Davidson County, North Carolina Obamacare 2024 Rates

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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 Davidson County, NC.

The health insurance rates listed below are for calendar year 2024.

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, 89 Plans and 2024 Rates for Davidson County, North Carolina

Below, you’ll find a summary of the 89 plans for Davidson County, North Carolina and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |



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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

(EPO) Blue Home Gold | 3 Free PCP | $10 Tier 1 Rx | with Novant 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
$457.45
$519.21
$584.62
$817.01
$1,241.52
$807.40
$869.16
$934.57
$1,166.96
$1,157.35
$1,219.11
$1,284.52
$1,516.91
$1,507.30
$1,569.06
$1,634.47
$1,866.86
$349.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$914.90
$1,038.42
$1,169.24
$1,634.02
$2,483.04
$1,264.85
$1,388.37
$1,519.19
$1,983.97
$1,614.80
$1,738.32
$1,869.14
$2,333.92
$1,964.75
$2,088.27
$2,219.09
$2,683.87
$349.95
Toc - Plan #2 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Home Gold Standard | with Novant Health

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$457.50
$519.26
$584.69
$817.10
$1,241.66
$807.49
$869.25
$934.68
$1,167.09
$1,157.48
$1,219.24
$1,284.67
$1,517.08
$1,507.47
$1,569.23
$1,634.66
$1,867.07
$349.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$915.00
$1,038.52
$1,169.38
$1,634.20
$2,483.32
$1,264.99
$1,388.51
$1,519.37
$1,984.19
$1,614.98
$1,738.50
$1,869.36
$2,334.18
$1,964.97
$2,088.49
$2,219.35
$2,684.17
$349.99
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Preferred | 3 Free PCP | $10 Tier 1 Rx | Integrated | with Novant Health

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

Annual Out of Pocket Expenses:

Individual Family
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.02
$500.56
$563.62
$787.66
$1,196.93
$778.40
$837.94
$901.00
$1,125.04
$1,115.78
$1,175.32
$1,238.38
$1,462.42
$1,453.16
$1,512.70
$1,575.76
$1,799.80
$337.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$882.04
$1,001.12
$1,127.24
$1,575.32
$2,393.86
$1,219.42
$1,338.50
$1,464.62
$1,912.70
$1,556.80
$1,675.88
$1,802.00
$2,250.08
$1,894.18
$2,013.26
$2,139.38
$2,587.46
$337.38
Toc - Plan #4 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Home Silver Standard | with Novant Health

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

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
$447.65
$508.08
$572.10
$799.50
$1,214.92
$790.10
$850.53
$914.55
$1,141.95
$1,132.55
$1,192.98
$1,257.00
$1,484.40
$1,475.00
$1,535.43
$1,599.45
$1,826.85
$342.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.30
$1,016.16
$1,144.20
$1,599.00
$2,429.84
$1,237.75
$1,358.61
$1,486.65
$1,941.45
$1,580.20
$1,701.06
$1,829.10
$2,283.90
$1,922.65
$2,043.51
$2,171.55
$2,626.35
$342.45
Toc - Plan #5 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze | 3 Free PCP | $20 Tier 1 Rx | Integrated | with Novant 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$333.92
$379.00
$426.75
$596.38
$906.26
$589.37
$634.45
$682.20
$851.83
$844.82
$889.90
$937.65
$1,107.28
$1,100.27
$1,145.35
$1,193.10
$1,362.73
$255.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667.84
$758.00
$853.50
$1,192.76
$1,812.52
$923.29
$1,013.45
$1,108.95
$1,448.21
$1,178.74
$1,268.90
$1,364.40
$1,703.66
$1,434.19
$1,524.35
$1,619.85
$1,959.11
$255.45
Toc - Plan #6 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Home Bronze Standard | with Novant 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
$9,400 $18,800 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
$342.65
$388.91
$437.91
$611.97
$929.95
$604.78
$651.04
$700.04
$874.10
$866.91
$913.17
$962.17
$1,136.23
$1,129.04
$1,175.30
$1,224.30
$1,398.36
$262.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.30
$777.82
$875.82
$1,223.94
$1,859.90
$947.43
$1,039.95
$1,137.95
$1,486.07
$1,209.56
$1,302.08
$1,400.08
$1,748.20
$1,471.69
$1,564.21
$1,662.21
$2,010.33
$262.13
Toc - Plan #7 Blue Cross and Blue Shield of NC
Catastrophic

(EPO) Blue Home Catastrophic | 3 PCP $35 | Integrated | with Novant Health

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$264.63
$300.36
$338.20
$472.63
$718.21
$467.07
$502.80
$540.64
$675.07
$669.51
$705.24
$743.08
$877.51
$871.95
$907.68
$945.52
$1,079.95
$202.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$529.26
$600.72
$676.40
$945.26
$1,436.42
$731.70
$803.16
$878.84
$1,147.70
$934.14
$1,005.60
$1,081.28
$1,350.14
$1,136.58
$1,208.04
$1,283.72
$1,552.58
$202.44
Toc - Plan #8 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold | 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
$347.59
$394.51
$444.22
$620.80
$943.36
$613.50
$660.42
$710.13
$886.71
$879.41
$926.33
$976.04
$1,152.62
$1,145.32
$1,192.24
$1,241.95
$1,418.53
$265.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.18
$789.02
$888.44
$1,241.60
$1,886.72
$961.09
$1,054.93
$1,154.35
$1,507.51
$1,227.00
$1,320.84
$1,420.26
$1,773.42
$1,492.91
$1,586.75
$1,686.17
$2,039.33
$265.91
Toc - Plan #9 Blue Cross and Blue Shield of NC
Gold

(EPO) Blue Local Gold Standard | with Atrium Health

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.63
$394.56
$444.27
$620.87
$943.47
$613.57
$660.50
$710.21
$886.81
$879.51
$926.44
$976.15
$1,152.75
$1,145.45
$1,192.38
$1,242.09
$1,418.69
$265.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$695.26
$789.12
$888.54
$1,241.74
$1,886.94
$961.20
$1,055.06
$1,154.48
$1,507.68
$1,227.14
$1,321.00
$1,420.42
$1,773.62
$1,493.08
$1,586.94
$1,686.36
$2,039.56
$265.94
Toc - Plan #10 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Preferred | 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
$2,750 $5,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.14
$380.38
$428.31
$598.56
$909.57
$591.52
$636.76
$684.69
$854.94
$847.90
$893.14
$941.07
$1,111.32
$1,104.28
$1,149.52
$1,197.45
$1,367.70
$256.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.28
$760.76
$856.62
$1,197.12
$1,819.14
$926.66
$1,017.14
$1,113.00
$1,453.50
$1,183.04
$1,273.52
$1,369.38
$1,709.88
$1,439.42
$1,529.90
$1,625.76
$1,966.26
$256.38
Toc - Plan #11 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Secure | $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
$1,600 $3,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$349.20
$396.34
$446.28
$623.67
$947.73
$616.34
$663.48
$713.42
$890.81
$883.48
$930.62
$980.56
$1,157.95
$1,150.62
$1,197.76
$1,247.70
$1,425.09
$267.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.40
$792.68
$892.56
$1,247.34
$1,895.46
$965.54
$1,059.82
$1,159.70
$1,514.48
$1,232.68
$1,326.96
$1,426.84
$1,781.62
$1,499.82
$1,594.10
$1,693.98
$2,048.76
$267.14
Toc - Plan #12 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Choice | 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.57
$399.03
$449.31
$627.90
$954.16
$620.52
$667.98
$718.26
$896.85
$889.47
$936.93
$987.21
$1,165.80
$1,158.42
$1,205.88
$1,256.16
$1,434.75
$268.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$703.14
$798.06
$898.62
$1,255.80
$1,908.32
$972.09
$1,067.01
$1,167.57
$1,524.75
$1,241.04
$1,335.96
$1,436.52
$1,793.70
$1,509.99
$1,604.91
$1,705.47
$2,062.65
$268.95
Toc - Plan #13 Blue Cross and Blue Shield of NC
Silver

