McDowell County, North Carolina Obamacare 2024 Rates

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 McDowell 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, 110 Plans and 2024 Rates for McDowell County, North Carolina

Below, you’ll find a summary of the 110 plans for McDowell 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 |

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

Silver

(PPO) Blue Advantage Silver Preferred | 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

$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

$476.52
$540.85
$608.99
$851.06
$1,293.28

$841.06
$905.39
$973.53
$1,215.60

$1,205.60
$1,269.93
$1,338.07
$1,580.14

$1,570.14
$1,634.47
$1,702.61
$1,944.68

$364.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$953.04
$1,081.70
$1,217.98
$1,702.12
$2,586.56

$1,317.58
$1,446.24
$1,582.52
$2,066.66

$1,682.12
$1,810.78
$1,947.06
$2,431.20

$2,046.66
$2,175.32
$2,311.60
$2,795.74

$364.54

Toc - Plan #2 Blue Cross and Blue Shield of NC

Silver

(PPO) Blue Advantage Silver Secure | $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

$1,600 $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

$496.49
$563.52
$634.51
$886.73
$1,347.47

$876.30
$943.33
$1,014.32
$1,266.54

$1,256.11
$1,323.14
$1,394.13
$1,646.35

$1,635.92
$1,702.95
$1,773.94
$2,026.16

$379.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$992.98
$1,127.04
$1,269.02
$1,773.46
$2,694.94

$1,372.79
$1,506.85
$1,648.83
$2,153.27

$1,752.60
$1,886.66
$2,028.64
$2,533.08

$2,132.41
$2,266.47
$2,408.45
$2,912.89

$379.81

Toc - Plan #3 Blue Cross and Blue Shield of NC

Expanded Bronze

(PPO) Blue Advantage Bronze | 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

$9,450 $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

$360.84
$409.55
$461.15
$644.46
$979.32

$636.88
$685.59
$737.19
$920.50

$912.92
$961.63
$1,013.23
$1,196.54

$1,188.96
$1,237.67
$1,289.27
$1,472.58

$276.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$721.68
$819.10
$922.30
$1,288.92
$1,958.64

$997.72
$1,095.14
$1,198.34
$1,564.96

$1,273.76
$1,371.18
$1,474.38
$1,841.00

$1,549.80
$1,647.22
$1,750.42
$2,117.04

$276.04

Toc - Plan #4 Blue Cross and Blue Shield of NC

Gold

(PPO) Blue Advantage Gold | 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

$494.19
$560.91
$631.57
$882.62
$1,341.23

$872.25
$938.97
$1,009.63
$1,260.68

$1,250.31
$1,317.03
$1,387.69
$1,638.74

$1,628.37
$1,695.09
$1,765.75
$2,016.80

$378.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$988.38
$1,121.82
$1,263.14
$1,765.24
$2,682.46

$1,366.44
$1,499.88
$1,641.20
$2,143.30

$1,744.50
$1,877.94
$2,019.26
$2,521.36

$2,122.56
$2,256.00
$2,397.32
$2,899.42

$378.06

Toc - Plan #5 Blue Cross and Blue Shield of NC

Expanded Bronze

(PPO) Blue Advantage Bronze | 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

$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

$361.97
$410.84
$462.60
$646.48
$982.39

$638.88
$687.75
$739.51
$923.39

$915.79
$964.66
$1,016.42
$1,200.30

$1,192.70
$1,241.57
$1,293.33
$1,477.21

$276.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$723.94
$821.68
$925.20
$1,292.96
$1,964.78

$1,000.85
$1,098.59
$1,202.11
$1,569.87

$1,277.76
$1,375.50
$1,479.02
$1,846.78

$1,554.67
$1,652.41
$1,755.93
$2,123.69

$276.91

Toc - Plan #6 Blue Cross and Blue Shield of NC

Catastrophic

(PPO) Blue Advantage Catastrophic | 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

$9,450 $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

$285.91
$324.51
$365.39
$510.64
$775.96

$504.63
$543.23
$584.11
$729.36

$723.35
$761.95
$802.83
$948.08

$942.07
$980.67
$1,021.55
$1,166.80

$218.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$571.82
$649.02
$730.78
$1,021.28
$1,551.92

$790.54
$867.74
$949.50
$1,240.00

$1,009.26
$1,086.46
$1,168.22
$1,458.72

$1,227.98
$1,305.18
$1,386.94
$1,677.44

$218.72

Toc - Plan #7 Blue Cross and Blue Shield of NC

Silver

(PPO) Blue Advantage Silver Choice | 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

$9,450 $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

$499.88
$567.36
$638.85
$892.79
$1,356.67

$882.29
$949.77
$1,021.26
$1,275.20

$1,264.70
$1,332.18
$1,403.67
$1,657.61

$1,647.11
$1,714.59
$1,786.08
$2,040.02

$382.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$999.76
$1,134.72
$1,277.70
$1,785.58
$2,713.34

$1,382.17
$1,517.13
$1,660.11
$2,167.99

$1,764.58
$1,899.54
$2,042.52
$2,550.40

$2,146.99
$2,281.95
$2,424.93
$2,932.81

$382.41

Toc - Plan #8 Blue Cross and Blue Shield of NC

Expanded Bronze

(PPO) Blue Advantage Bronze | $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

$9,450 $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

$382.27
$433.88
$488.54
$682.73
$1,037.48

$674.71
$726.32
$780.98
$975.17

$967.15
$1,018.76
$1,073.42
$1,267.61

$1,259.59
$1,311.20
$1,365.86
$1,560.05

$292.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$764.54
$867.76
$977.08
$1,365.46
$2,074.96

$1,056.98
$1,160.20
$1,269.52
$1,657.90

$1,349.42
$1,452.64
$1,561.96
$1,950.34

$1,641.86
$1,745.08
$1,854.40
$2,242.78

$292.44

Toc - Plan #9 Blue Cross and Blue Shield of NC

Gold

(PPO) Blue Advantage Gold Standard | Nationwide Doctors

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

$494.24
$560.96
$631.64
$882.71
$1,341.37

$872.33
$939.05
$1,009.73
$1,260.80

$1,250.42
$1,317.14
$1,387.82
$1,638.89

$1,628.51
$1,695.23
$1,765.91
$2,016.98

$378.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$988.48
$1,121.92
$1,263.28
$1,765.42
$2,682.74

$1,366.57
$1,500.01
$1,641.37
$2,143.51

$1,744.66
$1,878.10
$2,019.46
$2,521.60

$2,122.75
$2,256.19
$2,397.55
$2,899.69

$378.09

Toc - Plan #10 Blue Cross and Blue Shield of NC

Silver

(PPO) Blue Advantage Silver Standard | Nationwide Doctors

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

$483.60
$548.89
$618.04
$863.71
$1,312.49

$853.55
$918.84
$987.99
$1,233.66

$1,223.50
$1,288.79
$1,357.94
$1,603.61

$1,593.45
$1,658.74
$1,727.89
$1,973.56

$369.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$967.20
$1,097.78
$1,236.08
$1,727.42
$2,624.98

$1,337.15
$1,467.73
$1,606.03
$2,097.37

$1,707.10
$1,837.68
$1,975.98
$2,467.32

$2,077.05
$2,207.63
$2,345.93
$2,837.27

$369.95

Toc - Plan #11 Blue Cross and Blue Shield of NC

Expanded Bronze

(PPO) Blue Advantage Bronze Standard | 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

$9,400 $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

$370.18
$420.15
$473.09
$661.14
$1,004.67

$653.37
$703.34
$756.28
$944.33

$936.56
$986.53
$1,039.47
$1,227.52

$1,219.75
$1,269.72
$1,322.66
$1,510.71

$283.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$740.36
$840.30
$946.18
$1,322.28
$2,009.34

$1,023.55
$1,123.49
$1,229.37
$1,605.47

$1,306.74
$1,406.68
$1,512.56
$1,888.66

$1,589.93
$1,689.87
$1,795.75
$2,171.85

$283.19

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-735-2962

Toc - Plan #12 CareSource

Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$353.84
$401.60
$452.20
$631.95
$960.31

$624.52
$672.28
$722.88
$902.63

$895.20
$942.96
$993.56
$1,173.31

$1,165.88
$1,213.64
$1,264.24
$1,443.99

$270.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.68
$803.20
$904.40
$1,263.90
$1,920.62

$978.36
$1,073.88
$1,175.08
$1,534.58

$1,249.04
$1,344.56
$1,445.76
$1,805.26

$1,519.72
$1,615.24
$1,716.44
$2,075.94

$270.68

Toc - Plan #13 CareSource

Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$438.45
$497.63
$560.33
$783.06
$1,189.94

$773.86
$833.04
$895.74
$1,118.47

$1,109.27
$1,168.45
$1,231.15
$1,453.88

$1,444.68
$1,503.86
$1,566.56
$1,789.29

$335.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$876.90
$995.26
$1,120.66
$1,566.12
$2,379.88

$1,212.31
$1,330.67
$1,456.07
$1,901.53

$1,547.72
$1,666.08
$1,791.48
$2,236.94

$1,883.13
$2,001.49
$2,126.89
$2,572.35

$335.41

Toc - Plan #14 CareSource

Silver

(HMO) CareSource Marketplace Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$433.73
$492.28
$554.30
$774.63
$1,177.13

$765.53
$824.08
$886.10
$1,106.43

$1,097.33
$1,155.88
$1,217.90
$1,438.23

$1,429.13
$1,487.68
$1,549.70
$1,770.03

$331.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$867.46
$984.56
$1,108.60
$1,549.26
$2,354.26

