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Obamacare 2023 Rates for Cumberland County

Obamacare > Rates > North Carolina > Cumberland 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 Cumberland 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, 87 Plans and 2023 Rates for Cumberland County, North Carolina

Below, you’ll find a summary of the 87 plans for Cumberland 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

(PPO) Blue Advantage Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Nationwide 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
$535.39
$607.67
$684.23
$956.21
$1,453.05
$944.96
$1,017.24
$1,093.80
$1,365.78
$1,354.53
$1,426.81
$1,503.37
$1,775.35
$1,764.10
$1,836.38
$1,912.94
$2,184.92
$409.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,070.78
$1,215.34
$1,368.46
$1,912.42
$2,906.10
$1,480.35
$1,624.91
$1,778.03
$2,321.99
$1,889.92
$2,034.48
$2,187.60
$2,731.56
$2,299.49
$2,444.05
$2,597.17
$3,141.13
$409.57
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide 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
$550.33
$624.62
$703.32
$982.89
$1,493.60
$971.33
$1,045.62
$1,124.32
$1,403.89
$1,392.33
$1,466.62
$1,545.32
$1,824.89
$1,813.33
$1,887.62
$1,966.32
$2,245.89
$421.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,100.66
$1,249.24
$1,406.64
$1,965.78
$2,987.20
$1,521.66
$1,670.24
$1,827.64
$2,386.78
$1,942.66
$2,091.24
$2,248.64
$2,807.78
$2,363.66
$2,512.24
$2,669.64
$3,228.78
$421.00
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Simple | $0 Deductible | 3 Free PCP | Nationwide 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
$562.85
$638.83
$719.32
$1,005.25
$1,527.57
$993.43
$1,069.41
$1,149.90
$1,435.83
$1,424.01
$1,499.99
$1,580.48
$1,866.41
$1,854.59
$1,930.57
$2,011.06
$2,296.99
$430.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,125.70
$1,277.66
$1,438.64
$2,010.50
$3,055.14
$1,556.28
$1,708.24
$1,869.22
$2,441.08
$1,986.86
$2,138.82
$2,299.80
$2,871.66
$2,417.44
$2,569.40
$2,730.38
$3,302.24
$430.58
Toc - Plan #4 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide 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
$521.13
$591.48
$666.00
$930.74
$1,414.35
$919.79
$990.14
$1,064.66
$1,329.40
$1,318.45
$1,388.80
$1,463.32
$1,728.06
$1,717.11
$1,787.46
$1,861.98
$2,126.72
$398.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,042.26
$1,182.96
$1,332.00
$1,861.48
$2,828.70
$1,440.92
$1,581.62
$1,730.66
$2,260.14
$1,839.58
$1,980.28
$2,129.32
$2,658.80
$2,238.24
$2,378.94
$2,527.98
$3,057.46
$398.66
Toc - Plan #5 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide 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
$541.88
$615.03
$692.52
$967.80
$1,470.66
$956.42
$1,029.57
$1,107.06
$1,382.34
$1,370.96
$1,444.11
$1,521.60
$1,796.88
$1,785.50
$1,858.65
$1,936.14
$2,211.42
$414.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,083.76
$1,230.06
$1,385.04
$1,935.60
$2,941.32
$1,498.30
$1,644.60
$1,799.58
$2,350.14
$1,912.84
$2,059.14
$2,214.12
$2,764.68
$2,327.38
$2,473.68
$2,628.66
$3,179.22
$414.54
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide 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
$544.07
$617.52
$695.32
$971.71
$1,476.61
$960.28
$1,033.73
$1,111.53
$1,387.92
$1,376.49
$1,449.94
$1,527.74
$1,804.13
$1,792.70
$1,866.15
$1,943.95
$2,220.34
$416.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,088.14
$1,235.04
$1,390.64
$1,943.42
$2,953.22
$1,504.35
$1,651.25
$1,806.85
$2,359.63
$1,920.56
$2,067.46
$2,223.06
$2,775.84
$2,336.77
$2,483.67
$2,639.27
$3,192.05
$416.21
Toc - Plan #7 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide 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
$401.99
$456.26
$513.74
$717.95
$1,091.00
$709.51
$763.78
$821.26
$1,025.47
$1,017.03
$1,071.30
$1,128.78
$1,332.99
$1,324.55
$1,378.82
$1,436.30
$1,640.51
$307.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.98
$912.52
$1,027.48
$1,435.90
$2,182.00
$1,111.50
$1,220.04
$1,335.00
$1,743.42
$1,419.02
$1,527.56
$1,642.52
$2,050.94
$1,726.54
$1,835.08
$1,950.04
$2,358.46
$307.52
Toc - Plan #8 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide 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
$380.40
$431.75
$486.15
$679.39
$1,032.41
$671.41
$722.76
$777.16
$970.40
$962.42
$1,013.77
$1,068.17
$1,261.41
$1,253.43
$1,304.78
$1,359.18
$1,552.42
$291.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.80
$863.50
$972.30
$1,358.78
$2,064.82
$1,051.81
$1,154.51
$1,263.31
$1,649.79
$1,342.82
$1,445.52
$1,554.32
$1,940.80
$1,633.83
$1,736.53
$1,845.33
$2,231.81
$291.01
Toc - Plan #9 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide 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
$399.18
$453.07
$510.15
$712.94
$1,083.37
$704.55
$758.44
$815.52
$1,018.31
$1,009.92
$1,063.81
$1,120.89
$1,323.68
$1,315.29
$1,369.18
$1,426.26
$1,629.05
$305.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.36
$906.14
$1,020.30
$1,425.88
$2,166.74
$1,103.73
$1,211.51
$1,325.67
$1,731.25
$1,409.10
$1,516.88
$1,631.04
$2,036.62
$1,714.47
$1,822.25
$1,936.41
$2,341.99
$305.37
Toc - Plan #10 Blue Cross and Blue Shield of NC
Bronze

(PPO) Blue Advantage Bronze 9100 | Integrated | Nationwide 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
$381.13
$432.58
$487.08
$680.70
$1,034.39
$672.69
$724.14
$778.64
$972.26
$964.25
$1,015.70
$1,070.20
$1,263.82
$1,255.81
$1,307.26
$1,361.76
$1,555.38
$291.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$762.26
$865.16
$974.16
$1,361.40
$2,068.78
$1,053.82
$1,156.72
$1,265.72
$1,652.96
$1,345.38
$1,448.28
$1,557.28
$1,944.52
$1,636.94
$1,739.84
$1,848.84
$2,236.08
$291.56
Toc - Plan #11 Blue Cross and Blue Shield of NC
Catastrophic