(EPO) Blue Local Silver Standard | with Atrium Health

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

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
$340.16
$386.08
$434.72
$607.53
$923.19
$600.38
$646.30
$694.94
$867.75
$860.60
$906.52
$955.16
$1,127.97
$1,120.82
$1,166.74
$1,215.38
$1,388.19
$260.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.32
$772.16
$869.44
$1,215.06
$1,846.38
$940.54
$1,032.38
$1,129.66
$1,475.28
$1,200.76
$1,292.60
$1,389.88
$1,735.50
$1,460.98
$1,552.82
$1,650.10
$1,995.72
$260.22
Toc - Plan #14 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze | $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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$268.85
$305.14
$343.59
$480.17
$729.66
$474.52
$510.81
$549.26
$685.84
$680.19
$716.48
$754.93
$891.51
$885.86
$922.15
$960.60
$1,097.18
$205.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.70
$610.28
$687.18
$960.34
$1,459.32
$743.37
$815.95
$892.85
$1,166.01
$949.04
$1,021.62
$1,098.52
$1,371.68
$1,154.71
$1,227.29
$1,304.19
$1,577.35
$205.67
Toc - Plan #15 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze | 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$253.79
$288.05
$324.34
$453.27
$688.79
$447.94
$482.20
$518.49
$647.42
$642.09
$676.35
$712.64
$841.57
$836.24
$870.50
$906.79
$1,035.72
$194.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$507.58
$576.10
$648.68
$906.54
$1,377.58
$701.73
$770.25
$842.83
$1,100.69
$895.88
$964.40
$1,036.98
$1,294.84
$1,090.03
$1,158.55
$1,231.13
$1,488.99
$194.15
Toc - Plan #16 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze Standard | 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
$9,400 $18,800 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
$260.40
$295.55
$332.79
$465.07
$706.73
$459.61
$494.76
$532.00
$664.28
$658.82
$693.97
$731.21
$863.49
$858.03
$893.18
$930.42
$1,062.70
$199.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$520.80
$591.10
$665.58
$930.14
$1,413.46
$720.01
$790.31
$864.79
$1,129.35
$919.22
$989.52
$1,064.00
$1,328.56
$1,118.43
$1,188.73
$1,263.21
$1,527.77
$199.21
Toc - Plan #17 Blue Cross and Blue Shield of NC
Expanded Bronze

(EPO) Blue Local Bronze | 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
$8,050 $16,100 Annual Deductible
$8,050 $16,100 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
$254.58
$288.95
$325.35
$454.68
$690.93
$449.33
$483.70
$520.10
$649.43
$644.08
$678.45
$714.85
$844.18
$838.83
$873.20
$909.60
$1,038.93
$194.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509.16
$577.90
$650.70
$909.36
$1,381.86
$703.91
$772.65
$845.45
$1,104.11
$898.66
$967.40
$1,040.20
$1,298.86
$1,093.41
$1,162.15
$1,234.95
$1,493.61
$194.75
Toc - Plan #18 Blue Cross and Blue Shield of NC
Catastrophic

(EPO) Blue Local Catastrophic | 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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$201.09
$228.24
$256.99
$359.15
$545.76
$354.92
$382.07
$410.82
$512.98
$508.75
$535.90
$564.65
$666.81
$662.58
$689.73
$718.48
$820.64
$153.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$402.18
$456.48
$513.98
$718.30
$1,091.52
$556.01
$610.31
$667.81
$872.13
$709.84
$764.14
$821.64
$1,025.96
$863.67
$917.97
$975.47
$1,179.79
$153.83

ADVERTISEMENT

AmeriHealth Caritas Next

Local: 1-984-245-3613 | Toll Free: 1-833-613-2262 | TTY: 1-844-214-2471

Toc - Plan #19 AmeriHealth Caritas Next
Bronze

(HMO) AmeriHealth Caritas Next Bronze Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$239.59
$271.93
$306.19
$427.90
$650.23
$422.88
$455.22
$489.48
$611.19
$606.17
$638.51
$672.77
$794.48
$789.46
$821.80
$856.06
$977.77
$183.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$479.18
$543.86
$612.38
$855.80
$1,300.46
$662.47
$727.15
$795.67
$1,039.09
$845.76
$910.44
$978.96
$1,222.38
$1,029.05
$1,093.73
$1,162.25
$1,405.67
$183.29
Toc - Plan #20 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$269.25
$305.60
$344.10
$480.88
$730.74
$475.23
$511.58
$550.08
$686.86
$681.21
$717.56
$756.06
$892.84
$887.19
$923.54
$962.04
$1,098.82
$205.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$538.50
$611.20
$688.20
$961.76
$1,461.48
$744.48
$817.18
$894.18
$1,167.74
$950.46
$1,023.16
$1,100.16
$1,373.72
$1,156.44
$1,229.14
$1,306.14
$1,579.70
$205.98
Toc - Plan #21 AmeriHealth Caritas Next
Silver

(HMO) AmeriHealth Caritas Next Silver Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

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
$335.12
$380.35
$428.28
$598.51
$909.49
$591.48
$636.71
$684.64
$854.87
$847.84
$893.07
$941.00
$1,111.23
$1,104.20
$1,149.43
$1,197.36
$1,367.59
$256.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.24
$760.70
$856.56
$1,197.02
$1,818.98
$926.60
$1,017.06
$1,112.92
$1,453.38
$1,182.96
$1,273.42
$1,369.28
$1,709.74
$1,439.32
$1,529.78
$1,625.64
$1,966.10
$256.36
Toc - Plan #22 AmeriHealth Caritas Next
Gold

(HMO) AmeriHealth Caritas Next Gold Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.67
$433.19
$487.77
$681.65
$1,035.83
$673.65
$725.17
$779.75
$973.63
$965.63
$1,017.15
$1,071.73
$1,265.61
$1,257.61
$1,309.13
$1,363.71
$1,557.59
$291.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.34
$866.38
$975.54
$1,363.30
$2,071.66
$1,055.32
$1,158.36
$1,267.52
$1,655.28
$1,347.30
$1,450.34
$1,559.50
$1,947.26
$1,639.28
$1,742.32
$1,851.48
$2,239.24
$291.98
Toc - Plan #23 AmeriHealth Caritas Next
Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze Premier + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$275.33
$312.50
$351.87
$491.73
$747.24
$485.96
$523.13
$562.50
$702.36
$696.59
$733.76
$773.13
$912.99
$907.22
$944.39
$983.76
$1,123.62
$210.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$550.66
$625.00
$703.74
$983.46
$1,494.48
$761.29
$835.63
$914.37
$1,194.09
$971.92
$1,046.26
$1,125.00
$1,404.72
$1,182.55
$1,256.89
$1,335.63
$1,615.35
$210.63
Toc - Plan #24 AmeriHealth Caritas Next
Silver