$1,199.26
$1,316.36
$1,440.40
$1,881.06

$1,531.06
$1,648.16
$1,772.20
$2,212.86

$1,862.86
$1,979.96
$2,104.00
$2,544.66

$331.80

Toc - Plan #15 CareSource

Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$505.43
$573.66
$645.93
$902.69
$1,371.72

$892.08
$960.31
$1,032.58
$1,289.34

$1,278.73
$1,346.96
$1,419.23
$1,675.99

$1,665.38
$1,733.61
$1,805.88
$2,062.64

$386.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,010.86
$1,147.32
$1,291.86
$1,805.38
$2,743.44

$1,397.51
$1,533.97
$1,678.51
$2,192.03

$1,784.16
$1,920.62
$2,065.16
$2,578.68

$2,170.81
$2,307.27
$2,451.81
$2,965.33

$386.65

Toc - Plan #16 CareSource

Silver

(HMO) CareSource Marketplace Diabetes Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$454.82
$516.22
$581.26
$812.30
$1,234.38

$802.76
$864.16
$929.20
$1,160.24

$1,150.70
$1,212.10
$1,277.14
$1,508.18

$1,498.64
$1,560.04
$1,625.08
$1,856.12

$347.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$909.64
$1,032.44
$1,162.52
$1,624.60
$2,468.76

$1,257.58
$1,380.38
$1,510.46
$1,972.54

$1,605.52
$1,728.32
$1,858.40
$2,320.48

$1,953.46
$2,076.26
$2,206.34
$2,668.42

$347.94

Toc - Plan #17 CareSource

Gold

(HMO) CareSource Marketplace Diabetes Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 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

$516.85
$586.63
$660.54
$923.10
$1,402.73

$912.24
$982.02
$1,055.93
$1,318.49

$1,307.63
$1,377.41
$1,451.32
$1,713.88

$1,703.02
$1,772.80
$1,846.71
$2,109.27

$395.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,033.70
$1,173.26
$1,321.08
$1,846.20
$2,805.46

$1,429.09
$1,568.65
$1,716.47
$2,241.59

$1,824.48
$1,964.04
$2,111.86
$2,636.98

$2,219.87
$2,359.43
$2,507.25
$3,032.37

$395.39

Toc - Plan #18 CareSource

Gold

(HMO) CareSource Marketplace Core Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$475.80
$540.03
$608.07
$849.77
$1,291.31

$839.78
$904.01
$972.05
$1,213.75

$1,203.76
$1,267.99
$1,336.03
$1,577.73

$1,567.74
$1,631.97
$1,700.01
$1,941.71

$363.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$951.60
$1,080.06
$1,216.14
$1,699.54
$2,582.62

$1,315.58
$1,444.04
$1,580.12
$2,063.52

$1,679.56
$1,808.02
$1,944.10
$2,427.50

$2,043.54
$2,172.00
$2,308.08
$2,791.48

$363.98

Toc - Plan #19 CareSource

Expanded Bronze

(HMO) CareSource Marketplace Bronze First Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$361.90
$410.75
$462.50
$646.34
$982.18

$638.75
$687.60
$739.35
$923.19

$915.60
$964.45
$1,016.20
$1,200.04

$1,192.45
$1,241.30
$1,293.05
$1,476.89

$276.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$723.80
$821.50
$925.00
$1,292.68
$1,964.36

$1,000.65
$1,098.35
$1,201.85
$1,569.53

$1,277.50
$1,375.20
$1,478.70
$1,846.38

$1,554.35
$1,652.05
$1,755.55
$2,123.23

$276.85

Toc - Plan #20 CareSource

Silver

(HMO) CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$446.34
$506.59
$570.42
$797.15
$1,211.35

$787.79
$848.04
$911.87
$1,138.60

$1,129.24
$1,189.49
$1,253.32
$1,480.05

$1,470.69
$1,530.94
$1,594.77
$1,821.50

$341.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.68
$1,013.18
$1,140.84
$1,594.30
$2,422.70

$1,234.13
$1,354.63
$1,482.29
$1,935.75

$1,575.58
$1,696.08
$1,823.74
$2,277.20

$1,917.03
$2,037.53
$2,165.19
$2,618.65

$341.45

Toc - Plan #21 CareSource

Silver

(HMO) CareSource Marketplace Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$441.62
$501.24
$564.39
$788.73
$1,198.55

$779.46
$839.08
$902.23
$1,126.57

$1,117.30
$1,176.92
$1,240.07
$1,464.41

$1,455.14
$1,514.76
$1,577.91
$1,802.25

$337.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$883.24
$1,002.48
$1,128.78
$1,577.46
$2,397.10

$1,221.08
$1,340.32
$1,466.62
$1,915.30

$1,558.92
$1,678.16
$1,804.46
$2,253.14

$1,896.76
$2,016.00
$2,142.30
$2,590.98

$337.84

Toc - Plan #22 CareSource

Gold

(HMO) CareSource Marketplace Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$513.87
$583.24
$656.72
$917.76
$1,394.63

$906.98
$976.35
$1,049.83
$1,310.87

$1,300.09
$1,369.46
$1,442.94
$1,703.98

$1,693.20
$1,762.57
$1,836.05
$2,097.09

$393.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,027.74
$1,166.48
$1,313.44
$1,835.52
$2,789.26

$1,420.85
$1,559.59
$1,706.55
$2,228.63

$1,813.96
$1,952.70
$2,099.66
$2,621.74

$2,207.07
$2,345.81
$2,492.77
$3,014.85

$393.11

Toc - Plan #23 CareSource

Silver

(HMO) CareSource Marketplace Diabetes Silver Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

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

$462.72
$525.19
$591.36
$826.42
$1,255.82

$816.70
$879.17
$945.34
$1,180.40

$1,170.68
$1,233.15
$1,299.32
$1,534.38

$1,524.66
$1,587.13
$1,653.30
$1,888.36

$353.98

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$925.44
$1,050.38
$1,182.72
$1,652.84
$2,511.64

$1,279.42
$1,404.36
$1,536.70
$2,006.82

$1,633.40
$1,758.34
$1,890.68
$2,360.80

$1,987.38
$2,112.32
$2,244.66
$2,714.78

$353.98

Toc - Plan #24 CareSource

Gold

(HMO) CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$1,000 $2,000 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

$525.31
$596.22
$671.34
$938.19
$1,425.67

$927.17
$998.08
$1,073.20
$1,340.05

$1,329.03
$1,399.94
$1,475.06
$1,741.91

$1,730.89
$1,801.80
$1,876.92
$2,143.77

$401.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,050.62
$1,192.44
$1,342.68
$1,876.38
$2,851.34

$1,452.48
$1,594.30
$1,744.54
$2,278.24

$1,854.34
$1,996.16
$2,146.40
$2,680.10

$2,256.20
$2,398.02
$2,548.26
$3,081.96

$401.86

Toc - Plan #25 CareSource

Gold

(HMO) CareSource Marketplace Core Gold Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 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

$484.25
$549.62
$618.87
$864.87
$1,314.25

$854.70
$920.07
$989.32
$1,235.32

$1,225.15
$1,290.52
$1,359.77
$1,605.77

$1,595.60
$1,660.97
$1,730.22
$1,976.22

$370.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$968.50
$1,099.24
$1,237.74
$1,729.74
$2,628.50

$1,338.95
$1,469.69
$1,608.19
$2,100.19

$1,709.40
$1,840.14
$1,978.64
$2,470.64

$2,079.85
$2,210.59
$2,349.09
$2,841.09

$370.45

AmeriHealth Caritas Next

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

Toc - Plan #26 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

$319.16
$362.25
$407.89
$570.02
$866.19

$563.32
$606.41
$652.05
$814.18

$807.48
$850.57
$896.21
$1,058.34

$1,051.64
$1,094.73
$1,140.37
$1,302.50

$244.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$638.32
$724.50
$815.78
$1,140.04
$1,732.38

$882.48
$968.66
$1,059.94
$1,384.20

$1,126.64
$1,212.82
$1,304.10
$1,628.36

$1,370.80
$1,456.98
$1,548.26
$1,872.52

$244.16

Toc - Plan #27 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

$358.67
$407.10
$458.38
$640.59
$973.43

$633.06
$681.49
$732.77
$914.98

$907.45
$955.88
$1,007.16
$1,189.37

$1,181.84
$1,230.27
$1,281.55
$1,463.76

$274.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$717.34
$814.20
$916.76
$1,281.18
$1,946.86

$991.73
$1,088.59
$1,191.15
$1,555.57

$1,266.12
$1,362.98
$1,465.54
$1,829.96

$1,540.51
$1,637.37
$1,739.93
$2,104.35

$274.39

Toc - Plan #28 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

$446.42
$506.68
$570.52
$797.30
$1,211.57

$787.93
$848.19
$912.03
$1,138.81

$1,129.44
$1,189.70
$1,253.54
$1,480.32

$1,470.95
$1,531.21
$1,595.05
$1,821.83

$341.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.84
$1,013.36
$1,141.04
$1,594.60
$2,423.14