(PPO) Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide 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
$279.52
$317.26
$357.23
$499.22
$758.62
$493.35
$531.09
$571.06
$713.05
$707.18
$744.92
$784.89
$926.88
$921.01
$958.75
$998.72
$1,140.71
$213.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$559.04
$634.52
$714.46
$998.44
$1,517.24
$772.87
$848.35
$928.29
$1,212.27
$986.70
$1,062.18
$1,142.12
$1,426.10
$1,200.53
$1,276.01
$1,355.95
$1,639.93
$213.83
Toc - Plan #12 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold Standard 2000 | Nationwide 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
$533.42
$605.43
$681.71
$952.69
$1,447.70
$941.49
$1,013.50
$1,089.78
$1,360.76
$1,349.56
$1,421.57
$1,497.85
$1,768.83
$1,757.63
$1,829.64
$1,905.92
$2,176.90
$408.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,066.84
$1,210.86
$1,363.42
$1,905.38
$2,895.40
$1,474.91
$1,618.93
$1,771.49
$2,313.45
$1,882.98
$2,027.00
$2,179.56
$2,721.52
$2,291.05
$2,435.07
$2,587.63
$3,129.59
$408.07
Toc - Plan #13 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Standard 5800 | Nationwide 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
$539.62
$612.47
$689.63
$963.76
$1,464.53
$952.43
$1,025.28
$1,102.44
$1,376.57
$1,365.24
$1,438.09
$1,515.25
$1,789.38
$1,778.05
$1,850.90
$1,928.06
$2,202.19
$412.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,079.24
$1,224.94
$1,379.26
$1,927.52
$2,929.06
$1,492.05
$1,637.75
$1,792.07
$2,340.33
$1,904.86
$2,050.56
$2,204.88
$2,753.14
$2,317.67
$2,463.37
$2,617.69
$3,165.95
$412.81
Toc - Plan #14 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze Standard 7500 | Nationwide 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
$380.85
$432.26
$486.73
$680.20
$1,033.63
$672.20
$723.61
$778.08
$971.55
$963.55
$1,014.96
$1,069.43
$1,262.90
$1,254.90
$1,306.31
$1,360.78
$1,554.25
$291.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$761.70
$864.52
$973.46
$1,360.40
$2,067.26
$1,053.05
$1,155.87
$1,264.81
$1,651.75
$1,344.40
$1,447.22
$1,556.16
$1,943.10
$1,635.75
$1,738.57
$1,847.51
$2,234.45
$291.35

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #15 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
$574.73
$652.31
$734.49
$1,026.45
$1,559.79
$1,014.39
$1,091.97
$1,174.15
$1,466.11
$1,454.05
$1,531.63
$1,613.81
$1,905.77
$1,893.71
$1,971.29
$2,053.47
$2,345.43
$439.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,149.46
$1,304.62
$1,468.98
$2,052.90
$3,119.58
$1,589.12
$1,744.28
$1,908.64
$2,492.56
$2,028.78
$2,183.94
$2,348.30
$2,932.22
$2,468.44
$2,623.60
$2,787.96
$3,371.88
$439.66
Toc - Plan #16 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
$737.30
$836.83
$942.26
$1,316.81
$2,001.02
$1,301.33
$1,400.86
$1,506.29
$1,880.84
$1,865.36
$1,964.89
$2,070.32
$2,444.87
$2,429.39
$2,528.92
$2,634.35
$3,008.90
$564.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,474.60
$1,673.66
$1,884.52
$2,633.62
$4,002.04
$2,038.63
$2,237.69
$2,448.55
$3,197.65
$2,602.66
$2,801.72
$3,012.58
$3,761.68
$3,166.69
$3,365.75
$3,576.61
$4,325.71
$564.03
Toc - Plan #17 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
$762.89
$865.87
$974.96
$1,362.50
$2,070.45
$1,346.49
$1,449.47
$1,558.56
$1,946.10
$1,930.09
$2,033.07
$2,142.16
$2,529.70
$2,513.69
$2,616.67
$2,725.76
$3,113.30
$583.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,525.78
$1,731.74
$1,949.92
$2,725.00
$4,140.90
$2,109.38
$2,315.34
$2,533.52
$3,308.60
$2,692.98
$2,898.94
$3,117.12
$3,892.20
$3,276.58
$3,482.54
$3,700.72
$4,475.80
$583.60
Toc - Plan #18 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
$575.69
$653.40
$735.72
$1,028.16
$1,562.39
$1,016.08
$1,093.79
$1,176.11
$1,468.55
$1,456.47
$1,534.18
$1,616.50
$1,908.94
$1,896.86
$1,974.57
$2,056.89
$2,349.33
$440.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,151.38
$1,306.80
$1,471.44
$2,056.32
$3,124.78
$1,591.77
$1,747.19
$1,911.83
$2,496.71
$2,032.16
$2,187.58
$2,352.22
$2,937.10
$2,472.55
$2,627.97
$2,792.61
$3,377.49
$440.39
Toc - Plan #19 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
$728.38
$826.70
$930.86
$1,300.87
$1,976.80
$1,285.59
$1,383.91
$1,488.07
$1,858.08
$1,842.80
$1,941.12
$2,045.28
$2,415.29
$2,400.01
$2,498.33
$2,602.49
$2,972.50
$557.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,456.76
$1,653.40
$1,861.72
$2,601.74
$3,953.60
$2,013.97
$2,210.61
$2,418.93
$3,158.95
$2,571.18
$2,767.82
$2,976.14
$3,716.16
$3,128.39
$3,325.03
$3,533.35
$4,273.37
$557.21
Toc - Plan #20 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
$741.80
$841.93
$948.01
$1,324.84
$2,013.22
$1,309.27
$1,409.40
$1,515.48
$1,892.31
$1,876.74
$1,976.87
$2,082.95
$2,459.78
$2,444.21
$2,544.34
$2,650.42
$3,027.25
$567.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,483.60
$1,683.86
$1,896.02
$2,649.68
$4,026.44
$2,051.07
$2,251.33
$2,463.49
$3,217.15
$2,618.54
$2,818.80
$3,030.96
$3,784.62
$3,186.01
$3,386.27
$3,598.43
$4,352.09
$567.47