(HMO) AmeriHealth Caritas Next Silver Premier + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 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
$345.66
$392.33
$441.76
$617.35
$938.12
$610.09
$656.76
$706.19
$881.78
$874.52
$921.19
$970.62
$1,146.21
$1,138.95
$1,185.62
$1,235.05
$1,410.64
$264.43
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691.32
$784.66
$883.52
$1,234.70
$1,876.24
$955.75
$1,049.09
$1,147.95
$1,499.13
$1,220.18
$1,313.52
$1,412.38
$1,763.56
$1,484.61
$1,577.95
$1,676.81
$2,027.99
$264.43

ADVERTISEMENT

WellCare of North Carolina

Local: 1-833-925-2861 | Toll Free: 1-833-925-2861 | TTY: 1-833-925-2861

Toc - Plan #25 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-925-2861

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 Annual Deductible
$9,250 $18,500 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
$609.77
$692.08
$779.28
$1,089.04
$1,654.90
$1,076.24
$1,158.55
$1,245.75
$1,555.51
$1,542.71
$1,625.02
$1,712.22
$2,021.98
$2,009.18
$2,091.49
$2,178.69
$2,488.45
$466.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,219.54
$1,384.16
$1,558.56
$2,178.08
$3,309.80
$1,686.01
$1,850.63
$2,025.03
$2,644.55
$2,152.48
$2,317.10
$2,491.50
$3,111.02
$2,618.95
$2,783.57
$2,957.97
$3,577.49
$466.47
Toc - Plan #26 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-925-2861

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
$792.08
$899.00
$1,012.27
$1,414.64
$2,149.68
$1,398.01
$1,504.93
$1,618.20
$2,020.57
$2,003.94
$2,110.86
$2,224.13
$2,626.50
$2,609.87
$2,716.79
$2,830.06
$3,232.43
$605.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,584.16
$1,798.00
$2,024.54
$2,829.28
$4,299.36
$2,190.09
$2,403.93
$2,630.47
$3,435.21
$2,796.02
$3,009.86
$3,236.40
$4,041.14
$3,401.95
$3,615.79
$3,842.33
$4,647.07
$605.93
Toc - Plan #27 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-925-2861

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
$827.57
$939.28
$1,057.62
$1,478.02
$2,245.99
$1,460.65
$1,572.36
$1,690.70
$2,111.10
$2,093.73
$2,205.44
$2,323.78
$2,744.18
$2,726.81
$2,838.52
$2,956.86
$3,377.26
$633.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,655.14
$1,878.56
$2,115.24
$2,956.04
$4,491.98
$2,288.22
$2,511.64
$2,748.32
$3,589.12
$2,921.30
$3,144.72
$3,381.40
$4,222.20
$3,554.38
$3,777.80
$4,014.48
$4,855.28
$633.08
Toc - Plan #28 WellCare of North Carolina
Expanded Bronze

(PPO) Standard Expanded Bronze WellCare

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-925-2861

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$604.89
$686.54
$773.04
$1,080.32
$1,641.65
$1,067.62
$1,149.27
$1,235.77
$1,543.05
$1,530.35
$1,612.00
$1,698.50
$2,005.78
$1,993.08
$2,074.73
$2,161.23
$2,468.51
$462.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,209.78
$1,373.08
$1,546.08
$2,160.64
$3,283.30
$1,672.51
$1,835.81
$2,008.81
$2,623.37
$2,135.24
$2,298.54
$2,471.54
$3,086.10
$2,597.97
$2,761.27
$2,934.27
$3,548.83
$462.73
Toc - Plan #29 WellCare of North Carolina
Silver

(PPO) Standard Silver WellCare

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-925-2861

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
$774.80
$879.39
$990.19
$1,383.78
$2,102.79
$1,367.52
$1,472.11
$1,582.91
$1,976.50
$1,960.24
$2,064.83
$2,175.63
$2,569.22
$2,552.96
$2,657.55
$2,768.35
$3,161.94
$592.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,549.60
$1,758.78
$1,980.38
$2,767.56
$4,205.58
$2,142.32
$2,351.50
$2,573.10
$3,360.28
$2,735.04
$2,944.22
$3,165.82
$3,953.00
$3,327.76
$3,536.94
$3,758.54
$4,545.72
$592.72
Toc - Plan #30 WellCare of North Carolina
Gold

(PPO) Standard Gold WellCare

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-925-2861

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$803.94
$912.46
$1,027.42
$1,435.81
$2,181.85
$1,418.94
$1,527.46
$1,642.42
$2,050.81
$2,033.94
$2,142.46
$2,257.42
$2,665.81
$2,648.94
$2,757.46
$2,872.42
$3,280.81
$615.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,607.88
$1,824.92
$2,054.84
$2,871.62
$4,363.70
$2,222.88
$2,439.92
$2,669.84
$3,486.62
$2,837.88
$3,054.92
$3,284.84
$4,101.62
$3,452.88
$3,669.92
$3,899.84
$4,716.62
$615.00

ADVERTISEMENT

UnitedHealthcare

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

Toc - Plan #31 UnitedHealthcare
Silver

(HMO) UHC Silver Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$3,250 $6,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$489.70
$555.81
$625.84
$874.61
$1,329.05
$864.32
$930.43
$1,000.46
$1,249.23
$1,238.94
$1,305.05
$1,375.08
$1,623.85
$1,613.56
$1,679.67
$1,749.70
$1,998.47
$374.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$979.40
$1,111.62
$1,251.68
$1,749.22
$2,658.10
$1,354.02
$1,486.24
$1,626.30
$2,123.84
$1,728.64
$1,860.86
$2,000.92
$2,498.46
$2,103.26
$2,235.48
$2,375.54
$2,873.08
$374.62
Toc - Plan #32 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$555.73
$630.76
$710.23
$992.54
$1,508.26
$980.87
$1,055.90
$1,135.37
$1,417.68
$1,406.01
$1,481.04
$1,560.51
$1,842.82
$1,831.15
$1,906.18
$1,985.65
$2,267.96
$425.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,111.46
$1,261.52
$1,420.46
$1,985.08
$3,016.52
$1,536.60
$1,686.66
$1,845.60
$2,410.22
$1,961.74
$2,111.80
$2,270.74
$2,835.36
$2,386.88
$2,536.94
$2,695.88
$3,260.50
$425.14
Toc - Plan #33 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
$8,050 $16,100 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
$377.45
$428.41
$482.38
$674.13
$1,024.40
$666.20
$717.16
$771.13
$962.88
$954.95
$1,005.91
$1,059.88
$1,251.63
$1,243.70
$1,294.66
$1,348.63
$1,540.38
$288.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.90
$856.82
$964.76
$1,348.26
$2,048.80
$1,043.65
$1,145.57
$1,253.51
$1,637.01
$1,332.40
$1,434.32
$1,542.26
$1,925.76
$1,621.15
$1,723.07
$1,831.01
$2,214.51
$288.75
Toc - Plan #34 UnitedHealthcare
Silver