$1,234.35
$1,354.87
$1,482.55
$1,936.11

$1,575.86
$1,696.38
$1,824.06
$2,277.62

$1,917.37
$2,037.89
$2,165.57
$2,619.13

$341.51

Toc - Plan #29 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

$508.43
$577.07
$649.77
$908.05
$1,379.87

$897.38
$966.02
$1,038.72
$1,297.00

$1,286.33
$1,354.97
$1,427.67
$1,685.95

$1,675.28
$1,743.92
$1,816.62
$2,074.90

$388.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,016.86
$1,154.14
$1,299.54
$1,816.10
$2,759.74

$1,405.81
$1,543.09
$1,688.49
$2,205.05

$1,794.76
$1,932.04
$2,077.44
$2,594.00

$2,183.71
$2,320.99
$2,466.39
$2,982.95

$388.95

Toc - Plan #30 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

$366.77
$416.29
$468.74
$655.05
$995.42

$647.35
$696.87
$749.32
$935.63

$927.93
$977.45
$1,029.90
$1,216.21

$1,208.51
$1,258.03
$1,310.48
$1,496.79

$280.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$733.54
$832.58
$937.48
$1,310.10
$1,990.84

$1,014.12
$1,113.16
$1,218.06
$1,590.68

$1,294.70
$1,393.74
$1,498.64
$1,871.26

$1,575.28
$1,674.32
$1,779.22
$2,151.84

$280.58

Toc - Plan #31 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

$460.47
$522.63
$588.48
$822.39
$1,249.70

$812.73
$874.89
$940.74
$1,174.65

$1,164.99
$1,227.15
$1,293.00
$1,526.91

$1,517.25
$1,579.41
$1,645.26
$1,879.17

$352.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$920.94
$1,045.26
$1,176.96
$1,644.78
$2,499.40

$1,273.20
$1,397.52
$1,529.22
$1,997.04

$1,625.46
$1,749.78
$1,881.48
$2,349.30

$1,977.72
$2,102.04
$2,233.74
$2,701.56

$352.26

WellCare of North Carolina

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

Toc - Plan #32 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

$582.20
$660.78
$744.03
$1,039.78
$1,580.05

$1,027.57
$1,106.15
$1,189.40
$1,485.15

$1,472.94
$1,551.52
$1,634.77
$1,930.52

$1,918.31
$1,996.89
$2,080.14
$2,375.89

$445.37

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,164.40
$1,321.56
$1,488.06
$2,079.56
$3,160.10

$1,609.77
$1,766.93
$1,933.43
$2,524.93

$2,055.14
$2,212.30
$2,378.80
$2,970.30

$2,500.51
$2,657.67
$2,824.17
$3,415.67

$445.37

Toc - Plan #33 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

$756.26
$858.34
$966.49
$1,350.66
$2,052.46

$1,334.79
$1,436.87
$1,545.02
$1,929.19

$1,913.32
$2,015.40
$2,123.55
$2,507.72

$2,491.85
$2,593.93
$2,702.08
$3,086.25

$578.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,512.52
$1,716.68
$1,932.98
$2,701.32
$4,104.92

$2,091.05
$2,295.21
$2,511.51
$3,279.85

$2,669.58
$2,873.74
$3,090.04
$3,858.38

$3,248.11
$3,452.27
$3,668.57
$4,436.91

$578.53

Toc - Plan #34 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

$790.14
$896.80
$1,009.79
$1,411.17
$2,144.41

$1,394.59
$1,501.25
$1,614.24
$2,015.62

$1,999.04
$2,105.70
$2,218.69
$2,620.07

$2,603.49
$2,710.15
$2,823.14
$3,224.52

$604.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,580.28
$1,793.60
$2,019.58
$2,822.34
$4,288.82

$2,184.73
$2,398.05
$2,624.03
$3,426.79

$2,789.18
$3,002.50
$3,228.48
$4,031.24

$3,393.63
$3,606.95
$3,832.93
$4,635.69

$604.45

Toc - Plan #35 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

$577.54
$655.49
$738.08
$1,031.46
$1,567.40

$1,019.35
$1,097.30
$1,179.89
$1,473.27

$1,461.16
$1,539.11
$1,621.70
$1,915.08

$1,902.97
$1,980.92
$2,063.51
$2,356.89

$441.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,155.08
$1,310.98
$1,476.16
$2,062.92
$3,134.80

$1,596.89
$1,752.79
$1,917.97
$2,504.73

$2,038.70
$2,194.60
$2,359.78
$2,946.54

$2,480.51
$2,636.41
$2,801.59
$3,388.35

$441.81

Toc - Plan #36 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

$739.76
$839.62
$945.41
$1,321.20
$2,007.69

$1,305.67
$1,405.53
$1,511.32
$1,887.11

$1,871.58
$1,971.44
$2,077.23
$2,453.02

$2,437.49
$2,537.35
$2,643.14
$3,018.93

$565.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,479.52
$1,679.24
$1,890.82
$2,642.40
$4,015.38

$2,045.43
$2,245.15
$2,456.73
$3,208.31

$2,611.34
$2,811.06
$3,022.64
$3,774.22

$3,177.25
$3,376.97
$3,588.55
$4,340.13

$565.91

Toc - Plan #37 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

$767.58
$871.19
$980.95
$1,370.88
$2,083.18

$1,354.77
$1,458.38
$1,568.14
$1,958.07

$1,941.96
$2,045.57
$2,155.33
$2,545.26

$2,529.15
$2,632.76
$2,742.52
$3,132.45

$587.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,535.16
$1,742.38
$1,961.90
$2,741.76
$4,166.36

$2,122.35
$2,329.57
$2,549.09
$3,328.95

$2,709.54
$2,916.76
$3,136.28
$3,916.14

$3,296.73
$3,503.95
$3,723.47
$4,503.33

$587.19

UnitedHealthcare

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

Toc - Plan #38 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

$526.58
$597.67
$672.97
$940.48
$1,429.15

$929.42
$1,000.51
$1,075.81
$1,343.32

$1,332.26
$1,403.35
$1,478.65
$1,746.16

$1,735.10
$1,806.19
$1,881.49
$2,149.00

$402.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,053.16
$1,195.34
$1,345.94
$1,880.96
$2,858.30

$1,456.00
$1,598.18
$1,748.78
$2,283.80

$1,858.84
$2,001.02
$2,151.62
$2,686.64

$2,261.68
$2,403.86
$2,554.46
$3,089.48

$402.84

Toc - Plan #39 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

$597.59
$678.26
$763.72
$1,067.29
$1,621.85

$1,054.74
$1,135.41
$1,220.87
$1,524.44

$1,511.89
$1,592.56
$1,678.02
$1,981.59

$1,969.04
$2,049.71
$2,135.17
$2,438.74

$457.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,195.18
$1,356.52
$1,527.44
$2,134.58
$3,243.70

$1,652.33
$1,813.67
$1,984.59
$2,591.73

$2,109.48
$2,270.82
$2,441.74
$3,048.88

$2,566.63
$2,727.97
$2,898.89
$3,506.03

$457.15

Toc - Plan #40 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

$405.88
$460.67
$518.71
$724.90
$1,101.56

$716.38
$771.17
$829.21
$1,035.40

$1,026.88
$1,081.67
$1,139.71
$1,345.90

$1,337.38
$1,392.17
$1,450.21
$1,656.40

$310.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$811.76
$921.34
$1,037.42
$1,449.80
$2,203.12

$1,122.26
$1,231.84
$1,347.92
$1,760.30

$1,432.76
$1,542.34
$1,658.42
$2,070.80

$1,743.26
$1,852.84
$1,968.92
$2,381.30

$310.50

Toc - Plan #41 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

$531.50
$603.25
$679.25
$949.25
$1,442.48

$938.09
$1,009.84
$1,085.84
$1,355.84

$1,344.68
$1,416.43
$1,492.43
$1,762.43

$1,751.27
$1,823.02
$1,899.02
$2,169.02

$406.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,063.00
$1,206.50
$1,358.50
$1,898.50
$2,884.96

$1,469.59
$1,613.09
$1,765.09
$2,305.09

$1,876.18
$2,019.68
$2,171.68
$2,711.68

$2,282.77
$2,426.27
$2,578.27
$3,118.27

$406.59

Toc - Plan #42 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

$601.64
$682.86
$768.89
$1,074.52
$1,632.84

$1,061.89
$1,143.11
$1,229.14
$1,534.77

$1,522.14
$1,603.36
$1,689.39
$1,995.02

$1,982.39
$2,063.61
$2,149.64
$2,455.27

$460.25

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,203.28
$1,365.72
$1,537.78
$2,149.04
$3,265.68

$1,663.53
$1,825.97
$1,998.03
$2,609.29

$2,123.78
$2,286.22
$2,458.28
$3,069.54

$2,584.03
$2,746.47
$2,918.53
$3,529.79

$460.25

Toc - Plan #43 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

$537.47
$610.03
$686.89
$959.93
$1,458.70

$948.64
$1,021.20
$1,098.06
$1,371.10

$1,359.81
$1,432.37
$1,509.23
$1,782.27

$1,770.98
$1,843.54
$1,920.40
$2,193.44

$411.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,074.94
$1,220.06
$1,373.78
$1,919.86
$2,917.40

$1,486.11
$1,631.23
$1,784.95
$2,331.03

$1,897.28
$2,042.40
$2,196.12
$2,742.20

$2,308.45
$2,453.57
$2,607.29
$3,153.37

$411.17

Toc - Plan #44 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

$533.41
$605.42
$681.70
$952.68
$1,447.68

$941.47
$1,013.48
$1,089.76
$1,360.74

$1,349.53
$1,421.54
$1,497.82
$1,768.80

$1,757.59
$1,829.60
$1,905.88
$2,176.86

$408.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,066.82
$1,210.84
$1,363.40
$1,905.36
$2,895.36

