$1,933.82
$985.10
$1,081.26
$1,183.16
$1,545.12
$1,257.64
$1,353.80
$1,455.70
$1,817.66
$1,530.18
$1,626.34
$1,728.24
$2,090.20
$272.54
Toc - Plan #48 Ambetter of North Carolina
Silver

(HMO) Complete Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$402.39
$456.70
$514.24
$718.65
$1,092.06
$710.21
$764.52
$822.06
$1,026.47
$1,018.03
$1,072.34
$1,129.88
$1,334.29
$1,325.85
$1,380.16
$1,437.70
$1,642.11
$307.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$804.78
$913.40
$1,028.48
$1,437.30
$2,184.12
$1,112.60
$1,221.22
$1,336.30
$1,745.12
$1,420.42
$1,529.04
$1,644.12
$2,052.94
$1,728.24
$1,836.86
$1,951.94
$2,360.76
$307.82
Toc - Plan #49 Ambetter of North Carolina
Silver

(HMO) Everyday Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.65
$452.45
$509.46
$711.97
$1,081.91
$703.61
$757.41
$814.42
$1,016.93
$1,008.57
$1,062.37
$1,119.38
$1,321.89
$1,313.53
$1,367.33
$1,424.34
$1,626.85
$304.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$797.30
$904.90
$1,018.92
$1,423.94
$2,163.82
$1,102.26
$1,209.86
$1,323.88
$1,728.90
$1,407.22
$1,514.82
$1,628.84
$2,033.86
$1,712.18
$1,819.78
$1,933.80
$2,338.82
$304.96
Toc - Plan #50 Ambetter of North Carolina
Silver

(HMO) Clear Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$397.60
$451.27
$508.12
$710.10
$1,079.07
$701.76
$755.43
$812.28
$1,014.26
$1,005.92
$1,059.59
$1,116.44
$1,318.42
$1,310.08
$1,363.75
$1,420.60
$1,622.58
$304.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.20
$902.54
$1,016.24
$1,420.20
$2,158.14
$1,099.36
$1,206.70
$1,320.40
$1,724.36
$1,403.52
$1,510.86
$1,624.56
$2,028.52
$1,707.68
$1,815.02
$1,928.72
$2,332.68
$304.16
Toc - Plan #51 Ambetter of North Carolina
Silver

(HMO) Focused Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$397.76
$451.45
$508.33
$710.39
$1,079.50
$702.04
$755.73
$812.61
$1,014.67
$1,006.32
$1,060.01
$1,116.89
$1,318.95
$1,310.60
$1,364.29
$1,421.17
$1,623.23
$304.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.52
$902.90
$1,016.66
$1,420.78
$2,159.00
$1,099.80
$1,207.18
$1,320.94
$1,725.06
$1,404.08
$1,511.46
$1,625.22
$2,029.34
$1,708.36
$1,815.74
$1,929.50
$2,333.62
$304.28
Toc - Plan #52 Ambetter of North Carolina
Gold

(HMO) Complete Gold with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$419.77
$476.43
$536.46
$749.70
$1,139.24
$740.89
$797.55
$857.58
$1,070.82
$1,062.01
$1,118.67
$1,178.70
$1,391.94
$1,383.13
$1,439.79
$1,499.82
$1,713.06
$321.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$839.54
$952.86
$1,072.92
$1,499.40
$2,278.48
$1,160.66
$1,273.98
$1,394.04
$1,820.52
$1,481.78
$1,595.10
$1,715.16
$2,141.64
$1,802.90
$1,916.22
$2,036.28
$2,462.76
$321.12
Toc - Plan #53 Ambetter of North Carolina
Expanded Bronze

(HMO) CMS Standard Expanded Bronze with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$310.45
$352.35
$396.74
$554.44
$842.53
$547.93
$589.83
$634.22
$791.92
$785.41
$827.31
$871.70
$1,029.40
$1,022.89
$1,064.79
$1,109.18
$1,266.88
$237.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.90
$704.70
$793.48
$1,108.88
$1,685.06
$858.38
$942.18
$1,030.96
$1,346.36
$1,095.86
$1,179.66
$1,268.44
$1,583.84
$1,333.34
$1,417.14
$1,505.92
$1,821.32
$237.48
Toc - Plan #54 Ambetter of North Carolina
Silver