ADVERTISEMENT

UnitedHealthcare

Local: 1-800-980-5357 | Toll Free: 1-800-980-5357 | TTY: 1-800-980-5357

Toc - Plan #21 UnitedHealthcare
Gold

(HMO) UHC Gold Value ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$470.97
$534.55
$601.90
$841.16
$1,278.22
$831.26
$894.84
$962.19
$1,201.45
$1,191.55
$1,255.13
$1,322.48
$1,561.74
$1,551.84
$1,615.42
$1,682.77
$1,922.03
$360.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$941.94
$1,069.10
$1,203.80
$1,682.32
$2,556.44
$1,302.23
$1,429.39
$1,564.09
$2,042.61
$1,662.52
$1,789.68
$1,924.38
$2,402.90
$2,022.81
$2,149.97
$2,284.67
$2,763.19
$360.29
Toc - Plan #22 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 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
$464.97
$527.74
$594.23
$830.43
$1,261.92
$820.67
$883.44
$949.93
$1,186.13
$1,176.37
$1,239.14
$1,305.63
$1,541.83
$1,532.07
$1,594.84
$1,661.33
$1,897.53
$355.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$929.94
$1,055.48
$1,188.46
$1,660.86
$2,523.84
$1,285.64
$1,411.18
$1,544.16
$2,016.56
$1,641.34
$1,766.88
$1,899.86
$2,372.26
$1,997.04
$2,122.58
$2,255.56
$2,727.96
$355.70
Toc - Plan #23 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,350 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$3,350 $6,700 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
$464.22
$526.89
$593.27
$829.10
$1,259.89
$819.35
$882.02
$948.40
$1,184.23
$1,174.48
$1,237.15
$1,303.53
$1,539.36
$1,529.61
$1,592.28
$1,658.66
$1,894.49
$355.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$928.44
$1,053.78
$1,186.54
$1,658.20
$2,519.78
$1,283.57
$1,408.91
$1,541.67
$2,013.33
$1,638.70
$1,764.04
$1,896.80
$2,368.46
$1,993.83
$2,119.17
$2,251.93
$2,723.59
$355.13
Toc - Plan #24 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded Saver ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$327.99
$372.27
$419.18
$585.80
$890.18
$578.91
$623.19
$670.10
$836.72
$829.83
$874.11
$921.02
$1,087.64
$1,080.75
$1,125.03
$1,171.94
$1,338.56
$250.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$655.98
$744.54
$838.36
$1,171.60
$1,780.36
$906.90
$995.46
$1,089.28
$1,422.52
$1,157.82
$1,246.38
$1,340.20
$1,673.44
$1,408.74
$1,497.30
$1,591.12
$1,924.36
$250.92
Toc - Plan #25 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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
$489.19
$555.23
$625.19
$873.70
$1,327.67
$863.42
$929.46
$999.42
$1,247.93
$1,237.65
$1,303.69
$1,373.65
$1,622.16
$1,611.88
$1,677.92
$1,747.88
$1,996.39
$374.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$978.38
$1,110.46
$1,250.38
$1,747.40
$2,655.34
$1,352.61
$1,484.69
$1,624.61
$2,121.63
$1,726.84
$1,858.92
$1,998.84
$2,495.86
$2,101.07
$2,233.15
$2,373.07
$2,870.09
$374.23
Toc - Plan #26 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $1 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$1,200 $2,400 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
$507.38
$575.88
$648.44
$906.19
$1,377.04
$895.53
$964.03
$1,036.59
$1,294.34
$1,283.68
$1,352.18
$1,424.74
$1,682.49
$1,671.83
$1,740.33
$1,812.89
$2,070.64
$388.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,014.76
$1,151.76
$1,296.88
$1,812.38
$2,754.08
$1,402.91
$1,539.91
$1,685.03
$2,200.53
$1,791.06
$1,928.06
$2,073.18
$2,588.68
$2,179.21
$2,316.21
$2,461.33
$2,976.83
$388.15
Toc - Plan #27 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$348.83
$395.93
$445.81
$623.02
$946.74
$615.69
$662.79
$712.67
$889.88
$882.55
$929.65
$979.53
$1,156.74
$1,149.41
$1,196.51
$1,246.39
$1,423.60
$266.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$697.66
$791.86
$891.62
$1,246.04
$1,893.48
$964.52
$1,058.72
$1,158.48
$1,512.90
$1,231.38
$1,325.58
$1,425.34
$1,779.76
$1,498.24
$1,592.44
$1,692.20
$2,046.62
$266.86
Toc - Plan #28 UnitedHealthcare
Silver

(HMO) UHC Silver Value $4,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$464.52
$527.23
$593.65
$829.62
$1,260.70
$819.87
$882.58
$949.00
$1,184.97
$1,175.22
$1,237.93
$1,304.35
$1,540.32
$1,530.57
$1,593.28
$1,659.70
$1,895.67
$355.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$929.04
$1,054.46
$1,187.30
$1,659.24
$2,521.40
$1,284.39
$1,409.81
$1,542.65
$2,014.59
$1,639.74
$1,765.16
$1,898.00
$2,369.94
$1,995.09
$2,120.51
$2,253.35
$2,725.29
$355.35
Toc - Plan #29 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $7,500 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$332.02
$376.84
$424.32
$592.98
$901.09
$586.01
$630.83
$678.31
$846.97
$840.00
$884.82
$932.30
$1,100.96
$1,093.99
$1,138.81
$1,186.29
$1,354.95
$253.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.04
$753.68
$848.64
$1,185.96
$1,802.18
$918.03
$1,007.67
$1,102.63
$1,439.95
$1,172.02
$1,261.66
$1,356.62
$1,693.94
$1,426.01
$1,515.65
$1,610.61
$1,947.93
$253.99
Toc - Plan #30 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$479.39
$544.10
$612.66
$856.18
$1,301.05
$846.12
$910.83
$979.39
$1,222.91
$1,212.85
$1,277.56
$1,346.12
$1,589.64
$1,579.58
$1,644.29
$1,712.85
$1,956.37
$366.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$958.78
$1,088.20
$1,225.32
$1,712.36
$2,602.10
$1,325.51
$1,454.93
$1,592.05
$2,079.09
$1,692.24
$1,821.66
$1,958.78
$2,445.82
$2,058.97
$2,188.39
$2,325.51
$2,812.55
$366.73
Toc - Plan #31 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$471.47
$535.12
$602.54
$842.05
$1,279.57
$832.15
$895.80
$963.22
$1,202.73
$1,192.83
$1,256.48
$1,323.90
$1,563.41
$1,553.51
$1,617.16
$1,684.58
$1,924.09
$360.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$942.94
$1,070.24
$1,205.08
$1,684.10
$2,559.14
$1,303.62
$1,430.92
$1,565.76
$2,044.78
$1,664.30
$1,791.60
$1,926.44
$2,405.46
$2,024.98
$2,152.28
$2,287.12
$2,766.14
$360.68
Toc - Plan #32 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $2,000 Indiv Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.35
$522.49
$588.32
$822.18
$1,249.38
$812.51
$874.65
$940.48
$1,174.34
$1,164.67
$1,226.81
$1,292.64
$1,526.50
$1,516.83
$1,578.97
$1,644.80
$1,878.66
$352.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$920.70
$1,044.98
$1,176.64
$1,644.36
$2,498.76
$1,272.86
$1,397.14
$1,528.80
$1,996.52
$1,625.02
$1,749.30
$1,880.96
$2,348.68
$1,977.18
$2,101.46
$2,233.12
$2,700.84
$352.16
Toc - Plan #33 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care + $0 PCP Visits, $3 Generic Rx Pref Pharm, Dental + Vision, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.36
$550.89
$620.30
$866.86
$1,317.28
$856.66
$922.19
$991.60
$1,238.16
$1,227.96
$1,293.49
$1,362.90
$1,609.46
$1,599.26
$1,664.79
$1,734.20
$1,980.76
$371.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$970.72
$1,101.78
$1,240.60
$1,733.72
$2,634.56
$1,342.02
$1,473.08
$1,611.90
$2,105.02
$1,713.32
$1,844.38
$1,983.20
$2,476.32
$2,084.62
$2,215.68
$2,354.50
$2,847.62
$371.30
Toc - Plan #34 UnitedHealthcare
Silver