$1,474.88
$1,618.90
$1,771.46
$2,313.42

$1,882.94
$2,026.96
$2,179.52
$2,721.48

$2,291.00
$2,435.02
$2,587.58
$3,129.54

$408.06

Toc - Plan #45 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

$398.27
$452.04
$508.99
$711.31
$1,080.90

$702.95
$756.72
$813.67
$1,015.99

$1,007.63
$1,061.40
$1,118.35
$1,320.67

$1,312.31
$1,366.08
$1,423.03
$1,625.35

$304.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$796.54
$904.08
$1,017.98
$1,422.62
$2,161.80

$1,101.22
$1,208.76
$1,322.66
$1,727.30

$1,405.90
$1,513.44
$1,627.34
$2,031.98

$1,710.58
$1,818.12
$1,932.02
$2,336.66

$304.68

Toc - Plan #46 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

$381.71
$433.24
$487.83
$681.74
$1,035.96

$673.72
$725.25
$779.84
$973.75

$965.73
$1,017.26
$1,071.85
$1,265.76

$1,257.74
$1,309.27
$1,363.86
$1,557.77

$292.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$763.42
$866.48
$975.66
$1,363.48
$2,071.92

$1,055.43
$1,158.49
$1,267.67
$1,655.49

$1,347.44
$1,450.50
$1,559.68
$1,947.50

$1,639.45
$1,742.51
$1,851.69
$2,239.51

$292.01

Toc - Plan #47 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

$390.75
$443.51
$499.38
$697.89
$1,060.51

$689.68
$742.44
$798.31
$996.82

$988.61
$1,041.37
$1,097.24
$1,295.75

$1,287.54
$1,340.30
$1,396.17
$1,594.68

$298.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$781.50
$887.02
$998.76
$1,395.78
$2,121.02

$1,080.43
$1,185.95
$1,297.69
$1,694.71

$1,379.36
$1,484.88
$1,596.62
$1,993.64

$1,678.29
$1,783.81
$1,895.55
$2,292.57

$298.93

Toc - Plan #48 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

$412.84
$468.57
$527.61
$737.33
$1,120.45

$728.66
$784.39
$843.43
$1,053.15

$1,044.48
$1,100.21
$1,159.25
$1,368.97

$1,360.30
$1,416.03
$1,475.07
$1,684.79

$315.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$825.68
$937.14
$1,055.22
$1,474.66
$2,240.90

$1,141.50
$1,252.96
$1,371.04
$1,790.48

$1,457.32
$1,568.78
$1,686.86
$2,106.30

$1,773.14
$1,884.60
$2,002.68
$2,422.12

$315.82

Toc - Plan #49 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

$529.38
$600.84
$676.54
$945.47
$1,436.73

$934.35
$1,005.81
$1,081.51
$1,350.44

$1,339.32
$1,410.78
$1,486.48
$1,755.41

$1,744.29
$1,815.75
$1,891.45
$2,160.38

$404.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,058.76
$1,201.68
$1,353.08
$1,890.94
$2,873.46

$1,463.73
$1,606.65
$1,758.05
$2,295.91

$1,868.70
$2,011.62
$2,163.02
$2,700.88

$2,273.67
$2,416.59
$2,567.99
$3,105.85

$404.97

Toc - Plan #50 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

$604.69
$686.32
$772.79
$1,079.98
$1,641.13

$1,067.28
$1,148.91
$1,235.38
$1,542.57

$1,529.87
$1,611.50
$1,697.97
$2,005.16

$1,992.46
$2,074.09
$2,160.56
$2,467.75

$462.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,209.38
$1,372.64
$1,545.58
$2,159.96
$3,282.26

$1,671.97
$1,835.23
$2,008.17
$2,622.55

$2,134.56
$2,297.82
$2,470.76
$3,085.14

$2,597.15
$2,760.41
$2,933.35
$3,547.73

$462.59

Toc - Plan #51 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

$552.42
$627.00
$705.99
$986.63
$1,499.27

$975.02
$1,049.60
$1,128.59
$1,409.23

$1,397.62
$1,472.20
$1,551.19
$1,831.83

$1,820.22
$1,894.80
$1,973.79
$2,254.43

$422.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,104.84
$1,254.00
$1,411.98
$1,973.26
$2,998.54

$1,527.44
$1,676.60
$1,834.58
$2,395.86

$1,950.04
$2,099.20
$2,257.18
$2,818.46

$2,372.64
$2,521.80
$2,679.78
$3,241.06

$422.60

Toc - Plan #52 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

$622.03
$706.00
$794.95
$1,110.94
$1,688.19

$1,097.88
$1,181.85
$1,270.80
$1,586.79

$1,573.73
$1,657.70
$1,746.65
$2,062.64

$2,049.58
$2,133.55
$2,222.50
$2,538.49

$475.85

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,244.06
$1,412.00
$1,589.90
$2,221.88
$3,376.38

$1,719.91
$1,887.85
$2,065.75
$2,697.73

$2,195.76
$2,363.70
$2,541.60
$3,173.58

$2,671.61
$2,839.55
$3,017.45
$3,649.43

$475.85

Aetna CVS Health

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

Toc - Plan #53 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

$347.45
$394.36
$444.04
$620.55
$942.98

$613.25
$660.16
$709.84
$886.35

$879.05
$925.96
$975.64
$1,152.15

$1,144.85
$1,191.76
$1,241.44
$1,417.95

$265.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$694.90
$788.72
$888.08
$1,241.10
$1,885.96

$960.70
$1,054.52
$1,153.88
$1,506.90

$1,226.50
$1,320.32
$1,419.68
$1,772.70

$1,492.30
$1,586.12
$1,685.48
$2,038.50

$265.80

Toc - Plan #54 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

$476.79
$541.15
$609.34
$851.54
$1,294.00

$841.53
$905.89
$974.08
$1,216.28

$1,206.27
$1,270.63
$1,338.82
$1,581.02

$1,571.01
$1,635.37
$1,703.56
$1,945.76

$364.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$953.58
$1,082.30
$1,218.68
$1,703.08
$2,588.00

$1,318.32
$1,447.04
$1,583.42
$2,067.82

$1,683.06
$1,811.78
$1,948.16
$2,432.56

$2,047.80
$2,176.52
$2,312.90
$2,797.30

$364.74

Toc - Plan #55 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

$483.39
$548.64
$617.77
$863.33
$1,311.90

$853.18
$918.43
$987.56
$1,233.12

$1,222.97
$1,288.22
$1,357.35
$1,602.91

$1,592.76
$1,658.01
$1,727.14
$1,972.70

$369.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$966.78
$1,097.28
$1,235.54
$1,726.66
$2,623.80

$1,336.57
$1,467.07
$1,605.33
$2,096.45

$1,706.36
$1,836.86
$1,975.12
$2,466.24

$2,076.15
$2,206.65
$2,344.91
$2,836.03

$369.79

Toc - Plan #56 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

$353.65
$401.39
$451.96
$631.61
$959.80

$624.19
$671.93
$722.50
$902.15

$894.73
$942.47
$993.04
$1,172.69

$1,165.27
$1,213.01
$1,263.58
$1,443.23

$270.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.30
$802.78
$903.92
$1,263.22
$1,919.60

$977.84
$1,073.32
$1,174.46
$1,533.76

$1,248.38
$1,343.86
$1,445.00
$1,804.30

$1,518.92
$1,614.40
$1,715.54
$2,074.84

$270.54

Toc - Plan #57 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

$477.56
$542.03
$610.32
$852.92
$1,296.10

$842.90
$907.37
$975.66
$1,218.26

$1,208.24
$1,272.71
$1,341.00
$1,583.60

$1,573.58
$1,638.05
$1,706.34
$1,948.94

$365.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$955.12
$1,084.06
$1,220.64
$1,705.84
$2,592.20

$1,320.46
$1,449.40
$1,585.98
$2,071.18

$1,685.80
$1,814.74
$1,951.32
$2,436.52

$2,051.14
$2,180.08
$2,316.66
$2,801.86

$365.34

Toc - Plan #58 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

$466.67
$529.67
$596.41
$833.47
$1,266.54

$823.68
$886.68
$953.42
$1,190.48

$1,180.69
$1,243.69
$1,310.43
$1,547.49

$1,537.70
$1,600.70
$1,667.44
$1,904.50

$357.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$933.34
$1,059.34
$1,192.82
$1,666.94
$2,533.08

$1,290.35
$1,416.35
$1,549.83
$2,023.95

$1,647.36
$1,773.36
$1,906.84
$2,380.96

$2,004.37
$2,130.37
$2,263.85
$2,737.97

$357.01

Toc - Plan #59 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

$391.79
$444.69
$500.71
$699.74
$1,063.32

$691.51
$744.41
$800.43
$999.46

$991.23
$1,044.13
$1,100.15
$1,299.18

$1,290.95
$1,343.85
$1,399.87
$1,598.90

$299.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$783.58
$889.38
$1,001.42
$1,399.48
$2,126.64

$1,083.30
$1,189.10
$1,301.14
$1,699.20

$1,383.02
$1,488.82
$1,600.86
$1,998.92

$1,682.74
$1,788.54
$1,900.58
$2,298.64

$299.72

Toc - Plan #60 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

$478.35
$542.93
$611.33
$854.33
$1,298.24

$844.29
$908.87
$977.27
$1,220.27

$1,210.23
$1,274.81
$1,343.21
$1,586.21

$1,576.17
$1,640.75
$1,709.15
$1,952.15

$365.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$956.70
$1,085.86
$1,222.66
$1,708.66
$2,596.48