(HMO) UHC Silver Value ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$494.27
$561.00
$631.68
$882.77
$1,341.45
$872.39
$939.12
$1,009.80
$1,260.89
$1,250.51
$1,317.24
$1,387.92
$1,639.01
$1,628.63
$1,695.36
$1,766.04
$2,017.13
$378.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$988.54
$1,122.00
$1,263.36
$1,765.54
$2,682.90
$1,366.66
$1,500.12
$1,641.48
$2,143.66
$1,744.78
$1,878.24
$2,019.60
$2,521.78
$2,122.90
$2,256.36
$2,397.72
$2,899.90
$378.12
Toc - Plan #35 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$559.50
$635.03
$715.04
$999.26
$1,518.47
$987.52
$1,063.05
$1,143.06
$1,427.28
$1,415.54
$1,491.07
$1,571.08
$1,855.30
$1,843.56
$1,919.09
$1,999.10
$2,283.32
$428.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,119.00
$1,270.06
$1,430.08
$1,998.52
$3,036.94
$1,547.02
$1,698.08
$1,858.10
$2,426.54
$1,975.04
$2,126.10
$2,286.12
$2,854.56
$2,403.06
$2,554.12
$2,714.14
$3,282.58
$428.02
Toc - Plan #36 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $5 Tier 2 Rx, 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$499.83
$567.30
$638.78
$892.69
$1,356.53
$882.20
$949.67
$1,021.15
$1,275.06
$1,264.57
$1,332.04
$1,403.52
$1,657.43
$1,646.94
$1,714.41
$1,785.89
$2,039.80
$382.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$999.66
$1,134.60
$1,277.56
$1,785.38
$2,713.06
$1,382.03
$1,516.97
$1,659.93
$2,167.75
$1,764.40
$1,899.34
$2,042.30
$2,550.12
$2,146.77
$2,281.71
$2,424.67
$2,932.49
$382.37
Toc - Plan #37 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
$5,900 $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
$496.05
$563.02
$633.96
$885.95
$1,346.29
$875.53
$942.50
$1,013.44
$1,265.43
$1,255.01
$1,321.98
$1,392.92
$1,644.91
$1,634.49
$1,701.46
$1,772.40
$2,024.39
$379.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992.10
$1,126.04
$1,267.92
$1,771.90
$2,692.58
$1,371.58
$1,505.52
$1,647.40
$2,151.38
$1,751.06
$1,885.00
$2,026.88
$2,530.86
$2,130.54
$2,264.48
$2,406.36
$2,910.34
$379.48
Toc - Plan #38 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard (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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.37
$420.38
$473.34
$661.49
$1,005.20
$653.71
$703.72
$756.68
$944.83
$937.05
$987.06
$1,040.02
$1,228.17
$1,220.39
$1,270.40
$1,323.36
$1,511.51
$283.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.74
$840.76
$946.68
$1,322.98
$2,010.40
$1,024.08
$1,124.10
$1,230.02
$1,606.32
$1,307.42
$1,407.44
$1,513.36
$1,889.66
$1,590.76
$1,690.78
$1,796.70
$2,173.00
$283.34
Toc - Plan #39 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($0 Virtual Urgent Care, $3 Tier 2 Rx, 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.98
$402.90
$453.66
$633.99
$963.40
$626.54
$674.46
$725.22
$905.55
$898.10
$946.02
$996.78
$1,177.11
$1,169.66
$1,217.58
$1,268.34
$1,448.67
$271.56
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.96
$805.80
$907.32
$1,267.98
$1,926.80
$981.52
$1,077.36
$1,178.88
$1,539.54
$1,253.08
$1,348.92
$1,450.44
$1,811.10
$1,524.64
$1,620.48
$1,722.00
$2,082.66
$271.56
Toc - Plan #40 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$8,250 $16,500 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.39
$412.44
$464.41
$649.01
$986.23
$641.38
$690.43
$742.40
$927.00
$919.37
$968.42
$1,020.39
$1,204.99
$1,197.36
$1,246.41
$1,298.38
$1,482.98
$277.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$726.78
$824.88
$928.82
$1,298.02
$1,972.46
$1,004.77
$1,102.87
$1,206.81
$1,576.01
$1,282.76
$1,380.86
$1,484.80
$1,854.00
$1,560.75
$1,658.85
$1,762.79
$2,131.99
$277.99
Toc - Plan #41 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$383.92
$435.75
$490.66
$685.69
$1,041.97
$677.62
$729.45
$784.36
$979.39
$971.32
$1,023.15
$1,078.06
$1,273.09
$1,265.02
$1,316.85
$1,371.76
$1,566.79
$293.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$767.84
$871.50
$981.32
$1,371.38
$2,083.94
$1,061.54
$1,165.20
$1,275.02
$1,665.08
$1,355.24
$1,458.90
$1,568.72
$1,958.78
$1,648.94
$1,752.60
$1,862.42
$2,252.48
$293.70
Toc - Plan #42 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$492.30
$558.76
$629.16
$879.25
$1,336.10
$868.91
$935.37
$1,005.77
$1,255.86
$1,245.52
$1,311.98
$1,382.38
$1,632.47
$1,622.13
$1,688.59
$1,758.99
$2,009.08
$376.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$984.60
$1,117.52
$1,258.32
$1,758.50
$2,672.20
$1,361.21
$1,494.13
$1,634.93
$2,135.11
$1,737.82
$1,870.74
$2,011.54
$2,511.72
$2,114.43
$2,247.35
$2,388.15
$2,888.33
$376.61
Toc - Plan #43 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, 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
$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
$562.34
$638.25
$718.67
$1,004.33
$1,526.18
$992.53
$1,068.44
$1,148.86
$1,434.52
$1,422.72
$1,498.63
$1,579.05
$1,864.71
$1,852.91
$1,928.82
$2,009.24
$2,294.90
$430.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,124.68
$1,276.50
$1,437.34
$2,008.66
$3,052.36
$1,554.87
$1,706.69
$1,867.53
$2,438.85
$1,985.06
$2,136.88
$2,297.72
$2,869.04
$2,415.25
$2,567.07
$2,727.91
$3,299.23
$430.19
Toc - Plan #44 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$513.73
$583.08
$656.55
$917.52
$1,394.26
$906.73
$976.08
$1,049.55
$1,310.52
$1,299.73
$1,369.08
$1,442.55
$1,703.52
$1,692.73
$1,762.08
$1,835.55
$2,096.52
$393.00
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,027.46
$1,166.16
$1,313.10
$1,835.04
$2,788.52
$1,420.46
$1,559.16
$1,706.10
$2,228.04
$1,813.46
$1,952.16
$2,099.10
$2,621.04
$2,206.46
$2,345.16
$2,492.10
$3,014.04
$393.00
Toc - Plan #45 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$578.46
$656.55
$739.27
$1,033.13
$1,569.95
$1,020.98
$1,099.07
$1,181.79
$1,475.65
$1,463.50
$1,541.59
$1,624.31
$1,918.17
$1,906.02
$1,984.11
$2,066.83
$2,360.69
$442.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,156.92
$1,313.10
$1,478.54
$2,066.26
$3,139.90
$1,599.44
$1,755.62
$1,921.06
$2,508.78
$2,041.96
$2,198.14
$2,363.58
$2,951.30
$2,484.48
$2,640.66
$2,806.10
$3,393.82
$442.52