(HMO) CMS Standard Silver with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$393.70
$446.84
$503.13
$703.13
$1,068.47
$694.87
$748.01
$804.30
$1,004.30
$996.04
$1,049.18
$1,105.47
$1,305.47
$1,297.21
$1,350.35
$1,406.64
$1,606.64
$301.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.40
$893.68
$1,006.26
$1,406.26
$2,136.94
$1,088.57
$1,194.85
$1,307.43
$1,707.43
$1,389.74
$1,496.02
$1,608.60
$2,008.60
$1,690.91
$1,797.19
$1,909.77
$2,309.77
$301.17
Toc - Plan #55 Ambetter of North Carolina
Gold

(HMO) CMS Standard Gold with Atrium Health

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$398.41
$452.18
$509.15
$711.54
$1,081.25
$703.18
$756.95
$813.92
$1,016.31
$1,007.95
$1,061.72
$1,118.69
$1,321.08
$1,312.72
$1,366.49
$1,423.46
$1,625.85
$304.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.82
$904.36
$1,018.30
$1,423.08
$2,162.50
$1,101.59
$1,209.13
$1,323.07
$1,727.85
$1,406.36
$1,513.90
$1,627.84
$2,032.62
$1,711.13
$1,818.67
$1,932.61
$2,337.39
$304.77
Toc - Plan #56 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$309.22
$350.96
$395.17
$552.25
$839.20
$545.77
$587.51
$631.72
$788.80
$782.32
$824.06
$868.27
$1,025.35
$1,018.87
$1,060.61
$1,104.82
$1,261.90
$236.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.44
$701.92
$790.34
$1,104.50
$1,678.40
$854.99
$938.47
$1,026.89
$1,341.05
$1,091.54
$1,175.02
$1,263.44
$1,577.60
$1,328.09
$1,411.57
$1,499.99
$1,814.15
$236.55
Toc - Plan #57 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$340.04
$385.94
$434.56
$607.30
$922.85
$600.17
$646.07
$694.69
$867.43
$860.30
$906.20
$954.82
$1,127.56
$1,120.43
$1,166.33
$1,214.95
$1,387.69
$260.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.08
$771.88
$869.12
$1,214.60
$1,845.70
$940.21
$1,032.01
$1,129.25
$1,474.73
$1,200.34
$1,292.14
$1,389.38
$1,734.86
$1,460.47
$1,552.27
$1,649.51
$1,994.99
$260.13
Toc - Plan #58 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$329.94
$374.47
$421.65
$589.25
$895.42
$582.33
$626.86
$674.04
$841.64
$834.72
$879.25
$926.43
$1,094.03
$1,087.11
$1,131.64
$1,178.82
$1,346.42
$252.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$659.88
$748.94
$843.30
$1,178.50
$1,790.84
$912.27
$1,001.33
$1,095.69
$1,430.89
$1,164.66
$1,253.72
$1,348.08
$1,683.28
$1,417.05
$1,506.11
$1,600.47
$1,935.67
$252.39
Toc - Plan #59 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$371.28
$421.40
$474.49
$663.10
$1,007.64
$655.30
$705.42
$758.51
$947.12
$939.32
$989.44
$1,042.53
$1,231.14
$1,223.34
$1,273.46
$1,326.55
$1,515.16
$284.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$742.56
$842.80
$948.98
$1,326.20
$2,015.28
$1,026.58
$1,126.82
$1,233.00
$1,610.22
$1,310.60
$1,410.84
$1,517.02
$1,894.24
$1,594.62
$1,694.86
$1,801.04
$2,178.26
$284.02
Toc - Plan #60 Ambetter of North Carolina
Silver

(HMO) Complete Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$419.34
$475.94
$535.90
$748.92
$1,138.06
$740.13
$796.73
$856.69
$1,069.71
$1,060.92
$1,117.52
$1,177.48
$1,390.50
$1,381.71
$1,438.31
$1,498.27
$1,711.29
$320.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838.68
$951.88
$1,071.80
$1,497.84
$2,276.12
$1,159.47
$1,272.67
$1,392.59
$1,818.63
$1,480.26
$1,593.46
$1,713.38
$2,139.42
$1,801.05
$1,914.25
$2,034.17
$2,460.21
$320.79
Toc - Plan #61 Ambetter of North Carolina
Silver