$1,322.64
$1,451.80
$1,588.60
$2,074.60

$1,688.58
$1,817.74
$1,954.54
$2,440.54

$2,054.52
$2,183.68
$2,320.48
$2,806.48

$365.94

Toc - Plan #61 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

$482.66
$547.82
$616.83
$862.02
$1,309.92

$851.89
$917.05
$986.06
$1,231.25

$1,221.12
$1,286.28
$1,355.29
$1,600.48

$1,590.35
$1,655.51
$1,724.52
$1,969.71

$369.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$965.32
$1,095.64
$1,233.66
$1,724.04
$2,619.84

$1,334.55
$1,464.87
$1,602.89
$2,093.27

$1,703.78
$1,834.10
$1,972.12
$2,462.50

$2,073.01
$2,203.33
$2,341.35
$2,831.73

$369.23

Toc - Plan #62 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

$466.86
$529.88
$596.64
$833.80
$1,267.04

$824.01
$887.03
$953.79
$1,190.95

$1,181.16
$1,244.18
$1,310.94
$1,548.10

$1,538.31
$1,601.33
$1,668.09
$1,905.25

$357.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$933.72
$1,059.76
$1,193.28
$1,667.60
$2,534.08

$1,290.87
$1,416.91
$1,550.43
$2,024.75

$1,648.02
$1,774.06
$1,907.58
$2,381.90

$2,005.17
$2,131.21
$2,264.73
$2,739.05

$357.15

Toc - Plan #63 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

$476.83
$541.20
$609.39
$851.62
$1,294.12

$841.61
$905.98
$974.17
$1,216.40

$1,206.39
$1,270.76
$1,338.95
$1,581.18

$1,571.17
$1,635.54
$1,703.73
$1,945.96

$364.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$953.66
$1,082.40
$1,218.78
$1,703.24
$2,588.24

$1,318.44
$1,447.18
$1,583.56
$2,068.02

$1,683.22
$1,811.96
$1,948.34
$2,432.80

$2,048.00
$2,176.74
$2,313.12
$2,797.58

$364.78

Oscar Health Plan of North Carolina, Inc

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755 | TTY: 1-855-672-2755

Toc - Plan #64 Oscar Health Plan of North Carolina, Inc

Expanded Bronze

(HMO) Bronze Classic PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$7,750 $15,500 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

$405.47
$460.20
$518.18
$724.16
$1,100.43

$715.65
$770.38
$828.36
$1,034.34

$1,025.83
$1,080.56
$1,138.54
$1,344.52

$1,336.01
$1,390.74
$1,448.72
$1,654.70

$310.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$810.94
$920.40
$1,036.36
$1,448.32
$2,200.86

$1,121.12
$1,230.58
$1,346.54
$1,758.50

$1,431.30
$1,540.76
$1,656.72
$2,068.68

$1,741.48
$1,850.94
$1,966.90
$2,378.86

$310.18

Toc - Plan #65 Oscar Health Plan of North Carolina, Inc

Expanded Bronze

(HMO) Bronze Elite + PCP Saver Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$483.78
$549.08
$618.26
$864.02
$1,312.96

$853.87
$919.17
$988.35
$1,234.11

$1,223.96
$1,289.26
$1,358.44
$1,604.20

$1,594.05
$1,659.35
$1,728.53
$1,974.29

$370.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$967.56
$1,098.16
$1,236.52
$1,728.04
$2,625.92

$1,337.65
$1,468.25
$1,606.61
$2,098.13

$1,707.74
$1,838.34
$1,976.70
$2,468.22

$2,077.83
$2,208.43
$2,346.79
$2,838.31

$370.09

Toc - Plan #66 Oscar Health Plan of North Carolina, Inc

Silver

(HMO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,400 $10,800 Annual Deductible

$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$543.43
$616.78
$694.49
$970.54
$1,474.84

$959.14
$1,032.49
$1,110.20
$1,386.25

$1,374.85
$1,448.20
$1,525.91
$1,801.96

$1,790.56
$1,863.91
$1,941.62
$2,217.67

$415.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,086.86
$1,233.56
$1,388.98
$1,941.08
$2,949.68

$1,502.57
$1,649.27
$1,804.69
$2,356.79

$1,918.28
$2,064.98
$2,220.40
$2,772.50

$2,333.99
$2,480.69
$2,636.11
$3,188.21

$415.71

Toc - Plan #67 Oscar Health Plan of North Carolina, Inc

Catastrophic

(HMO) Secure

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$319.82
$362.99
$408.72
$571.19
$867.97

$564.48
$607.65
$653.38
$815.85

$809.14
$852.31
$898.04
$1,060.51

$1,053.80
$1,096.97
$1,142.70
$1,305.17

$244.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$639.64
$725.98
$817.44
$1,142.38
$1,735.94

$884.30
$970.64
$1,062.10
$1,387.04

$1,128.96
$1,215.30
$1,306.76
$1,631.70

$1,373.62
$1,459.96
$1,551.42
$1,876.36

$244.66

Toc - Plan #68 Oscar Health Plan of North Carolina, Inc

Expanded Bronze

(HMO) Bronze Simple HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$7,450 $14,900 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

$396.36
$449.86
$506.54
$707.89
$1,075.70

$699.57
$753.07
$809.75
$1,011.10

$1,002.78
$1,056.28
$1,112.96
$1,314.31

$1,305.99
$1,359.49
$1,416.17
$1,617.52

$303.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$792.72
$899.72
$1,013.08
$1,415.78
$2,151.40

$1,095.93
$1,202.93
$1,316.29
$1,718.99

$1,399.14
$1,506.14
$1,619.50
$2,022.20

$1,702.35
$1,809.35
$1,922.71
$2,325.41

$303.21

Toc - Plan #69 Oscar Health Plan of North Carolina, Inc

Expanded Bronze

(HMO) Bronze Classic 4700

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$4,700 $9,400 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

$429.29
$487.23
$548.62
$766.69
$1,165.06

$757.69
$815.63
$877.02
$1,095.09

$1,086.09
$1,144.03
$1,205.42
$1,423.49

$1,414.49
$1,472.43
$1,533.82
$1,751.89

$328.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$858.58
$974.46
$1,097.24
$1,533.38
$2,330.12

$1,186.98
$1,302.86
$1,425.64
$1,861.78

$1,515.38
$1,631.26
$1,754.04
$2,190.18

$1,843.78
$1,959.66
$2,082.44
$2,518.58

$328.40

Toc - Plan #70 Oscar Health Plan of North Carolina, Inc

Silver

(HMO) Silver Simple PCP Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 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

$527.02
$598.16
$673.52
$941.25
$1,430.32

$930.19
$1,001.33
$1,076.69
$1,344.42

$1,333.36
$1,404.50
$1,479.86
$1,747.59

$1,736.53
$1,807.67
$1,883.03
$2,150.76

$403.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,054.04
$1,196.32
$1,347.04
$1,882.50
$2,860.64

$1,457.21
$1,599.49
$1,750.21
$2,285.67

$1,860.38
$2,002.66
$2,153.38
$2,688.84

$2,263.55
$2,405.83
$2,556.55
$3,092.01

$403.17

Toc - Plan #71 Oscar Health Plan of North Carolina, Inc

Silver

(HMO) Silver Elite Saver Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$567.53
$644.14
$725.29
$1,013.60
$1,540.26

$1,001.68
$1,078.29
$1,159.44
$1,447.75

$1,435.83
$1,512.44
$1,593.59
$1,881.90

$1,869.98
$1,946.59
$2,027.74
$2,316.05

$434.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,135.06
$1,288.28
$1,450.58
$2,027.20
$3,080.52

$1,569.21
$1,722.43
$1,884.73
$2,461.35

$2,003.36
$2,156.58
$2,318.88
$2,895.50

$2,437.51
$2,590.73
$2,753.03
$3,329.65

$434.15

Toc - Plan #72 Oscar Health Plan of North Carolina, Inc

Gold

(HMO) Gold Elite Saver Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$655.00
$743.42
$837.08
$1,169.82
$1,777.65

$1,156.07
$1,244.49
$1,338.15
$1,670.89

$1,657.14
$1,745.56
$1,839.22
$2,171.96

$2,158.21
$2,246.63
$2,340.29
$2,673.03

$501.07

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,310.00
$1,486.84
$1,674.16
$2,339.64
$3,555.30

$1,811.07
$1,987.91
$2,175.23
$2,840.71

$2,312.14
$2,488.98
$2,676.30
$3,341.78

$2,813.21
$2,990.05
$3,177.37
$3,842.85

$501.07

Toc - Plan #73 Oscar Health Plan of North Carolina, Inc

Silver

(HMO) Silver Simple Diabetes

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,450 $12,900 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

$547.04
$620.88
$699.10
$976.99
$1,484.63

$965.52
$1,039.36
$1,117.58
$1,395.47

$1,384.00
$1,457.84
$1,536.06
$1,813.95

$1,802.48
$1,876.32
$1,954.54
$2,232.43

$418.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,094.08
$1,241.76
$1,398.20
$1,953.98
$2,969.26