(HMO) UHC Silver Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$462.93
$525.42
$591.62
$826.79
$1,256.39
$817.07
$879.56
$945.76
$1,180.93
$1,171.21
$1,233.70
$1,299.90
$1,535.07
$1,525.35
$1,587.84
$1,654.04
$1,889.21
$354.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$925.86
$1,050.84
$1,183.24
$1,653.58
$2,512.78
$1,280.00
$1,404.98
$1,537.38
$2,007.72
$1,634.14
$1,759.12
$1,891.52
$2,361.86
$1,988.28
$2,113.26
$2,245.66
$2,716.00
$354.14
Toc - Plan #35 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $9,100 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$317.26
$360.09
$405.45
$566.62
$861.04
$559.96
$602.79
$648.15
$809.32
$802.66
$845.49
$890.85
$1,052.02
$1,045.36
$1,088.19
$1,133.55
$1,294.72
$242.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.52
$720.18
$810.90
$1,133.24
$1,722.08
$877.22
$962.88
$1,053.60
$1,375.94
$1,119.92
$1,205.58
$1,296.30
$1,618.64
$1,362.62
$1,448.28
$1,539.00
$1,861.34
$242.70
Toc - Plan #36 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$316.16
$358.84
$404.05
$564.66
$858.06
$558.02
$600.70
$645.91
$806.52
$799.88
$842.56
$887.77
$1,048.38
$1,041.74
$1,084.42
$1,129.63
$1,290.24
$241.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.32
$717.68
$808.10
$1,129.32
$1,716.12
$874.18
$959.54
$1,049.96
$1,371.18
$1,116.04
$1,201.40
$1,291.82
$1,613.04
$1,357.90
$1,443.26
$1,533.68
$1,854.90
$241.86
Toc - Plan #37 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Indiv Ded (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

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
$332.56
$377.46
$425.01
$593.95
$902.57
$586.97
$631.87
$679.42
$848.36
$841.38
$886.28
$933.83
$1,102.77
$1,095.79
$1,140.69
$1,188.24
$1,357.18
$254.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$665.12
$754.92
$850.02
$1,187.90
$1,805.14
$919.53
$1,009.33
$1,104.43
$1,442.31
$1,173.94
$1,263.74
$1,358.84
$1,696.72
$1,428.35
$1,518.15
$1,613.25
$1,951.13
$254.41
Toc - Plan #38 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential $6,350 Indiv Ded ($3 Generic Rx Pref Pharm, No Referrals)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 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
$323.83
$367.55
$413.86
$578.37
$878.89
$571.56
$615.28
$661.59
$826.10
$819.29
$863.01
$909.32
$1,073.83
$1,067.02
$1,110.74
$1,157.05
$1,321.56
$247.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.66
$735.10
$827.72
$1,156.74
$1,757.78
$895.39
$982.83
$1,075.45
$1,404.47
$1,143.12
$1,230.56
$1,323.18
$1,652.20
$1,390.85
$1,478.29
$1,570.91
$1,899.93
$247.73

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #39 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
$323.58
$367.26
$413.54
$577.91
$878.20
$571.12
$614.80
$661.08
$825.45
$818.66
$862.34
$908.62
$1,072.99
$1,066.20
$1,109.88
$1,156.16
$1,320.53
$247.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$647.16
$734.52
$827.08
$1,155.82
$1,756.40
$894.70
$982.06
$1,074.62
$1,403.36
$1,142.24
$1,229.60
$1,322.16
$1,650.90
$1,389.78
$1,477.14
$1,569.70
$1,898.44
$247.54
Toc - Plan #40 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
$291.17
$330.48
$372.12
$520.04
$790.25
$513.92
$553.23
$594.87
$742.79
$736.67
$775.98
$817.62
$965.54
$959.42
$998.73
$1,040.37
$1,188.29
$222.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$582.34
$660.96
$744.24
$1,040.08
$1,580.50
$805.09
$883.71
$966.99
$1,262.83
$1,027.84
$1,106.46
$1,189.74
$1,485.58
$1,250.59
$1,329.21
$1,412.49
$1,708.33
$222.75
Toc - Plan #41 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
$477.53
$541.99
$610.28
$852.87
$1,296.01
$842.84
$907.30
$975.59
$1,218.18
$1,208.15
$1,272.61
$1,340.90
$1,583.49
$1,573.46
$1,637.92
$1,706.21
$1,948.80
$365.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$955.06
$1,083.98
$1,220.56
$1,705.74
$2,592.02
$1,320.37
$1,449.29
$1,585.87
$2,071.05
$1,685.68
$1,814.60
$1,951.18
$2,436.36
$2,050.99
$2,179.91
$2,316.49
$2,801.67
$365.31
Toc - Plan #42 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
$448.13
$508.62
$572.71
$800.36
$1,216.22
$790.95
$851.44
$915.53
$1,143.18
$1,133.77
$1,194.26
$1,258.35
$1,486.00
$1,476.59
$1,537.08
$1,601.17
$1,828.82
$342.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.26
$1,017.24
$1,145.42
$1,600.72
$2,432.44
$1,239.08
$1,360.06
$1,488.24
$1,943.54
$1,581.90
$1,702.88
$1,831.06
$2,286.36
$1,924.72
$2,045.70
$2,173.88
$2,629.18
$342.82
Toc - Plan #43 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
$425.35
$482.77
$543.59
$759.67
$1,154.39
$750.74
$808.16
$868.98
$1,085.06
$1,076.13
$1,133.55
$1,194.37
$1,410.45
$1,401.52
$1,458.94
$1,519.76
$1,735.84
$325.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$850.70
$965.54
$1,087.18
$1,519.34
$2,308.78
$1,176.09
$1,290.93
$1,412.57
$1,844.73
$1,501.48
$1,616.32
$1,737.96
$2,170.12
$1,826.87
$1,941.71
$2,063.35
$2,495.51
$325.39
Toc - Plan #44 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
$301.78
$342.52
$385.68
$538.98
$819.04
$532.64
$573.38
$616.54
$769.84
$763.50
$804.24
$847.40
$1,000.70
$994.36
$1,035.10
$1,078.26
$1,231.56
$230.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$603.56
$685.04
$771.36
$1,077.96
$1,638.08
$834.42
$915.90
$1,002.22
$1,308.82
$1,065.28
$1,146.76
$1,233.08
$1,539.68
$1,296.14
$1,377.62
$1,463.94
$1,770.54
$230.86
Toc - Plan #45 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
$468.73
$532.01
$599.04
$837.16
$1,272.14
$827.31
$890.59
$957.62
$1,195.74
$1,185.89
$1,249.17
$1,316.20
$1,554.32
$1,544.47
$1,607.75
$1,674.78
$1,912.90
$358.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$937.46
$1,064.02
$1,198.08
$1,674.32
$2,544.28
$1,296.04
$1,422.60
$1,556.66
$2,032.90
$1,654.62
$1,781.18
$1,915.24
$2,391.48
$2,013.20
$2,139.76
$2,273.82
$2,750.06
$358.58
Toc - Plan #46 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
$439.97
$499.36
$562.28
$785.78
$1,194.07
$776.55
$835.94
$898.86
$1,122.36
$1,113.13
$1,172.52
$1,235.44
$1,458.94
$1,449.71
$1,509.10
$1,572.02
$1,795.52
$336.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.94
$998.72
$1,124.56
$1,571.56
$2,388.14
$1,216.52
$1,335.30
$1,461.14
$1,908.14
$1,553.10
$1,671.88
$1,797.72
$2,244.72
$1,889.68
$2,008.46
$2,134.30
$2,581.30
$336.58
Toc - Plan #47 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
$415.40
$471.48
$530.88
$741.91
$1,127.40
$733.18
$789.26
$848.66
$1,059.69
$1,050.96
$1,107.04
$1,166.44
$1,377.47
$1,368.74
$1,424.82
$1,484.22
$1,695.25
$317.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.80
$942.96
$1,061.76
$1,483.82
$2,254.80
$1,148.58
$1,260.74
$1,379.54
$1,801.60
$1,466.36
$1,578.52
$1,697.32
$2,119.38
$1,784.14
$1,896.30
$2,015.10
$2,437.16
$317.78