(HMO) Everyday Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.44
$471.51
$530.92
$741.96
$1,127.47
$733.24
$789.31
$848.72
$1,059.76
$1,051.04
$1,107.11
$1,166.52
$1,377.56
$1,368.84
$1,424.91
$1,484.32
$1,695.36
$317.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.88
$943.02
$1,061.84
$1,483.92
$2,254.94
$1,148.68
$1,260.82
$1,379.64
$1,801.72
$1,466.48
$1,578.62
$1,697.44
$2,119.52
$1,784.28
$1,896.42
$2,015.24
$2,437.32
$317.80
Toc - Plan #62 Ambetter of North Carolina
Silver

(HMO) Clear Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$414.35
$470.27
$529.53
$740.01
$1,124.52
$731.32
$787.24
$846.50
$1,056.98
$1,048.29
$1,104.21
$1,163.47
$1,373.95
$1,365.26
$1,421.18
$1,480.44
$1,690.92
$316.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828.70
$940.54
$1,059.06
$1,480.02
$2,249.04
$1,145.67
$1,257.51
$1,376.03
$1,796.99
$1,462.64
$1,574.48
$1,693.00
$2,113.96
$1,779.61
$1,891.45
$2,009.97
$2,430.93
$316.97
Toc - Plan #63 Ambetter of North Carolina
Silver

(HMO) Focused Silver with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$414.52
$470.47
$529.74
$740.31
$1,124.97
$731.62
$787.57
$846.84
$1,057.41
$1,048.72
$1,104.67
$1,163.94
$1,374.51
$1,365.82
$1,421.77
$1,481.04
$1,691.61
$317.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$829.04
$940.94
$1,059.48
$1,480.62
$2,249.94
$1,146.14
$1,258.04
$1,376.58
$1,797.72
$1,463.24
$1,575.14
$1,693.68
$2,114.82
$1,780.34
$1,892.24
$2,010.78
$2,431.92
$317.10
Toc - Plan #64 Ambetter of North Carolina
Gold

(HMO) Complete Gold with Atrium Health + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-863-1310

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
$437.45
$496.50
$559.05
$781.27
$1,187.22
$772.09
$831.14
$893.69
$1,115.91
$1,106.73
$1,165.78
$1,228.33
$1,450.55
$1,441.37
$1,500.42
$1,562.97
$1,785.19
$334.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.90
$993.00
$1,118.10
$1,562.54
$2,374.44
$1,209.54
$1,327.64
$1,452.74
$1,897.18
$1,544.18
$1,662.28
$1,787.38
$2,231.82
$1,878.82
$1,996.92
$2,122.02
$2,566.46
$334.64