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #46 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 2 HSA: Aetna network of doctors & hospitals + MinuteClinic + Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 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
$264.11
$299.77
$337.53
$471.70
$716.79
$466.16
$501.82
$539.58
$673.75
$668.21
$703.87
$741.63
$875.80
$870.26
$905.92
$943.68
$1,077.85
$202.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$528.22
$599.54
$675.06
$943.40
$1,433.58
$730.27
$801.59
$877.11
$1,145.45
$932.32
$1,003.64
$1,079.16
$1,347.50
$1,134.37
$1,205.69
$1,281.21
$1,549.55
$202.05
Toc - Plan #47 Aetna CVS Health
Silver

(HMO) Silver 7: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,845 $17,690 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$362.42
$411.35
$463.18
$647.29
$983.61
$639.68
$688.61
$740.44
$924.55
$916.94
$965.87
$1,017.70
$1,201.81
$1,194.20
$1,243.13
$1,294.96
$1,479.07
$277.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.84
$822.70
$926.36
$1,294.58
$1,967.22
$1,002.10
$1,099.96
$1,203.62
$1,571.84
$1,279.36
$1,377.22
$1,480.88
$1,849.10
$1,556.62
$1,654.48
$1,758.14
$2,126.36
$277.26
Toc - Plan #48 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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
$367.44
$417.04
$469.59
$656.24
$997.22
$648.53
$698.13
$750.68
$937.33
$929.62
$979.22
$1,031.77
$1,218.42
$1,210.71
$1,260.31
$1,312.86
$1,499.51
$281.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.88
$834.08
$939.18
$1,312.48
$1,994.44
$1,015.97
$1,115.17
$1,220.27
$1,593.57
$1,297.06
$1,396.26
$1,501.36
$1,874.66
$1,578.15
$1,677.35
$1,782.45
$2,155.75
$281.09
Toc - Plan #49 Aetna CVS Health
Expanded Bronze

(HMO) Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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
$9,400 $18,800 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
$268.82
$305.11
$343.55
$480.11
$729.57
$474.47
$510.76
$549.20
$685.76
$680.12
$716.41
$754.85
$891.41
$885.77
$922.06
$960.50
$1,097.06
$205.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$537.64
$610.22
$687.10
$960.22
$1,459.14
$743.29
$815.87
$892.75
$1,165.87
$948.94
$1,021.52
$1,098.40
$1,371.52
$1,154.59
$1,227.17
$1,304.05
$1,577.17
$205.65
Toc - Plan #50 Aetna CVS Health
Gold

(HMO) Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 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
$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
$363.01
$412.02
$463.93
$648.34
$985.21
$640.72
$689.73
$741.64
$926.05
$918.43
$967.44
$1,019.35
$1,203.76
$1,196.14
$1,245.15
$1,297.06
$1,481.47
$277.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$726.02
$824.04
$927.86
$1,296.68
$1,970.42
$1,003.73
$1,101.75
$1,205.57
$1,574.39
$1,281.44
$1,379.46
$1,483.28
$1,852.10
$1,559.15
$1,657.17
$1,760.99
$2,129.81
$277.71
Toc - Plan #51 Aetna CVS Health
Silver

(HMO) Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

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
$354.73
$402.62
$453.35
$633.55
$962.74
$626.10
$673.99
$724.72
$904.92
$897.47
$945.36
$996.09
$1,176.29
$1,168.84
$1,216.73
$1,267.46
$1,447.66
$271.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.46
$805.24
$906.70
$1,267.10
$1,925.48
$980.83
$1,076.61
$1,178.07
$1,538.47
$1,252.20
$1,347.98
$1,449.44
$1,809.84
$1,523.57
$1,619.35
$1,720.81
$2,081.21
$271.37
Toc - Plan #52 Aetna CVS Health
Expanded Bronze

(HMO) Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 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
$297.82
$338.02
$380.61
$531.90
$808.26
$525.65
$565.85
$608.44
$759.73
$753.48
$793.68
$836.27
$987.56
$981.31
$1,021.51
$1,064.10
$1,215.39
$227.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.64
$676.04
$761.22
$1,063.80
$1,616.52
$823.47
$903.87
$989.05
$1,291.63
$1,051.30
$1,131.70
$1,216.88
$1,519.46
$1,279.13
$1,359.53
$1,444.71
$1,747.29
$227.83
Toc - Plan #53 Aetna CVS Health
Gold

(HMO) Gold 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$795 $1,590 Annual Deductible
$9,195 $18,390 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$363.61
$412.70
$464.69
$649.41
$986.83
$641.77
$690.86
$742.85
$927.57
$919.93
$969.02
$1,021.01
$1,205.73
$1,198.09
$1,247.18
$1,299.17
$1,483.89
$278.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.22
$825.40
$929.38
$1,298.82
$1,973.66
$1,005.38
$1,103.56
$1,207.54
$1,576.98
$1,283.54
$1,381.72
$1,485.70
$1,855.14
$1,561.70
$1,659.88
$1,763.86
$2,133.30
$278.16
Toc - Plan #54 Aetna CVS Health
Gold

(HMO) Gold 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 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
$366.88
$416.41
$468.88
$655.25
$995.72
$647.55
$697.08
$749.55
$935.92
$928.22
$977.75
$1,030.22
$1,216.59
$1,208.89
$1,258.42
$1,310.89
$1,497.26
$280.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.76
$832.82
$937.76
$1,310.50
$1,991.44
$1,014.43
$1,113.49
$1,218.43
$1,591.17
$1,295.10
$1,394.16
$1,499.10
$1,871.84
$1,575.77
$1,674.83
$1,779.77
$2,152.51
$280.67
Toc - Plan #55 Aetna CVS Health
Silver

(HMO) Silver 5: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$8,395 $16,790 Annual Deductible
$8,885 $17,770 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.87
$402.78
$453.53
$633.80
$963.12
$626.35
$674.26
$725.01
$905.28
$897.83
$945.74
$996.49
$1,176.76
$1,169.31
$1,217.22
$1,267.97
$1,448.24
$271.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.74
$805.56
$907.06
$1,267.60
$1,926.24
$981.22
$1,077.04
$1,178.54
$1,539.08
$1,252.70
$1,348.52
$1,450.02
$1,810.56
$1,524.18
$1,620.00
$1,721.50
$2,082.04
$271.48
Toc - Plan #56 Aetna CVS Health
Silver