$1,512.56
$1,660.24
$1,816.68
$2,372.46

$1,931.04
$2,078.72
$2,235.16
$2,790.94

$2,349.52
$2,497.20
$2,653.64
$3,209.42

$418.48

Toc - Plan #74 Oscar Health Plan of North Carolina, Inc

Expanded Bronze

(HMO) Bronze Classic Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$414.14
$470.04
$529.26
$739.64
$1,123.96

$730.95
$786.85
$846.07
$1,056.45

$1,047.76
$1,103.66
$1,162.88
$1,373.26

$1,364.57
$1,420.47
$1,479.69
$1,690.07

$316.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$828.28
$940.08
$1,058.52
$1,479.28
$2,247.92

$1,145.09
$1,256.89
$1,375.33
$1,796.09

$1,461.90
$1,573.70
$1,692.14
$2,112.90

$1,778.71
$1,890.51
$2,008.95
$2,429.71

$316.81

Toc - Plan #75 Oscar Health Plan of North Carolina, Inc

Silver

(HMO) Silver Classic Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$521.59
$591.99
$666.58
$931.54
$1,415.56

$920.60
$991.00
$1,065.59
$1,330.55

$1,319.61
$1,390.01
$1,464.60
$1,729.56

$1,718.62
$1,789.02
$1,863.61
$2,128.57

$399.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,043.18
$1,183.98
$1,333.16
$1,863.08
$2,831.12

$1,442.19
$1,582.99
$1,732.17
$2,262.09

$1,841.20
$1,982.00
$2,131.18
$2,661.10

$2,240.21
$2,381.01
$2,530.19
$3,060.11

$399.01

Toc - Plan #76 Oscar Health Plan of North Carolina, Inc

Gold

(HMO) Gold Classic Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

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

$546.92
$620.75
$698.95
$976.79
$1,484.32

$965.31
$1,039.14
$1,117.34
$1,395.18

$1,383.70
$1,457.53
$1,535.73
$1,813.57

$1,802.09
$1,875.92
$1,954.12
$2,231.96

$418.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,093.84
$1,241.50
$1,397.90
$1,953.58
$2,968.64

$1,512.23
$1,659.89
$1,816.29
$2,371.97

$1,930.62
$2,078.28
$2,234.68
$2,790.36

$2,349.01
$2,496.67
$2,653.07
$3,208.75

$418.39

Cigna Healthcare

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

Toc - Plan #77 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

$490.96
$557.24
$627.44
$876.85
$1,332.46

$866.54
$932.82
$1,003.02
$1,252.43

$1,242.12
$1,308.40
$1,378.60
$1,628.01

$1,617.70
$1,683.98
$1,754.18
$2,003.59

$375.58

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$981.92
$1,114.48
$1,254.88
$1,753.70
$2,664.92

$1,357.50
$1,490.06
$1,630.46
$2,129.28

$1,733.08
$1,865.64
$2,006.04
$2,504.86

$2,108.66
$2,241.22
$2,381.62
$2,880.44

$375.58

Toc - Plan #78 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

$519.07
$589.15
$663.38
$927.07
$1,408.77

$916.16
$986.24
$1,060.47
$1,324.16

$1,313.25
$1,383.33
$1,457.56
$1,721.25

$1,710.34
$1,780.42
$1,854.65
$2,118.34

$397.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,038.14
$1,178.30
$1,326.76
$1,854.14
$2,817.54

$1,435.23
$1,575.39
$1,723.85
$2,251.23

$1,832.32
$1,972.48
$2,120.94
$2,648.32

$2,229.41
$2,369.57
$2,518.03
$3,045.41

$397.09

Toc - Plan #79 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

$514.74
$584.23
$657.84
$919.33
$1,397.01

$908.52
$978.01
$1,051.62
$1,313.11

$1,302.30
$1,371.79
$1,445.40
$1,706.89

$1,696.08
$1,765.57
$1,839.18
$2,100.67

$393.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,029.48
$1,168.46
$1,315.68
$1,838.66
$2,794.02

$1,423.26
$1,562.24
$1,709.46
$2,232.44

$1,817.04
$1,956.02
$2,103.24
$2,626.22

$2,210.82
$2,349.80
$2,497.02
$3,020.00

$393.78

Toc - Plan #80 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

$600.19
$681.22
$767.04
$1,071.94
$1,628.91

$1,059.33
$1,140.36
$1,226.18
$1,531.08

$1,518.47
$1,599.50
$1,685.32
$1,990.22

$1,977.61
$2,058.64
$2,144.46
$2,449.36

$459.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,200.38
$1,362.44
$1,534.08
$2,143.88
$3,257.82

$1,659.52
$1,821.58
$1,993.22
$2,603.02

$2,118.66
$2,280.72
$2,452.36
$3,062.16

$2,577.80
$2,739.86
$2,911.50
$3,521.30

$459.14

Toc - Plan #81 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

$600.05
$681.06
$766.87
$1,071.69
$1,628.54

$1,059.09
$1,140.10
$1,225.91
$1,530.73

$1,518.13
$1,599.14
$1,684.95
$1,989.77

$1,977.17
$2,058.18
$2,143.99
$2,448.81

$459.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,200.10
$1,362.12
$1,533.74
$2,143.38
$3,257.08

$1,659.14
$1,821.16
$1,992.78
$2,602.42

$2,118.18
$2,280.20
$2,451.82
$3,061.46

$2,577.22
$2,739.24
$2,910.86
$3,520.50

$459.04

Toc - Plan #82 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

$607.20
$689.17
$776.00
$1,084.46
$1,647.94

$1,071.71
$1,153.68
$1,240.51
$1,548.97

$1,536.22
$1,618.19
$1,705.02
$2,013.48

$2,000.73
$2,082.70
$2,169.53
$2,477.99

$464.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,214.40
$1,378.34
$1,552.00
$2,168.92
$3,295.88

$1,678.91
$1,842.85
$2,016.51
$2,633.43

$2,143.42
$2,307.36
$2,481.02
$3,097.94

$2,607.93
$2,771.87
$2,945.53
$3,562.45

$464.51

Toc - Plan #83 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

$605.48
$687.22
$773.81
$1,081.39
$1,643.28

$1,068.67
$1,150.41
$1,237.00
$1,544.58

$1,531.86
$1,613.60
$1,700.19
$2,007.77

$1,995.05
$2,076.79
$2,163.38
$2,470.96

$463.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,210.96
$1,374.44
$1,547.62
$2,162.78
$3,286.56

$1,674.15
$1,837.63
$2,010.81
$2,625.97

$2,137.34
$2,300.82
$2,474.00
$3,089.16

$2,600.53
$2,764.01
$2,937.19
$3,552.35

$463.19

Toc - Plan #84 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

$511.72
$580.80
$653.98
$913.93
$1,388.80

$903.18
$972.26
$1,045.44
$1,305.39

$1,294.64
$1,363.72
$1,436.90
$1,696.85

$1,686.10
$1,755.18
$1,828.36
$2,088.31

$391.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,023.44
$1,161.60
$1,307.96
$1,827.86
$2,777.60

$1,414.90
$1,553.06
$1,699.42
$2,219.32

$1,806.36
$1,944.52
$2,090.88
$2,610.78

$2,197.82
$2,335.98
$2,482.34
$3,002.24

$391.46

Toc - Plan #85 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

$546.16
$619.89
$697.99
$975.44
$1,482.27

$963.97
$1,037.70
$1,115.80
$1,393.25

$1,381.78
$1,455.51
$1,533.61
$1,811.06

$1,799.59
$1,873.32
$1,951.42
$2,228.87

$417.81

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,092.32
$1,239.78
$1,395.98
$1,950.88
$2,964.54

$1,510.13
$1,657.59
$1,813.79
$2,368.69

$1,927.94
$2,075.40
$2,231.60
$2,786.50

$2,345.75
$2,493.21
$2,649.41
$3,204.31

$417.81

Toc - Plan #86 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

$599.50
$680.43
$766.16
$1,070.71
$1,627.05

$1,058.12
$1,139.05
$1,224.78
$1,529.33

$1,516.74
$1,597.67
$1,683.40
$1,987.95

$1,975.36
$2,056.29
$2,142.02
$2,446.57

$458.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,199.00
$1,360.86
$1,532.32
$2,141.42
$3,254.10

$1,657.62
$1,819.48
$1,990.94
$2,600.04

$2,116.24
$2,278.10
$2,449.56
$3,058.66

$2,574.86
$2,736.72
$2,908.18
$3,517.28

$458.62

Toc - Plan #87 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

$813.98
$923.87
$1,040.26
$1,453.77
$2,209.14

$1,436.67
$1,546.56
$1,662.95
$2,076.46

$2,059.36
$2,169.25
$2,285.64
$2,699.15

$2,682.05
$2,791.94
$2,908.33
$3,321.84

$622.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,627.96
$1,847.74
$2,080.52
$2,907.54
$4,418.28

$2,250.65
$2,470.43
$2,703.21
$3,530.23

$2,873.34
$3,093.12
$3,325.90
$4,152.92

$3,496.03
$3,715.81
$3,948.59
$4,775.61

$622.69

Ambetter of North Carolina

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

Toc - Plan #88 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

$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

$433.48
$491.99
$553.97
$774.17
$1,176.43

$765.08
$823.59
$885.57
$1,105.77

$1,096.68
$1,155.19
$1,217.17
$1,437.37

$1,428.28
$1,486.79
$1,548.77
$1,768.97

$331.60

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$866.96
$983.98
$1,107.94
$1,548.34
$2,352.86