ADVERTISEMENT

Friday Health Plans

Local: 1-844-465-5500 | Toll Free: 1-844-465-5500 | TTY: 1-800-659-2656

Toc - Plan #65 Friday Health Plans
Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$228.58
$259.44
$292.13
$408.25
$620.37
$403.44
$434.30
$466.99
$583.11
$578.30
$609.16
$641.85
$757.97
$753.16
$784.02
$816.71
$932.83
$174.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$457.16
$518.88
$584.26
$816.50
$1,240.74
$632.02
$693.74
$759.12
$991.36
$806.88
$868.60
$933.98
$1,166.22
$981.74
$1,043.46
$1,108.84
$1,341.08
$174.86
Toc - Plan #66 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$299.66
$340.11
$382.96
$535.18
$813.27
$528.90
$569.35
$612.20
$764.42
$758.14
$798.59
$841.44
$993.66
$987.38
$1,027.83
$1,070.68
$1,222.90
$229.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$599.32
$680.22
$765.92
$1,070.36
$1,626.54
$828.56
$909.46
$995.16
$1,299.60
$1,057.80
$1,138.70
$1,224.40
$1,528.84
$1,287.04
$1,367.94
$1,453.64
$1,758.08
$229.24
Toc - Plan #67 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$302.67
$343.53
$386.81
$540.57
$821.44
$534.21
$575.07
$618.35
$772.11
$765.75
$806.61
$849.89
$1,003.65
$997.29
$1,038.15
$1,081.43
$1,235.19
$231.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$605.34
$687.06
$773.62
$1,081.14
$1,642.88
$836.88
$918.60
$1,005.16
$1,312.68
$1,068.42
$1,150.14
$1,236.70
$1,544.22
$1,299.96
$1,381.68
$1,468.24
$1,775.76
$231.54
Toc - Plan #68 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$319.97
$363.16
$408.92
$571.46
$868.39
$564.74
$607.93
$653.69
$816.23
$809.51
$852.70
$898.46
$1,061.00
$1,054.28
$1,097.47
$1,143.23
$1,305.77
$244.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.94
$726.32
$817.84
$1,142.92
$1,736.78
$884.71
$971.09
$1,062.61
$1,387.69
$1,129.48
$1,215.86
$1,307.38
$1,632.46
$1,374.25
$1,460.63
$1,552.15
$1,877.23
$244.77
Toc - Plan #69 Friday Health Plans
Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$417.46
$473.82
$533.51
$745.58
$1,132.99
$736.82
$793.18
$852.87
$1,064.94
$1,056.18
$1,112.54
$1,172.23
$1,384.30
$1,375.54
$1,431.90
$1,491.59
$1,703.66
$319.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.92
$947.64
$1,067.02
$1,491.16
$2,265.98
$1,154.28
$1,267.00
$1,386.38
$1,810.52
$1,473.64
$1,586.36
$1,705.74
$2,129.88
$1,793.00
$1,905.72
$2,025.10
$2,449.24
$319.36
Toc - Plan #70 Friday Health Plans
Gold

(HMO) Friday Gold + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 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
$438.89
$498.14
$560.90
$783.85
$1,191.14
$774.64
$833.89
$896.65
$1,119.60
$1,110.39
$1,169.64
$1,232.40
$1,455.35
$1,446.14
$1,505.39
$1,568.15
$1,791.10
$335.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.78
$996.28
$1,121.80
$1,567.70
$2,382.28
$1,213.53
$1,332.03
$1,457.55
$1,903.45
$1,549.28
$1,667.78
$1,793.30
$2,239.20
$1,885.03
$2,003.53
$2,129.05
$2,574.95
$335.75
Toc - Plan #71 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$299.44
$339.86
$382.68
$534.80
$812.68
$528.51
$568.93
$611.75
$763.87
$757.58
$798.00
$840.82
$992.94
$986.65
$1,027.07
$1,069.89
$1,222.01
$229.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.88
$679.72
$765.36
$1,069.60
$1,625.36
$827.95
$908.79
$994.43
$1,298.67
$1,057.02
$1,137.86
$1,223.50
$1,527.74
$1,286.09
$1,366.93
$1,452.57
$1,756.81
$229.07
Toc - Plan #72 Friday Health Plans
Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$428.51
$486.36
$547.64
$765.32
$1,162.98
$756.32
$814.17
$875.45
$1,093.13
$1,084.13
$1,141.98
$1,203.26
$1,420.94
$1,411.94
$1,469.79
$1,531.07
$1,748.75
$327.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.02
$972.72
$1,095.28
$1,530.64
$2,325.96
$1,184.83
$1,300.53
$1,423.09
$1,858.45
$1,512.64
$1,628.34
$1,750.90
$2,186.26
$1,840.45
$1,956.15
$2,078.71
$2,514.07
$327.81
Toc - Plan #73 Friday Health Plans
Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 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
$455.95
$517.51
$582.71
$814.33
$1,237.46
$804.76
$866.32
$931.52
$1,163.14
$1,153.57
$1,215.13
$1,280.33
$1,511.95
$1,502.38
$1,563.94
$1,629.14
$1,860.76
$348.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$911.90
$1,035.02
$1,165.42
$1,628.66
$2,474.92
$1,260.71
$1,383.83
$1,514.23
$1,977.47
$1,609.52
$1,732.64
$1,863.04
$2,326.28
$1,958.33
$2,081.45
$2,211.85
$2,675.09
$348.81
Toc - Plan #74 Friday Health Plans
Bronze