(HMO) Silver 6: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$7,795 $15,590 Annual Deductible
$8,445 $16,890 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$362.46
$411.39
$463.22
$647.34
$983.70
$639.74
$688.67
$740.50
$924.62
$917.02
$965.95
$1,017.78
$1,201.90
$1,194.30
$1,243.23
$1,295.06
$1,479.18
$277.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$724.92
$822.78
$926.44
$1,294.68
$1,967.40
$1,002.20
$1,100.06
$1,203.72
$1,571.96
$1,279.48
$1,377.34
$1,481.00
$1,849.24
$1,556.76
$1,654.62
$1,758.28
$2,126.52
$277.28

ADVERTISEMENT

Cigna Healthcare

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

Toc - Plan #57 Cigna Healthcare
Bronze

(HMO) Connect Bronze 9450 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$323.06
$366.67
$412.87
$576.99
$876.79
$570.20
$613.81
$660.01
$824.13
$817.34
$860.95
$907.15
$1,071.27
$1,064.48
$1,108.09
$1,154.29
$1,318.41
$247.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.12
$733.34
$825.74
$1,153.98
$1,753.58
$893.26
$980.48
$1,072.88
$1,401.12
$1,140.40
$1,227.62
$1,320.02
$1,648.26
$1,387.54
$1,474.76
$1,567.16
$1,895.40
$247.14
Toc - Plan #58 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 6500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$341.56
$387.67
$436.52
$610.03
$927.00
$602.85
$648.96
$697.81
$871.32
$864.14
$910.25
$959.10
$1,132.61
$1,125.43
$1,171.54
$1,220.39
$1,393.90
$261.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$683.12
$775.34
$873.04
$1,220.06
$1,854.00
$944.41
$1,036.63
$1,134.33
$1,481.35
$1,205.70
$1,297.92
$1,395.62
$1,742.64
$1,466.99
$1,559.21
$1,656.91
$2,003.93
$261.29
Toc - Plan #59 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 5500 Indiv Med Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$338.71
$384.44
$432.87
$604.94
$919.26
$597.82
$643.55
$691.98
$864.05
$856.93
$902.66
$951.09
$1,123.16
$1,116.04
$1,161.77
$1,210.20
$1,382.27
$259.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$677.42
$768.88
$865.74
$1,209.88
$1,838.52
$936.53
$1,027.99
$1,124.85
$1,468.99
$1,195.64
$1,287.10
$1,383.96
$1,728.10
$1,454.75
$1,546.21
$1,643.07
$1,987.21
$259.11
Toc - Plan #60 Cigna Healthcare
Silver

(HMO) Connect Silver 4500 Indiv Med Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.94
$448.25
$504.73
$705.36
$1,071.86
$697.07
$750.38
$806.86
$1,007.49
$999.20
$1,052.51
$1,108.99
$1,309.62
$1,301.33
$1,354.64
$1,411.12
$1,611.75
$302.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$789.88
$896.50
$1,009.46
$1,410.72
$2,143.72
$1,092.01
$1,198.63
$1,311.59
$1,712.85
$1,394.14
$1,500.76
$1,613.72
$2,014.98
$1,696.27
$1,802.89
$1,915.85
$2,317.11
$302.13
Toc - Plan #61 Cigna Healthcare
Silver

(HMO) Connect Silver 3500 Indiv Med Deductible

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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$394.85
$448.15
$504.61
$705.20
$1,071.61
$696.91
$750.21
$806.67
$1,007.26
$998.97
$1,052.27
$1,108.73
$1,309.32
$1,301.03
$1,354.33
$1,410.79
$1,611.38
$302.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$789.70
$896.30
$1,009.22
$1,410.40
$2,143.22
$1,091.76
$1,198.36
$1,311.28
$1,712.46
$1,393.82
$1,500.42
$1,613.34
$2,014.52
$1,695.88
$1,802.48
$1,915.40
$2,316.58
$302.06
Toc - Plan #62 Cigna Healthcare
Silver

(HMO) Connect Silver 1500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$399.55
$453.49
$510.63
$713.60
$1,084.38
$705.21
$759.15
$816.29
$1,019.26
$1,010.87
$1,064.81
$1,121.95
$1,324.92
$1,316.53
$1,370.47
$1,427.61
$1,630.58
$305.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$799.10
$906.98
$1,021.26
$1,427.20
$2,168.76
$1,104.76
$1,212.64
$1,326.92
$1,732.86
$1,410.42
$1,518.30
$1,632.58
$2,038.52
$1,716.08
$1,823.96
$1,938.24
$2,344.18
$305.66
Toc - Plan #63 Cigna Healthcare
Silver

(HMO) Connect Silver 2500 Indiv Med Deductible Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.42
$452.21
$509.18
$711.58
$1,081.31
$703.21
$757.00
$813.97
$1,016.37
$1,008.00
$1,061.79
$1,118.76
$1,321.16
$1,312.79
$1,366.58
$1,423.55
$1,625.95
$304.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.84
$904.42
$1,018.36
$1,423.16
$2,162.62
$1,101.63
$1,209.21
$1,323.15
$1,727.95
$1,406.42
$1,514.00
$1,627.94
$2,032.74
$1,711.21
$1,818.79
$1,932.73
$2,337.53
$304.79
Toc - Plan #64 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze CMS Standard

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
$9,400 $18,800 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
$336.72
$382.18
$430.33
$601.38
$913.86
$594.31
$639.77
$687.92
$858.97
$851.90
$897.36
$945.51
$1,116.56
$1,109.49
$1,154.95
$1,203.10
$1,374.15
$257.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$673.44
$764.36
$860.66
$1,202.76
$1,827.72
$931.03
$1,021.95
$1,118.25
$1,460.35
$1,188.62
$1,279.54
$1,375.84
$1,717.94
$1,446.21
$1,537.13
$1,633.43
$1,975.53
$257.59
Toc - Plan #65 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 0 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.38
$407.90
$459.29
$641.86
$975.37
$634.31
$682.83
$734.22
$916.79
$909.24
$957.76
$1,009.15
$1,191.72
$1,184.17
$1,232.69
$1,284.08
$1,466.65
$274.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.76
$815.80
$918.58
$1,283.72
$1,950.74
$993.69
$1,090.73
$1,193.51
$1,558.65
$1,268.62
$1,365.66
$1,468.44
$1,833.58
$1,543.55
$1,640.59
$1,743.37
$2,108.51
$274.93
Toc - Plan #66 Cigna Healthcare
Silver

(HMO) Connect Silver CMS Standard

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
$394.48
$447.74
$504.15
$704.55
$1,070.63
$696.26
$749.52
$805.93
$1,006.33
$998.04
$1,051.30
$1,107.71
$1,308.11
$1,299.82
$1,353.08
$1,409.49
$1,609.89
$301.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.96
$895.48
$1,008.30
$1,409.10
$2,141.26
$1,090.74
$1,197.26
$1,310.08
$1,710.88
$1,392.52
$1,499.04
$1,611.86
$2,012.66
$1,694.30
$1,800.82
$1,913.64
$2,314.44
$301.78
Toc - Plan #67 Cigna Healthcare
Gold