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777

Toc - Plan #48 Cigna Healthcare
Gold

(HMO) Cigna Connect 2100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$2,100 $4,200 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
$738.52
$838.22
$943.83
$1,319.00
$2,004.35
$1,303.49
$1,403.19
$1,508.80
$1,883.97
$1,868.46
$1,968.16
$2,073.77
$2,448.94
$2,433.43
$2,533.13
$2,638.74
$3,013.91
$564.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,477.04
$1,676.44
$1,887.66
$2,638.00
$4,008.70
$2,042.01
$2,241.41
$2,452.63
$3,202.97
$2,606.98
$2,806.38
$3,017.60
$3,767.94
$3,171.95
$3,371.35
$3,582.57
$4,332.91
$564.97
Toc - Plan #49 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$8,700 $17,400 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
$434.50
$493.15
$555.29
$776.01
$1,179.22
$766.89
$825.54
$887.68
$1,108.40
$1,099.28
$1,157.93
$1,220.07
$1,440.79
$1,431.67
$1,490.32
$1,552.46
$1,773.18
$332.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.00
$986.30
$1,110.58
$1,552.02
$2,358.44
$1,201.39
$1,318.69
$1,442.97
$1,884.41
$1,533.78
$1,651.08
$1,775.36
$2,216.80
$1,866.17
$1,983.47
$2,107.75
$2,549.19
$332.39
Toc - Plan #50 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 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
$457.38
$519.13
$584.53
$816.88
$1,241.33
$807.28
$869.03
$934.43
$1,166.78
$1,157.18
$1,218.93
$1,284.33
$1,516.68
$1,507.08
$1,568.83
$1,634.23
$1,866.58
$349.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$914.76
$1,038.26
$1,169.06
$1,633.76
$2,482.66
$1,264.66
$1,388.16
$1,518.96
$1,983.66
$1,614.56
$1,738.06
$1,868.86
$2,333.56
$1,964.46
$2,087.96
$2,218.76
$2,683.46
$349.90
Toc - Plan #51 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5900

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 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
$451.46
$512.41
$576.97
$806.31
$1,225.27
$796.83
$857.78
$922.34
$1,151.68
$1,142.20
$1,203.15
$1,267.71
$1,497.05
$1,487.57
$1,548.52
$1,613.08
$1,842.42
$345.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$902.92
$1,024.82
$1,153.94
$1,612.62
$2,450.54
$1,248.29
$1,370.19
$1,499.31
$1,957.99
$1,593.66
$1,715.56
$1,844.68
$2,303.36
$1,939.03
$2,060.93
$2,190.05
$2,648.73
$345.37
Toc - Plan #52 Cigna Healthcare
Silver

(HMO) Cigna Connect 5500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$532.99
$604.94
$681.16
$951.92
$1,446.54
$940.73
$1,012.68
$1,088.90
$1,359.66
$1,348.47
$1,420.42
$1,496.64
$1,767.40
$1,756.21
$1,828.16
$1,904.38
$2,175.14
$407.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,065.98
$1,209.88
$1,362.32
$1,903.84
$2,893.08
$1,473.72
$1,617.62
$1,770.06
$2,311.58
$1,881.46
$2,025.36
$2,177.80
$2,719.32
$2,289.20
$2,433.10
$2,585.54
$3,127.06
$407.74
Toc - Plan #53 Cigna Healthcare
Silver

(HMO) Cigna Connect 4500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$532.26
$604.11
$680.23
$950.61
$1,444.55
$939.44
$1,011.29
$1,087.41
$1,357.79
$1,346.62
$1,418.47
$1,494.59
$1,764.97
$1,753.80
$1,825.65
$1,901.77
$2,172.15
$407.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,064.52
$1,208.22
$1,360.46
$1,901.22
$2,889.10
$1,471.70
$1,615.40
$1,767.64
$2,308.40
$1,878.88
$2,022.58
$2,174.82
$2,715.58
$2,286.06
$2,429.76
$2,582.00
$3,122.76
$407.18
Toc - Plan #54 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$534.52
$606.68
$683.11
$954.65
$1,450.68
$943.43
$1,015.59
$1,092.02
$1,363.56
$1,352.34
$1,424.50
$1,500.93
$1,772.47
$1,761.25
$1,833.41
$1,909.84
$2,181.38
$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
$1,366.22
$1,909.30
$2,901.36
$1,477.95
$1,622.27
$1,775.13
$2,318.21
$1,886.86
$2,031.18
$2,184.04
$2,727.12
$2,295.77
$2,440.09
$2,592.95
$3,136.03
$408.91
Toc - Plan #55 Cigna Healthcare
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 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
$537.26
$609.79
$686.62
$959.55
$1,458.13
$948.27
$1,020.80
$1,097.63
$1,370.56
$1,359.28
$1,431.81
$1,508.64
$1,781.57
$1,770.29
$1,842.82
$1,919.65
$2,192.58
$411.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,074.52
$1,219.58
$1,373.24
$1,919.10
$2,916.26
$1,485.53
$1,630.59
$1,784.25
$2,330.11
$1,896.54
$2,041.60
$2,195.26
$2,741.12
$2,307.55
$2,452.61
$2,606.27
$3,152.13
$411.01
Toc - Plan #56 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7050