(HMO) Friday Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$299.28
$339.68
$382.47
$534.51
$812.24
$528.23
$568.63
$611.42
$763.46
$757.18
$797.58
$840.37
$992.41
$986.13
$1,026.53
$1,069.32
$1,221.36
$228.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.56
$679.36
$764.94
$1,069.02
$1,624.48
$827.51
$908.31
$993.89
$1,297.97
$1,056.46
$1,137.26
$1,222.84
$1,526.92
$1,285.41
$1,366.21
$1,451.79
$1,755.87
$228.95
Toc - Plan #75 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$302.29
$343.10
$386.33
$539.89
$820.41
$533.54
$574.35
$617.58
$771.14
$764.79
$805.60
$848.83
$1,002.39
$996.04
$1,036.85
$1,080.08
$1,233.64
$231.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$604.58
$686.20
$772.66
$1,079.78
$1,640.82
$835.83
$917.45
$1,003.91
$1,311.03
$1,067.08
$1,148.70
$1,235.16
$1,542.28
$1,298.33
$1,379.95
$1,466.41
$1,773.53
$231.25
Toc - Plan #76 Friday Health Plans
Expanded Bronze

(HMO) Friday Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$299.06
$339.43
$382.20
$534.12
$811.65
$527.84
$568.21
$610.98
$762.90
$756.62
$796.99
$839.76
$991.68
$985.40
$1,025.77
$1,068.54
$1,220.46
$228.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.12
$678.86
$764.40
$1,068.24
$1,623.30
$826.90
$907.64
$993.18
$1,297.02
$1,055.68
$1,136.42
$1,221.96
$1,525.80
$1,284.46
$1,365.20
$1,450.74
$1,754.58
$228.78
Toc - Plan #77 Friday Health Plans
Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$417.08
$473.39
$533.03
$744.91
$1,131.96
$736.15
$792.46
$852.10
$1,063.98
$1,055.22
$1,111.53
$1,171.17
$1,383.05
$1,374.29
$1,430.60
$1,490.24
$1,702.12
$319.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.16
$946.78
$1,066.06
$1,489.82
$2,263.92
$1,153.23
$1,265.85
$1,385.13
$1,808.89
$1,472.30
$1,584.92
$1,704.20
$2,127.96
$1,791.37
$1,903.99
$2,023.27
$2,447.03
$319.07
Toc - Plan #78 Friday Health Plans
Silver

(HMO) Friday Silver HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$422.16
$479.15
$539.52
$753.97
$1,145.73
$745.11
$802.10
$862.47
$1,076.92
$1,068.06
$1,125.05
$1,185.42
$1,399.87
$1,391.01
$1,448.00
$1,508.37
$1,722.82
$322.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$844.32
$958.30
$1,079.04
$1,507.94
$2,291.46
$1,167.27
$1,281.25
$1,401.99
$1,830.89
$1,490.22
$1,604.20
$1,724.94
$2,153.84
$1,813.17
$1,927.15
$2,047.89
$2,476.79
$322.95
Toc - Plan #79 Friday Health Plans
Silver