$1,198.56
$1,315.58
$1,439.54
$1,879.94

$1,530.16
$1,647.18
$1,771.14
$2,211.54

$1,861.76
$1,978.78
$2,102.74
$2,543.14

$331.60

Toc - Plan #89 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

$544.67
$618.19
$696.07
$972.76
$1,478.20

$961.33
$1,034.85
$1,112.73
$1,389.42

$1,377.99
$1,451.51
$1,529.39
$1,806.08

$1,794.65
$1,868.17
$1,946.05
$2,222.74

$416.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,089.34
$1,236.38
$1,392.14
$1,945.52
$2,956.40

$1,506.00
$1,653.04
$1,808.80
$2,362.18

$1,922.66
$2,069.70
$2,225.46
$2,778.84

$2,339.32
$2,486.36
$2,642.12
$3,195.50

$416.66

Toc - Plan #90 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

$567.63
$644.25
$725.42
$1,013.77
$1,540.53

$1,001.86
$1,078.48
$1,159.65
$1,448.00

$1,436.09
$1,512.71
$1,593.88
$1,882.23

$1,870.32
$1,946.94
$2,028.11
$2,316.46

$434.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,135.26
$1,288.50
$1,450.84
$2,027.54
$3,081.06

$1,569.49
$1,722.73
$1,885.07
$2,461.77

$2,003.72
$2,156.96
$2,319.30
$2,896.00

$2,437.95
$2,591.19
$2,753.53
$3,330.23

$434.23

Toc - Plan #91 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

$8,450 $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

$425.12
$482.50
$543.29
$759.25
$1,153.75

$750.33
$807.71
$868.50
$1,084.46

$1,075.54
$1,132.92
$1,193.71
$1,409.67

$1,400.75
$1,458.13
$1,518.92
$1,734.88

$325.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$850.24
$965.00
$1,086.58
$1,518.50
$2,307.50

$1,175.45
$1,290.21
$1,411.79
$1,843.71

$1,500.66
$1,615.42
$1,737.00
$2,168.92

$1,825.87
$1,940.63
$2,062.21
$2,494.13

$325.21

Toc - Plan #92 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

$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

$485.39
$550.91
$620.32
$866.90
$1,317.33

$856.71
$922.23
$991.64
$1,238.22

$1,228.03
$1,293.55
$1,362.96
$1,609.54

$1,599.35
$1,664.87
$1,734.28
$1,980.86

$371.32

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$970.78
$1,101.82
$1,240.64
$1,733.80
$2,634.66

$1,342.10
$1,473.14
$1,611.96
$2,105.12

$1,713.42
$1,844.46
$1,983.28
$2,476.44

$2,084.74
$2,215.78
$2,354.60
$2,847.76

$371.32

Toc - Plan #93 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

$529.06
$600.47
$676.13
$944.89
$1,435.85

$933.78
$1,005.19
$1,080.85
$1,349.61

$1,338.50
$1,409.91
$1,485.57
$1,754.33

$1,743.22
$1,814.63
$1,890.29
$2,159.05

$404.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,058.12
$1,200.94
$1,352.26
$1,889.78
$2,871.70

$1,462.84
$1,605.66
$1,756.98
$2,294.50

$1,867.56
$2,010.38
$2,161.70
$2,699.22

$2,272.28
$2,415.10
$2,566.42
$3,103.94

$404.72

Toc - Plan #94 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

$6,300 $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

$536.16
$608.53
$685.19
$957.56
$1,455.10

$946.31
$1,018.68
$1,095.34
$1,367.71

$1,356.46
$1,428.83
$1,505.49
$1,777.86

$1,766.61
$1,838.98
$1,915.64
$2,188.01

$410.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,072.32
$1,217.06
$1,370.38
$1,915.12
$2,910.20

$1,482.47
$1,627.21
$1,780.53
$2,325.27

$1,892.62
$2,037.36
$2,190.68
$2,735.42

$2,302.77
$2,447.51
$2,600.83
$3,145.57

$410.15

Toc - Plan #95 Ambetter of North Carolina

Expanded Bronze

(HMO) 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

$9,400 $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

$417.66
$474.03
$533.76
$745.92
$1,133.50

$737.16
$793.53
$853.26
$1,065.42

$1,056.66
$1,113.03
$1,172.76
$1,384.92

$1,376.16
$1,432.53
$1,492.26
$1,704.42

$319.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$835.32
$948.06
$1,067.52
$1,491.84
$2,267.00

$1,154.82
$1,267.56
$1,387.02
$1,811.34

$1,474.32
$1,587.06
$1,706.52
$2,130.84

$1,793.82
$1,906.56
$2,026.02
$2,450.34

$319.50

Toc - Plan #96 Ambetter of North Carolina

Silver

(HMO) Standard Silver

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

$525.49
$596.42
$671.56
$938.51
$1,426.15

$927.48
$998.41
$1,073.55
$1,340.50

$1,329.47
$1,400.40
$1,475.54
$1,742.49

$1,731.46
$1,802.39
$1,877.53
$2,144.48

$401.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,050.98
$1,192.84
$1,343.12
$1,877.02
$2,852.30

$1,452.97
$1,594.83
$1,745.11
$2,279.01

$1,854.96
$1,996.82
$2,147.10
$2,681.00

$2,256.95
$2,398.81
$2,549.09
$3,082.99

$401.99

Toc - Plan #97 Ambetter of North Carolina

Gold

(HMO) Standard Gold

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

$544.83
$618.37
$696.28
$973.04
$1,478.63

$961.61
$1,035.15
$1,113.06
$1,389.82

$1,378.39
$1,451.93
$1,529.84
$1,806.60

$1,795.17
$1,868.71
$1,946.62
$2,223.38

$416.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,089.66
$1,236.74
$1,392.56
$1,946.08
$2,957.26

$1,506.44
$1,653.52
$1,809.34
$2,362.86

$1,923.22
$2,070.30
$2,226.12
$2,779.64

$2,340.00
$2,487.08
$2,642.90
$3,196.42

$416.78

Toc - Plan #98 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

$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

$450.63
$511.45
$575.89
$804.81
$1,222.98

$795.35
$856.17
$920.61
$1,149.53

$1,140.07
$1,200.89
$1,265.33
$1,494.25

$1,484.79
$1,545.61
$1,610.05
$1,838.97

$344.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$901.26
$1,022.90
$1,151.78
$1,609.62
$2,445.96

$1,245.98
$1,367.62
$1,496.50
$1,954.34

$1,590.70
$1,712.34
$1,841.22
$2,299.06

$1,935.42
$2,057.06
$2,185.94
$2,643.78

$344.72

Toc - Plan #99 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

$566.22
$642.65
$723.62
$1,011.25
$1,536.70

$999.37
$1,075.80
$1,156.77
$1,444.40

$1,432.52
$1,508.95
$1,589.92
$1,877.55

$1,865.67
$1,942.10
$2,023.07
$2,310.70

$433.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,132.44
$1,285.30
$1,447.24
$2,022.50
$3,073.40

$1,565.59
$1,718.45
$1,880.39
$2,455.65

$1,998.74
$2,151.60
$2,313.54
$2,888.80

$2,431.89
$2,584.75
$2,746.69
$3,321.95

$433.15

Toc - Plan #100 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

$590.09
$669.75
$754.13
$1,053.89
$1,601.49

$1,041.50
$1,121.16
$1,205.54
$1,505.30

$1,492.91
$1,572.57
$1,656.95
$1,956.71

$1,944.32
$2,023.98
$2,108.36
$2,408.12

$451.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,180.18
$1,339.50
$1,508.26
$2,107.78
$3,202.98

$1,631.59
$1,790.91
$1,959.67
$2,559.19

$2,083.00
$2,242.32
$2,411.08
$3,010.60

$2,534.41
$2,693.73
$2,862.49
$3,462.01

$451.41

Toc - Plan #101 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

$8,450 $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

$441.94
$501.60
$564.79
$789.30
$1,199.41

$780.02
$839.68
$902.87
$1,127.38

$1,118.10
$1,177.76
$1,240.95
$1,465.46

$1,456.18
$1,515.84
$1,579.03
$1,803.54

$338.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$883.88
$1,003.20
$1,129.58
$1,578.60
$2,398.82

$1,221.96
$1,341.28
$1,467.66
$1,916.68

$1,560.04
$1,679.36
$1,805.74
$2,254.76

$1,898.12
$2,017.44
$2,143.82
$2,592.84

$338.08

Toc - Plan #102 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

$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

$504.60
$572.71
$644.87
$901.20
$1,369.46

$890.61
$958.72
$1,030.88
$1,287.21

$1,276.62
$1,344.73
$1,416.89
$1,673.22

$1,662.63
$1,730.74
$1,802.90
$2,059.23

$386.01

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,009.20
$1,145.42
$1,289.74
$1,802.40
$2,738.92

$1,395.21
$1,531.43
$1,675.75
$2,188.41

$1,781.22
$1,917.44
$2,061.76
$2,574.42

$2,167.23
$2,303.45
$2,447.77
$2,960.43

$386.01

Toc - Plan #103 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

$6,300 $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

$557.37
$632.61
$712.31
$995.45
$1,512.68

$983.75
$1,058.99
$1,138.69
$1,421.83

$1,410.13
$1,485.37
$1,565.07
$1,848.21

$1,836.51
$1,911.75
$1,991.45
$2,274.59

$426.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,114.74
$1,265.22
$1,424.62
$1,990.90
$3,025.36