(HMO) Connect Gold CMS Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$535.61
$607.92
$684.52
$956.61
$1,453.66
$945.36
$1,017.67
$1,094.27
$1,366.36
$1,355.11
$1,427.42
$1,504.02
$1,776.11
$1,764.86
$1,837.17
$1,913.77
$2,185.86
$409.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,071.22
$1,215.84
$1,369.04
$1,913.22
$2,907.32
$1,480.97
$1,625.59
$1,778.79
$2,322.97
$1,890.72
$2,035.34
$2,188.54
$2,732.72
$2,300.47
$2,445.09
$2,598.29
$3,142.47
$409.75

ADVERTISEMENT

Ambetter of North Carolina

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

Toc - Plan #68 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 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
$309.28
$351.03
$395.25
$552.36
$839.37
$545.87
$587.62
$631.84
$788.95
$782.46
$824.21
$868.43
$1,025.54
$1,019.05
$1,060.80
$1,105.02
$1,262.13
$236.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.56
$702.06
$790.50
$1,104.72
$1,678.74
$855.15
$938.65
$1,027.09
$1,341.31
$1,091.74
$1,175.24
$1,263.68
$1,577.90
$1,328.33
$1,411.83
$1,500.27
$1,814.49
$236.59
Toc - Plan #69 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 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
$303.32
$344.26
$387.63
$541.72
$823.19
$535.35
$576.29
$619.66
$773.75
$767.38
$808.32
$851.69
$1,005.78
$999.41
$1,040.35
$1,083.72
$1,237.81
$232.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$606.64
$688.52
$775.26
$1,083.44
$1,646.38
$838.67
$920.55
$1,007.29
$1,315.47
$1,070.70
$1,152.58
$1,239.32
$1,547.50
$1,302.73
$1,384.61
$1,471.35
$1,779.53
$232.03
Toc - Plan #70 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
$9,250 $18,500 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
$346.33
$393.07
$442.59
$618.52
$939.90
$611.26
$658.00
$707.52
$883.45
$876.19
$922.93
$972.45
$1,148.38
$1,141.12
$1,187.86
$1,237.38
$1,413.31
$264.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$692.66
$786.14
$885.18
$1,237.04
$1,879.80
$957.59
$1,051.07
$1,150.11
$1,501.97
$1,222.52
$1,316.00
$1,415.04
$1,766.90
$1,487.45
$1,580.93
$1,679.97
$2,031.83
$264.93
Toc - Plan #71 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
$388.62
$441.07
$496.64
$694.05
$1,054.68
$685.91
$738.36
$793.93
$991.34
$983.20
$1,035.65
$1,091.22
$1,288.63
$1,280.49
$1,332.94
$1,388.51
$1,585.92
$297.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.24
$882.14
$993.28
$1,388.10
$2,109.36
$1,074.53
$1,179.43
$1,290.57
$1,685.39
$1,371.82
$1,476.72
$1,587.86
$1,982.68
$1,669.11
$1,774.01
$1,885.15
$2,279.97
$297.29
Toc - Plan #72 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
$385.02
$436.98
$492.04
$687.63
$1,044.91
$679.55
$731.51
$786.57
$982.16
$974.08
$1,026.04
$1,081.10
$1,276.69
$1,268.61
$1,320.57
$1,375.63
$1,571.22
$294.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.04
$873.96
$984.08
$1,375.26
$2,089.82
$1,064.57
$1,168.49
$1,278.61
$1,669.79
$1,359.10
$1,463.02
$1,573.14
$1,964.32
$1,653.63
$1,757.55
$1,867.67
$2,258.85
$294.53
Toc - Plan #73 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
$377.48
$428.43
$482.41
$674.17
$1,024.46
$666.25
$717.20
$771.18
$962.94
$955.02
$1,005.97
$1,059.95
$1,251.71
$1,243.79
$1,294.74
$1,348.72
$1,540.48
$288.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$754.96
$856.86
$964.82
$1,348.34
$2,048.92
$1,043.73
$1,145.63
$1,253.59
$1,637.11
$1,332.50
$1,434.40
$1,542.36
$1,925.88
$1,621.27
$1,723.17
$1,831.13
$2,214.65
$288.77
Toc - Plan #74 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
$6,300 $12,600 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
$382.54
$434.18
$488.88
$683.21
$1,038.20
$675.18
$726.82
$781.52
$975.85
$967.82
$1,019.46
$1,074.16
$1,268.49
$1,260.46
$1,312.10
$1,366.80
$1,561.13
$292.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$765.08
$868.36
$977.76
$1,366.42
$2,076.40
$1,057.72
$1,161.00
$1,270.40
$1,659.06
$1,350.36
$1,453.64
$1,563.04
$1,951.70
$1,643.00
$1,746.28
$1,855.68
$2,244.34
$292.64
Toc - Plan #75 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
$405.00
$459.67
$517.58
$723.32
$1,099.15
$714.82
$769.49
$827.40
$1,033.14
$1,024.64
$1,079.31
$1,137.22
$1,342.96
$1,334.46
$1,389.13
$1,447.04
$1,652.78
$309.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.00
$919.34
$1,035.16
$1,446.64
$2,198.30
$1,119.82
$1,229.16
$1,344.98
$1,756.46
$1,429.64
$1,538.98
$1,654.80
$2,066.28
$1,739.46
$1,848.80
$1,964.62
$2,376.10
$309.82
Toc - Plan #76 Ambetter of North Carolina
Expanded Bronze

(HMO) 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
$9,400 $18,800 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
$298.00
$338.22
$380.83
$532.21
$808.74
$525.96
$566.18
$608.79
$760.17
$753.92
$794.14
$836.75
$988.13
$981.88
$1,022.10
$1,064.71
$1,216.09
$227.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$596.00
$676.44
$761.66
$1,064.42
$1,617.48
$823.96
$904.40
$989.62
$1,292.38
$1,051.92
$1,132.36
$1,217.58
$1,520.34
$1,279.88
$1,360.32
$1,445.54
$1,748.30
$227.96
Toc - Plan #77 Ambetter of North Carolina
Silver

(HMO) 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
$5,900 $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
$374.93
$425.54
$479.15
$669.61
$1,017.54
$661.75
$712.36
$765.97
$956.43
$948.57
$999.18
$1,052.79
$1,243.25
$1,235.39
$1,286.00
$1,339.61
$1,530.07
$286.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.86
$851.08
$958.30
$1,339.22
$2,035.08
$1,036.68
$1,137.90
$1,245.12
$1,626.04
$1,323.50
$1,424.72
$1,531.94
$1,912.86
$1,610.32
$1,711.54
$1,818.76
$2,199.68
$286.82
Toc - Plan #78 Ambetter of North Carolina
Gold