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 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
$453.60
$514.83
$579.70
$810.13
$1,231.06
$800.60
$861.83
$926.70
$1,157.13
$1,147.60
$1,208.83
$1,273.70
$1,504.13
$1,494.60
$1,555.83
$1,620.70
$1,851.13
$347.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$907.20
$1,029.66
$1,159.40
$1,620.26
$2,462.12
$1,254.20
$1,376.66
$1,506.40
$1,967.26
$1,601.20
$1,723.66
$1,853.40
$2,314.26
$1,948.20
$2,070.66
$2,200.40
$2,661.26
$347.00
Toc - Plan #57 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 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
$535.68
$607.99
$684.59
$956.72
$1,453.82
$945.47
$1,017.78
$1,094.38
$1,366.51
$1,355.26
$1,427.57
$1,504.17
$1,776.30
$1,765.05
$1,837.36
$1,913.96
$2,186.09
$409.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,071.36
$1,215.98
$1,369.18
$1,913.44
$2,907.64
$1,481.15
$1,625.77
$1,778.97
$2,323.23
$1,890.94
$2,035.56
$2,188.76
$2,733.02
$2,300.73
$2,445.35
$2,598.55
$3,142.81
$409.79
Toc - Plan #58 Cigna Healthcare
Bronze

(HMO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$430.23
$488.31
$549.83
$768.38
$1,167.63
$759.35
$817.43
$878.95
$1,097.50
$1,088.47
$1,146.55
$1,208.07
$1,426.62
$1,417.59
$1,475.67
$1,537.19
$1,755.74
$329.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$860.46
$976.62
$1,099.66
$1,536.76
$2,335.26
$1,189.58
$1,305.74
$1,428.78
$1,865.88
$1,518.70
$1,634.86
$1,757.90
$2,195.00
$1,847.82
$1,963.98
$2,087.02
$2,524.12
$329.12
Toc - Plan #59 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$448.47
$509.02
$573.15
$800.97
$1,217.15
$791.55
$852.10
$916.23
$1,144.05
$1,134.63
$1,195.18
$1,259.31
$1,487.13
$1,477.71
$1,538.26
$1,602.39
$1,830.21
$343.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.94
$1,018.04
$1,146.30
$1,601.94
$2,434.30
$1,240.02
$1,361.12
$1,489.38
$1,945.02
$1,583.10
$1,704.20
$1,832.46
$2,288.10
$1,926.18
$2,047.28
$2,175.54
$2,631.18
$343.08
Toc - Plan #60 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 0A

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$479.41
$544.13
$612.69
$856.23
$1,301.12
$846.16
$910.88
$979.44
$1,222.98
$1,212.91
$1,277.63
$1,346.19
$1,589.73
$1,579.66
$1,644.38
$1,712.94
$1,956.48
$366.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$958.82
$1,088.26
$1,225.38
$1,712.46
$2,602.24
$1,325.57
$1,455.01
$1,592.13
$2,079.21
$1,692.32
$1,821.76
$1,958.88
$2,445.96
$2,059.07
$2,188.51
$2,325.63
$2,812.71
$366.75
Toc - Plan #61 Cigna Healthcare
Silver

(HMO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$532.50
$604.39
$680.54
$951.05
$1,445.21
$939.86
$1,011.75
$1,087.90
$1,358.41
$1,347.22
$1,419.11
$1,495.26
$1,765.77
$1,754.58
$1,826.47
$1,902.62
$2,173.13
$407.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,065.00
$1,208.78
$1,361.08
$1,902.10
$2,890.42
$1,472.36
$1,616.14
$1,768.44
$2,309.46
$1,879.72
$2,023.50
$2,175.80
$2,716.82
$2,287.08
$2,430.86
$2,583.16
$3,124.18
$407.36
Toc - Plan #62 Cigna Healthcare
Gold

(HMO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

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
$742.37
$842.59
$948.74
$1,325.87
$2,014.78
$1,310.28
$1,410.50
$1,516.65
$1,893.78
$1,878.19
$1,978.41
$2,084.56
$2,461.69
$2,446.10
$2,546.32
$2,652.47
$3,029.60
$567.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,484.74
$1,685.18
$1,897.48
$2,651.74
$4,029.56
$2,052.65
$2,253.09
$2,465.39
$3,219.65
$2,620.56
$2,821.00
$3,033.30
$3,787.56
$3,188.47
$3,388.91
$3,601.21
$4,355.47
$567.91
Toc - Plan #63 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 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
$451.83
$512.82
$577.44
$806.96
$1,226.26
$797.48
$858.47
$923.09
$1,152.61
$1,143.13
$1,204.12
$1,268.74
$1,498.26
$1,488.78
$1,549.77
$1,614.39
$1,843.91
$345.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$903.66
$1,025.64
$1,154.88
$1,613.92
$2,452.52
$1,249.31
$1,371.29
$1,500.53
$1,959.57
$1,594.96
$1,716.94
$1,846.18
$2,305.22
$1,940.61
$2,062.59
$2,191.83
$2,650.87
$345.65

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Ambetter of North Carolina

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

Toc - Plan #64 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze

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
$340.82
$386.82
$435.55
$608.69
$924.96
$601.54
$647.54
$696.27
$869.41
$862.26
$908.26
$956.99
$1,130.13
$1,122.98
$1,168.98
$1,217.71
$1,390.85
$260.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.64
$773.64
$871.10
$1,217.38
$1,849.92
$942.36
$1,034.36
$1,131.82
$1,478.10
$1,203.08
$1,295.08
$1,392.54
$1,738.82
$1,463.80
$1,555.80
$1,653.26
$1,999.54
$260.72
Toc - Plan #65 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA

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
$374.79
$425.37
$478.97
$669.36
$1,017.15
$661.50
$712.08
$765.68
$956.07
$948.21
$998.79
$1,052.39
$1,242.78
$1,234.92
$1,285.50
$1,339.10
$1,529.49
$286.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.58
$850.74
$957.94
$1,338.72
$2,034.30
$1,036.29
$1,137.45
$1,244.65
$1,625.43
$1,323.00
$1,424.16
$1,531.36
$1,912.14
$1,609.71
$1,710.87
$1,818.07
$2,198.85
$286.71
Toc - Plan #66 Ambetter of North Carolina
Silver

(HMO) Complete Silver

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
$462.19
$524.57
$590.66
$825.45
$1,254.35
$815.76
$878.14
$944.23
$1,179.02
$1,169.33
$1,231.71
$1,297.80
$1,532.59
$1,522.90
$1,585.28
$1,651.37
$1,886.16
$353.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$924.38
$1,049.14
$1,181.32
$1,650.90
$2,508.70
$1,277.95
$1,402.71
$1,534.89
$2,004.47
$1,631.52
$1,756.28
$1,888.46
$2,358.04
$1,985.09
$2,109.85
$2,242.03
$2,711.61
$353.57
Toc - Plan #67 Ambetter of North Carolina
Gold