(HMO) Friday Silver Zero Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$430.86
$489.03
$550.64
$769.52
$1,169.36
$760.47
$818.64
$880.25
$1,099.13
$1,090.08
$1,148.25
$1,209.86
$1,428.74
$1,419.69
$1,477.86
$1,539.47
$1,758.35
$329.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$861.72
$978.06
$1,101.28
$1,539.04
$2,338.72
$1,191.33
$1,307.67
$1,430.89
$1,868.65
$1,520.94
$1,637.28
$1,760.50
$2,198.26
$1,850.55
$1,966.89
$2,090.11
$2,527.87
$329.61
Toc - Plan #80 Friday Health Plans
Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$428.13
$485.93
$547.15
$764.64
$1,161.95
$755.65
$813.45
$874.67
$1,092.16
$1,083.17
$1,140.97
$1,202.19
$1,419.68
$1,410.69
$1,468.49
$1,529.71
$1,747.20
$327.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$856.26
$971.86
$1,094.30
$1,529.28
$2,323.90
$1,183.78
$1,299.38
$1,421.82
$1,856.80
$1,511.30
$1,626.90
$1,749.34
$2,184.32
$1,838.82
$1,954.42
$2,076.86
$2,511.84
$327.52
Toc - Plan #81 Friday Health Plans
Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,250 $16,500 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
$438.51
$497.71
$560.41
$783.17
$1,190.11
$773.97
$833.17
$895.87
$1,118.63
$1,109.43
$1,168.63
$1,231.33
$1,454.09
$1,444.89
$1,504.09
$1,566.79
$1,789.55
$335.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$877.02
$995.42
$1,120.82
$1,566.34
$2,380.22
$1,212.48
$1,330.88
$1,456.28
$1,901.80
$1,547.94
$1,666.34
$1,791.74
$2,237.26
$1,883.40
$2,001.80
$2,127.20
$2,572.72
$335.46
Toc - Plan #82 Friday Health Plans
Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family
$2,300 $4,600 Annual Deductible
$8,250 $16,500 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
$455.57
$517.08
$582.22
$813.66
$1,236.43
$804.08
$865.59
$930.73
$1,162.17
$1,152.59
$1,214.10
$1,279.24
$1,510.68
$1,501.10
$1,562.61
$1,627.75
$1,859.19
$348.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$911.14
$1,034.16
$1,164.44
$1,627.32
$2,472.86
$1,259.65
$1,382.67
$1,512.95
$1,975.83
$1,608.16
$1,731.18
$1,861.46
$2,324.34
$1,956.67
$2,079.69
$2,209.97
$2,672.85
$348.51
Toc - Plan #83 Friday Health Plans
Bronze

(HMO) Friday Standard Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$299.28
$339.68
$382.47
$534.51
$812.24
$528.23
$568.63
$611.42
$763.46
$757.18
$797.58
$840.37
$992.41
$986.13
$1,026.53
$1,069.32
$1,221.36
$228.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$598.56
$679.36
$764.94
$1,069.02
$1,624.48
$827.51
$908.31
$993.89
$1,297.97
$1,056.46
$1,137.26
$1,222.84
$1,526.92
$1,285.41
$1,366.21
$1,451.79
$1,755.87
$228.95
Toc - Plan #84 Friday Health Plans
Expanded Bronze

(HMO) Friday Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$297.64
$337.82
$380.39
$531.59
$807.80
$525.34
$565.52
$608.09
$759.29
$753.04
$793.22
$835.79
$986.99
$980.74
$1,020.92
$1,063.49
$1,214.69
$227.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.28
$675.64
$760.78
$1,063.18
$1,615.60
$822.98
$903.34
$988.48
$1,290.88
$1,050.68
$1,131.04
$1,216.18
$1,518.58
$1,278.38
$1,358.74
$1,443.88
$1,746.28
$227.70
Toc - Plan #85 Friday Health Plans
Silver

(HMO) Friday Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$413.78
$469.64
$528.81
$739.01
$1,123.00
$730.32
$786.18
$845.35
$1,055.55
$1,046.86
$1,102.72
$1,161.89
$1,372.09
$1,363.40
$1,419.26
$1,478.43
$1,688.63
$316.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$827.56
$939.28
$1,057.62
$1,478.02
$2,246.00
$1,144.10
$1,255.82
$1,374.16
$1,794.56
$1,460.64
$1,572.36
$1,690.70
$2,111.10
$1,777.18
$1,888.90
$2,007.24
$2,427.64
$316.54
Toc - Plan #86 Friday Health Plans
Gold

(HMO) Friday Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-844-465-5500

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
$453.67
$514.91
$579.79
$810.25
$1,231.25
$800.72
$861.96
$926.84
$1,157.30
$1,147.77
$1,209.01
$1,273.89
$1,504.35
$1,494.82
$1,556.06
$1,620.94
$1,851.40
$347.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$907.34
$1,029.82
$1,159.58
$1,620.50
$2,462.50
$1,254.39
$1,376.87
$1,506.63
$1,967.55
$1,601.44
$1,723.92
$1,853.68
$2,314.60
$1,948.49
$2,070.97
$2,200.73
$2,661.65
$347.05

‡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 Cleveland County here.

Cleveland County is in “Rating Area 5” of North Carolina.

Currently, there are 86 plans offered in Rating Area 5.

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2023 Obamacare Plans for Cleveland County, NC

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