(HMO) 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$388.73
$441.20
$496.78
$694.25
$1,054.99
$686.10
$738.57
$794.15
$991.62
$983.47
$1,035.94
$1,091.52
$1,288.99
$1,280.84
$1,333.31
$1,388.89
$1,586.36
$297.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$777.46
$882.40
$993.56
$1,388.50
$2,109.98
$1,074.83
$1,179.77
$1,290.93
$1,685.87
$1,372.20
$1,477.14
$1,588.30
$1,983.24
$1,669.57
$1,774.51
$1,885.67
$2,280.61
$297.37
Toc - Plan #79 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
$7,250 $14,500 Annual Deductible
$7,250 $14,500 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
$321.52
$364.92
$410.89
$574.22
$872.59
$567.48
$610.88
$656.85
$820.18
$813.44
$856.84
$902.81
$1,066.14
$1,059.40
$1,102.80
$1,148.77
$1,312.10
$245.96
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$643.04
$729.84
$821.78
$1,148.44
$1,745.18
$889.00
$975.80
$1,067.74
$1,394.40
$1,134.96
$1,221.76
$1,313.70
$1,640.36
$1,380.92
$1,467.72
$1,559.66
$1,886.32
$245.96
Toc - Plan #80 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
$8,450 $16,900 Annual Deductible
$9,250 $18,500 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
$315.33
$357.88
$402.97
$563.15
$855.77
$556.55
$599.10
$644.19
$804.37
$797.77
$840.32
$885.41
$1,045.59
$1,038.99
$1,081.54
$1,126.63
$1,286.81
$241.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$630.66
$715.76
$805.94
$1,126.30
$1,711.54
$871.88
$956.98
$1,047.16
$1,367.52
$1,113.10
$1,198.20
$1,288.38
$1,608.74
$1,354.32
$1,439.42
$1,529.60
$1,849.96
$241.22
Toc - Plan #81 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
$9,250 $18,500 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
$360.03
$408.62
$460.11
$643.00
$977.10
$635.45
$684.04
$735.53
$918.42
$910.87
$959.46
$1,010.95
$1,193.84
$1,186.29
$1,234.88
$1,286.37
$1,469.26
$275.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$720.06
$817.24
$920.22
$1,286.00
$1,954.20
$995.48
$1,092.66
$1,195.64
$1,561.42
$1,270.90
$1,368.08
$1,471.06
$1,836.84
$1,546.32
$1,643.50
$1,746.48
$2,112.26
$275.42
Toc - Plan #82 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
$404.00
$458.52
$516.29
$721.52
$1,096.42
$713.05
$767.57
$825.34
$1,030.57
$1,022.10
$1,076.62
$1,134.39
$1,339.62
$1,331.15
$1,385.67
$1,443.44
$1,648.67
$309.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.00
$917.04
$1,032.58
$1,443.04
$2,192.84
$1,117.05
$1,226.09
$1,341.63
$1,752.09
$1,426.10
$1,535.14
$1,650.68
$2,061.14
$1,735.15
$1,844.19
$1,959.73
$2,370.19
$309.05
Toc - Plan #83 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
$400.25
$454.28
$511.51
$714.84
$1,086.26
$706.44
$760.47
$817.70
$1,021.03
$1,012.63
$1,066.66
$1,123.89
$1,327.22
$1,318.82
$1,372.85
$1,430.08
$1,633.41
$306.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$800.50
$908.56
$1,023.02
$1,429.68
$2,172.52
$1,106.69
$1,214.75
$1,329.21
$1,735.87
$1,412.88
$1,520.94
$1,635.40
$2,042.06
$1,719.07
$1,827.13
$1,941.59
$2,348.25
$306.19
Toc - Plan #84 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
$392.42
$445.39
$501.50
$700.84
$1,065.00
$692.61
$745.58
$801.69
$1,001.03
$992.80
$1,045.77
$1,101.88
$1,301.22
$1,292.99
$1,345.96
$1,402.07
$1,601.41
$300.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.84
$890.78
$1,003.00
$1,401.68
$2,130.00
$1,085.03
$1,190.97
$1,303.19
$1,701.87
$1,385.22
$1,491.16
$1,603.38
$2,002.06
$1,685.41
$1,791.35
$1,903.57
$2,302.25
$300.19
Toc - Plan #85 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
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$397.68
$451.36
$508.22
$710.24
$1,079.28
$701.90
$755.58
$812.44
$1,014.46
$1,006.12
$1,059.80
$1,116.66
$1,318.68
$1,310.34
$1,364.02
$1,420.88
$1,622.90
$304.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$795.36
$902.72
$1,016.44
$1,420.48
$2,158.56
$1,099.58
$1,206.94
$1,320.66
$1,724.70
$1,403.80
$1,511.16
$1,624.88
$2,028.92
$1,708.02
$1,815.38
$1,929.10
$2,333.14
$304.22
Toc - Plan #86 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
$421.03
$477.86
$538.06
$751.94
$1,142.64
$743.11
$799.94
$860.14
$1,074.02
$1,065.19
$1,122.02
$1,182.22
$1,396.10
$1,387.27
$1,444.10
$1,504.30
$1,718.18
$322.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$842.06
$955.72
$1,076.12
$1,503.88
$2,285.28
$1,164.14
$1,277.80
$1,398.20
$1,825.96
$1,486.22
$1,599.88
$1,720.28
$2,148.04
$1,808.30
$1,921.96
$2,042.36
$2,470.12
$322.08
Toc - Plan #87 Ambetter of North Carolina
Expanded Bronze

(HMO) Standard Expanded 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
$7,500 $15,000 Annual Deductible
$9,400 $18,800 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
$309.79
$351.60
$395.90
$553.27
$840.75
$546.77
$588.58
$632.88
$790.25
$783.75
$825.56
$869.86
$1,027.23
$1,020.73
$1,062.54
$1,106.84
$1,264.21
$236.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$619.58
$703.20
$791.80
$1,106.54
$1,681.50
$856.56
$940.18
$1,028.78
$1,343.52
$1,093.54
$1,177.16
$1,265.76
$1,580.50
$1,330.52
$1,414.14
$1,502.74
$1,817.48
$236.98
Toc - Plan #88 Ambetter of North Carolina
Silver

(HMO) Standard 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
$5,900 $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
$389.77
$442.38
$498.11
$696.11
$1,057.81
$687.94
$740.55
$796.28
$994.28
$986.11
$1,038.72
$1,094.45
$1,292.45
$1,284.28
$1,336.89
$1,392.62
$1,590.62
$298.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$779.54
$884.76
$996.22
$1,392.22
$2,115.62
$1,077.71
$1,182.93
$1,294.39
$1,690.39
$1,375.88
$1,481.10
$1,592.56
$1,988.56
$1,674.05
$1,779.27
$1,890.73
$2,286.73
$298.17
Toc - Plan #89 Ambetter of North Carolina
Gold

(HMO) Standard 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
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$404.11
$458.66
$516.44
$721.73
$1,096.74
$713.25
$767.80
$825.58
$1,030.87
$1,022.39
$1,076.94
$1,134.72
$1,340.01
$1,331.53
$1,386.08
$1,443.86
$1,649.15
$309.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$808.22
$917.32
$1,032.88
$1,443.46
$2,193.48
$1,117.36
$1,226.46
$1,342.02
$1,752.60
$1,426.50
$1,535.60
$1,651.16
$2,061.74
$1,735.64
$1,844.74
$1,960.30
$2,370.88
$309.14

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Davidson County here.

Davidson County is in “Rating Area 6” of North Carolina.

Currently, there are 89 plans offered in Rating Area 6.

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2024 Obamacare Plans for Davidson County, NC

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