(HMO) Complete Gold

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
$482.15
$547.23
$616.18
$861.11
$1,308.54
$850.99
$916.07
$985.02
$1,229.95
$1,219.83
$1,284.91
$1,353.86
$1,598.79
$1,588.67
$1,653.75
$1,722.70
$1,967.63
$368.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$964.30
$1,094.46
$1,232.36
$1,722.22
$2,617.08
$1,333.14
$1,463.30
$1,601.20
$2,091.06
$1,701.98
$1,832.14
$1,970.04
$2,459.90
$2,070.82
$2,200.98
$2,338.88
$2,828.74
$368.84
Toc - Plan #68 Ambetter of North Carolina
Silver

(HMO) Everyday Silver

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
$457.89
$519.69
$585.17
$817.77
$1,242.68
$808.17
$869.97
$935.45
$1,168.05
$1,158.45
$1,220.25
$1,285.73
$1,518.33
$1,508.73
$1,570.53
$1,636.01
$1,868.61
$350.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$915.78
$1,039.38
$1,170.34
$1,635.54
$2,485.36
$1,266.06
$1,389.66
$1,520.62
$1,985.82
$1,616.34
$1,739.94
$1,870.90
$2,336.10
$1,966.62
$2,090.22
$2,221.18
$2,686.38
$350.28
Toc - Plan #69 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze

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
$363.65
$412.73
$464.73
$649.46
$986.92
$641.84
$690.92
$742.92
$927.65
$920.03
$969.11
$1,021.11
$1,205.84
$1,198.22
$1,247.30
$1,299.30
$1,484.03
$278.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.30
$825.46
$929.46
$1,298.92
$1,973.84
$1,005.49
$1,103.65
$1,207.65
$1,577.11
$1,283.68
$1,381.84
$1,485.84
$1,855.30
$1,561.87
$1,660.03
$1,764.03
$2,133.49
$278.19
Toc - Plan #70 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze

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
$409.22
$464.45
$522.97
$730.85
$1,110.60
$722.27
$777.50
$836.02
$1,043.90
$1,035.32
$1,090.55
$1,149.07
$1,356.95
$1,348.37
$1,403.60
$1,462.12
$1,670.00
$313.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.44
$928.90
$1,045.94
$1,461.70
$2,221.20
$1,131.49
$1,241.95
$1,358.99
$1,774.75
$1,444.54
$1,555.00
$1,672.04
$2,087.80
$1,757.59
$1,868.05
$1,985.09
$2,400.85
$313.05
Toc - Plan #71 Ambetter of North Carolina
Silver

(HMO) Clear Silver

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
$456.69
$518.33
$583.63
$815.63
$1,239.42
$806.05
$867.69
$932.99
$1,164.99
$1,155.41
$1,217.05
$1,282.35
$1,514.35
$1,504.77
$1,566.41
$1,631.71
$1,863.71
$349.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$913.38
$1,036.66
$1,167.26
$1,631.26
$2,478.84
$1,262.74
$1,386.02
$1,516.62
$1,980.62
$1,612.10
$1,735.38
$1,865.98
$2,329.98
$1,961.46
$2,084.74
$2,215.34
$2,679.34
$349.36
Toc - Plan #72 Ambetter of North Carolina
Silver

(HMO) Focused Silver

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
$456.87
$518.54
$583.87
$815.96
$1,239.92
$806.37
$868.04
$933.37
$1,165.46
$1,155.87
$1,217.54
$1,282.87
$1,514.96
$1,505.37
$1,567.04
$1,632.37
$1,864.46
$349.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$913.74
$1,037.08
$1,167.74
$1,631.92
$2,479.84
$1,263.24
$1,386.58
$1,517.24
$1,981.42
$1,612.74
$1,736.08
$1,866.74
$2,330.92
$1,962.24
$2,085.58
$2,216.24
$2,680.42
$349.50
Toc - Plan #73 Ambetter of North Carolina
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

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
$356.58
$404.71
$455.70
$636.83
$967.73
$629.36
$677.49
$728.48
$909.61
$902.14
$950.27
$1,001.26
$1,182.39
$1,174.92
$1,223.05
$1,274.04
$1,455.17
$272.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.16
$809.42
$911.40
$1,273.66
$1,935.46
$985.94
$1,082.20
$1,184.18
$1,546.44
$1,258.72
$1,354.98
$1,456.96
$1,819.22
$1,531.50
$1,627.76
$1,729.74
$2,092.00
$272.78
Toc - Plan #74 Ambetter of North Carolina
Silver

(HMO) CMS Standard Silver

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
$452.20
$513.24
$577.90
$807.62
$1,227.25
$798.13
$859.17
$923.83
$1,153.55
$1,144.06
$1,205.10
$1,269.76
$1,499.48
$1,489.99
$1,551.03
$1,615.69
$1,845.41
$345.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$904.40
$1,026.48
$1,155.80
$1,615.24
$2,454.50
$1,250.33
$1,372.41
$1,501.73
$1,961.17
$1,596.26
$1,718.34
$1,847.66
$2,307.10
$1,942.19
$2,064.27
$2,193.59
$2,653.03
$345.93
Toc - Plan #75 Ambetter of North Carolina
Gold

(HMO) CMS Standard Gold

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
$457.61
$519.38
$584.81
$817.28
$1,241.93
$807.68
$869.45
$934.88
$1,167.35
$1,157.75
$1,219.52
$1,284.95
$1,517.42
$1,507.82
$1,569.59
$1,635.02
$1,867.49
$350.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$915.22
$1,038.76
$1,169.62
$1,634.56
$2,483.86
$1,265.29
$1,388.83
$1,519.69
$1,984.63
$1,615.36
$1,738.90
$1,869.76
$2,334.70
$1,965.43
$2,088.97
$2,219.83
$2,684.77
$350.07
Toc - Plan #76 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze + 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
$355.17
$403.11
$453.90
$634.32
$963.92
$626.87
$674.81
$725.60
$906.02
$898.57
$946.51
$997.30
$1,177.72
$1,170.27
$1,218.21
$1,269.00
$1,449.42
$271.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.34
$806.22
$907.80
$1,268.64
$1,927.84
$982.04
$1,077.92
$1,179.50
$1,540.34
$1,253.74
$1,349.62
$1,451.20
$1,812.04
$1,525.44
$1,621.32
$1,722.90
$2,083.74
$271.70
Toc - Plan #77 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA + 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
$390.57
$443.29
$499.14
$697.55
$1,059.99
$689.35
$742.07
$797.92
$996.33
$988.13
$1,040.85
$1,096.70
$1,295.11
$1,286.91
$1,339.63
$1,395.48
$1,593.89
$298.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.14
$886.58
$998.28
$1,395.10
$2,119.98
$1,079.92
$1,185.36
$1,297.06
$1,693.88
$1,378.70
$1,484.14
$1,595.84
$1,992.66
$1,677.48
$1,782.92
$1,894.62
$2,291.44
$298.78
Toc - Plan #78 Ambetter of North Carolina
Silver

(HMO) Complete Silver + 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
$481.65
$546.67
$615.54
$860.22
$1,307.18
$850.11
$915.13
$984.00
$1,228.68
$1,218.57
$1,283.59
$1,352.46
$1,597.14
$1,587.03
$1,652.05
$1,720.92
$1,965.60
$368.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$963.30
$1,093.34
$1,231.08
$1,720.44
$2,614.36
$1,331.76
$1,461.80
$1,599.54
$2,088.90
$1,700.22
$1,830.26
$1,968.00
$2,457.36
$2,068.68
$2,198.72
$2,336.46
$2,825.82
$368.46
Toc - Plan #79 Ambetter of North Carolina
Gold

(HMO) Complete Gold + 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
$502.46
$570.28
$642.13
$897.38
$1,363.65
$886.83
$954.65
$1,026.50
$1,281.75
$1,271.20
$1,339.02
$1,410.87
$1,666.12
$1,655.57
$1,723.39
$1,795.24
$2,050.49
$384.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,004.92
$1,140.56
$1,284.26
$1,794.76
$2,727.30
$1,389.29
$1,524.93
$1,668.63
$2,179.13
$1,773.66
$1,909.30
$2,053.00
$2,563.50
$2,158.03
$2,293.67
$2,437.37
$2,947.87
$384.37
Toc - Plan #80 Ambetter of North Carolina
Silver

(HMO) Everyday Silver + 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
$477.17
$541.58
$609.82
$852.22
$1,295.02
$842.20
$906.61
$974.85
$1,217.25
$1,207.23
$1,271.64
$1,339.88
$1,582.28
$1,572.26
$1,636.67
$1,704.91
$1,947.31
$365.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$954.34
$1,083.16
$1,219.64
$1,704.44
$2,590.04
$1,319.37
$1,448.19
$1,584.67
$2,069.47
$1,684.40
$1,813.22
$1,949.70
$2,434.50
$2,049.43
$2,178.25
$2,314.73
$2,799.53
$365.03
Toc - Plan #81 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze + 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
$378.97
$430.12
$484.31
$676.82
$1,028.49
$668.87
$720.02
$774.21
$966.72
$958.77
$1,009.92
$1,064.11
$1,256.62
$1,248.67
$1,299.82
$1,354.01
$1,546.52
$289.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.94
$860.24
$968.62
$1,353.64
$2,056.98
$1,047.84
$1,150.14
$1,258.52
$1,643.54
$1,337.74
$1,440.04
$1,548.42
$1,933.44
$1,627.64
$1,729.94
$1,838.32
$2,223.34
$289.90
Toc - Plan #82 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze + 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
$426.46
$484.02
$545.00
$761.63
$1,157.38
$752.69
$810.25
$871.23
$1,087.86
$1,078.92
$1,136.48
$1,197.46
$1,414.09
$1,405.15
$1,462.71
$1,523.69
$1,740.32
$326.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$852.92
$968.04
$1,090.00
$1,523.26
$2,314.76
$1,179.15
$1,294.27
$1,416.23
$1,849.49
$1,505.38
$1,620.50
$1,742.46
$2,175.72
$1,831.61
$1,946.73
$2,068.69
$2,501.95
$326.23
Toc - Plan #83 Ambetter of North Carolina
Silver

(HMO) Focused Silver + 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
$476.11
$540.38
$608.46
$850.32
$1,292.15
$840.33
$904.60
$972.68
$1,214.54
$1,204.55
$1,268.82
$1,336.90
$1,578.76
$1,568.77
$1,633.04
$1,701.12
$1,942.98
$364.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$952.22
$1,080.76
$1,216.92
$1,700.64
$2,584.30
$1,316.44
$1,444.98
$1,581.14
$2,064.86
$1,680.66
$1,809.20
$1,945.36
$2,429.08
$2,044.88
$2,173.42
$2,309.58
$2,793.30
$364.22
Toc - Plan #84 Ambetter of North Carolina
Silver

(HMO) Clear Silver + 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
$475.92
$540.16
$608.22
$849.98
$1,291.63
$839.99
$904.23
$972.29
$1,214.05
$1,204.06
$1,268.30
$1,336.36
$1,578.12
$1,568.13
$1,632.37
$1,700.43
$1,942.19
$364.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$951.84
$1,080.32
$1,216.44
$1,699.96
$2,583.26
$1,315.91
$1,444.39
$1,580.51
$2,064.03
$1,679.98
$1,808.46
$1,944.58
$2,428.10
$2,044.05
$2,172.53
$2,308.65
$2,792.17
$364.07
Toc - Plan #85 Ambetter of North Carolina
Expanded Bronze

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

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

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
$355.10
$403.03
$453.81
$634.19
$963.72
$626.74
$674.67
$725.45
$905.83
$898.38
$946.31
$997.09
$1,177.47
$1,170.02
$1,217.95
$1,268.73
$1,449.11
$271.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$710.20
$806.06
$907.62
$1,268.38
$1,927.44
$981.84
$1,077.70
$1,179.26
$1,540.02
$1,253.48
$1,349.34
$1,450.90
$1,811.66
$1,525.12
$1,620.98
$1,722.54
$2,083.30
$271.64
Toc - Plan #86 Ambetter of North Carolina
Silver

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

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

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
$446.89
$507.21
$571.11
$798.13
$1,212.83
$788.75
$849.07
$912.97
$1,139.99
$1,130.61
$1,190.93
$1,254.83
$1,481.85
$1,472.47
$1,532.79
$1,596.69
$1,823.71
$341.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$893.78
$1,014.42
$1,142.22
$1,596.26
$2,425.66
$1,235.64
$1,356.28
$1,484.08
$1,938.12
$1,577.50
$1,698.14
$1,825.94
$2,279.98
$1,919.36
$2,040.00
$2,167.80
$2,621.84
$341.86
Toc - Plan #87 Ambetter of North Carolina
Gold

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

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

Annual Out of Pocket Expenses:

Individual Family
$950 $1,900 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$468.47
$531.70
$598.70
$836.67
$1,271.41
$826.84
$890.07
$957.07
$1,195.04
$1,185.21
$1,248.44
$1,315.44
$1,553.41
$1,543.58
$1,606.81
$1,673.81
$1,911.78
$358.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$936.94
$1,063.40
$1,197.40
$1,673.34
$2,542.82
$1,295.31
$1,421.77
$1,555.77
$2,031.71
$1,653.68
$1,780.14
$1,914.14
$2,390.08
$2,012.05
$2,138.51
$2,272.51
$2,748.45
$358.37

‡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 Cumberland County here.

Cumberland County is in “Rating Area 9” of North Carolina.

Currently, there are 87 plans offered in Rating Area 9.

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2023 Obamacare Plans for Cumberland County, NC

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