$1,541.12
$1,691.60
$1,851.00
$2,417.28

$1,967.50
$2,117.98
$2,277.38
$2,843.66

$2,393.88
$2,544.36
$2,703.76
$3,270.04

$426.38

Toc - Plan #104 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

$550.00
$624.24
$702.88
$982.28
$1,492.67

$970.74
$1,044.98
$1,123.62
$1,403.02

$1,391.48
$1,465.72
$1,544.36
$1,823.76

$1,812.22
$1,886.46
$1,965.10
$2,244.50

$420.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,100.00
$1,248.48
$1,405.76
$1,964.56
$2,985.34

$1,520.74
$1,669.22
$1,826.50
$2,385.30

$1,941.48
$2,089.96
$2,247.24
$2,806.04

$2,362.22
$2,510.70
$2,667.98
$3,226.78

$420.74

Toc - Plan #105 Ambetter of North Carolina

Expanded Bronze

(HMO) Standard Expanded Bronze + 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

$434.19
$492.79
$554.88
$775.44
$1,178.36

$766.34
$824.94
$887.03
$1,107.59

$1,098.49
$1,157.09
$1,219.18
$1,439.74

$1,430.64
$1,489.24
$1,551.33
$1,771.89

$332.15

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$868.38
$985.58
$1,109.76
$1,550.88
$2,356.72

$1,200.53
$1,317.73
$1,441.91
$1,883.03

$1,532.68
$1,649.88
$1,774.06
$2,215.18

$1,864.83
$1,982.03
$2,106.21
$2,547.33

$332.15

Toc - Plan #106 Ambetter of North Carolina

Silver

(HMO) Standard Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$5,900 $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

$546.28
$620.02
$698.14
$975.64
$1,482.58

$964.18
$1,037.92
$1,116.04
$1,393.54

$1,382.08
$1,455.82
$1,533.94
$1,811.44

$1,799.98
$1,873.72
$1,951.84
$2,229.34

$417.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,092.56
$1,240.04
$1,396.28
$1,951.28
$2,965.16

$1,510.46
$1,657.94
$1,814.18
$2,369.18

$1,928.36
$2,075.84
$2,232.08
$2,787.08

$2,346.26
$2,493.74
$2,649.98
$3,204.98

$417.90

Toc - Plan #107 Ambetter of North Carolina

Gold

(HMO) Standard Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$1,500 $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

$566.39
$642.84
$723.83
$1,011.55
$1,537.14

$999.67
$1,076.12
$1,157.11
$1,444.83

$1,432.95
$1,509.40
$1,590.39
$1,878.11

$1,866.23
$1,942.68
$2,023.67
$2,311.39

$433.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,132.78
$1,285.68
$1,447.66
$2,023.10
$3,074.28

$1,566.06
$1,718.96
$1,880.94
$2,456.38

$1,999.34
$2,152.24
$2,314.22
$2,889.66

$2,432.62
$2,585.52
$2,747.50
$3,322.94

$433.28

Toc - Plan #108 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

$448.61
$509.16
$573.31
$801.20
$1,217.50

$791.79
$852.34
$916.49
$1,144.38

$1,134.97
$1,195.52
$1,259.67
$1,487.56

$1,478.15
$1,538.70
$1,602.85
$1,830.74

$343.18

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$897.22
$1,018.32
$1,146.62
$1,602.40
$2,435.00

$1,240.40
$1,361.50
$1,489.80
$1,945.58

$1,583.58
$1,704.68
$1,832.98
$2,288.76

$1,926.76
$2,047.86
$2,176.16
$2,631.94

$343.18

Toc - Plan #109 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

$554.71
$629.58
$708.90
$990.69
$1,505.44

$979.05
$1,053.92
$1,133.24
$1,415.03

$1,403.39
$1,478.26
$1,557.58
$1,839.37

$1,827.73
$1,902.60
$1,981.92
$2,263.71

$424.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,109.42
$1,259.16
$1,417.80
$1,981.38
$3,010.88

$1,533.76
$1,683.50
$1,842.14
$2,405.72

$1,958.10
$2,107.84
$2,266.48
$2,830.06

$2,382.44
$2,532.18
$2,690.82
$3,254.40

$424.34

Toc - Plan #110 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

$582.14
$660.71
$743.96
$1,039.68
$1,579.89

$1,027.47
$1,106.04
$1,189.29
$1,485.01

$1,472.80
$1,551.37
$1,634.62
$1,930.34

$1,918.13
$1,996.70
$2,079.95
$2,375.67

$445.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,164.28
$1,321.42
$1,487.92
$2,079.36
$3,159.78

$1,609.61
$1,766.75
$1,933.25
$2,524.69

$2,054.94
$2,212.08
$2,378.58
$2,970.02

$2,500.27
$2,657.41
$2,823.91
$3,415.35

$445.33

‡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 McDowell County here.

McDowell County is in “” of North Carolina.

Currently, there are 110 plans offered in .

Top

2024 Obamacare Plans for McDowell County, NC

Plan Browser: 110 Plans

Blue Cross and Blue Shield of NC

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

1. Silver Blue Advantage Silver Preferred | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

2. Silver Blue Advantage Silver Secure | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

3. Expanded Bronze Blue Advantage Bronze | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

4. Gold Blue Advantage Gold | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors

5. Expanded Bronze Blue Advantage Bronze | HSA Eligible | Integrated | Nationwide Doctors

6. Catastrophic Blue Advantage Catastrophic | 3 PCP $35 | Integrated | Nationwide Doctors

7. Silver Blue Advantage Silver Choice | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

8. Expanded Bronze Blue Advantage Bronze | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

9. Gold Blue Advantage Gold Standard | Nationwide Doctors

10. Silver Blue Advantage Silver Standard | Nationwide Doctors

11. Expanded Bronze Blue Advantage Bronze Standard | Nationwide Doctors

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-735-2962

12. Expanded Bronze CareSource Marketplace Bronze First

13. Silver CareSource Marketplace Low Premium Silver

14. Silver CareSource Marketplace Silver

15. Gold CareSource Marketplace Gold

16. Silver CareSource Marketplace Diabetes Silver

17. Gold CareSource Marketplace Diabetes Gold

18. Gold CareSource Marketplace Core Gold

19. Expanded Bronze CareSource Marketplace Bronze First Dental, Vision, & Fitness

20. Silver CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

21. Silver CareSource Marketplace Silver Dental, Vision, & Fitness

22. Gold CareSource Marketplace Gold Dental, Vision, & Fitness

23. Silver CareSource Marketplace Diabetes Silver Dental, Vision, & Fitness

24. Gold CareSource Marketplace Diabetes Gold Dental, Vision, & Fitness

25. Gold CareSource Marketplace Core Gold Dental, Vision, & Fitness

AmeriHealth Caritas Next

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

26. Bronze AmeriHealth Caritas Next Bronze Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

27. Expanded Bronze AmeriHealth Caritas Next Expanded Bronze Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

28. Silver AmeriHealth Caritas Next Silver Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

29. Gold AmeriHealth Caritas Next Gold Classic + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals

30. Expanded Bronze AmeriHealth Caritas Next Expanded Bronze Premier + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals Plan

31. Silver AmeriHealth Caritas Next Silver Premier + $0 Virtual Care 24/7 + $0 Preventive Care + No-Referrals Plan

WellCare of North Carolina

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

32. Expanded Bronze WellCare Secure Health Bronze

33. Silver WellCare Secure Health Silver

34. Gold WellCare Secure Health Gold

35. Expanded Bronze Standard Expanded Bronze WellCare

36. Silver Standard Silver WellCare

37. Gold Standard Gold WellCare

UnitedHealthcare

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

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

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

40. Expanded Bronze UHC Bronze Value HSA (No Referrals)

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

42. Gold UHC Gold Standard (No Referrals)

43. Silver UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $5 Tier 2 Rx, No Referrals)

44. Silver UHC Silver Standard (No Referrals)

45. Expanded Bronze UHC Bronze Standard (No Referrals)

46. Bronze UHC Bronze Essential ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)

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

48. Expanded Bronze UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)

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

50. Gold UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals)

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

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

Aetna CVS Health

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

53. Expanded Bronze Bronze 2 HSA: Aetna network of doctors & hospitals + MinuteClinic + Virtual Care 24/7

54. Silver Silver 7: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

55. Silver Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

56. Expanded Bronze Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

57. Gold Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

59. Expanded Bronze Bronze 4: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

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

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

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

Oscar Health Plan of North Carolina, Inc

Local: 1-855-672-2755 | Toll Free: 1-855-672-2755 | TTY: 1-855-672-2755

64. Expanded Bronze Bronze Classic PCP Saver

65. Expanded Bronze Bronze Elite + PCP Saver Plus

66. Silver Silver Classic

67. Catastrophic Secure

68. Expanded Bronze Bronze Simple HSA

69. Expanded Bronze Bronze Classic 4700

70. Silver Silver Simple PCP Saver

71. Silver Silver Elite Saver Plus

72. Gold Gold Elite Saver Plus

73. Silver Silver Simple Diabetes

74. Expanded Bronze Bronze Classic Standard

75. Silver Silver Classic Standard

76. Gold Gold Classic Standard

Cigna Healthcare

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

77. Bronze Connect Bronze 9450 Indiv Med Deductible

78. Expanded Bronze Connect Bronze 6500 Indiv Med Deductible

79. Expanded Bronze Connect Bronze 5500 Indiv Med Deductible

80. Silver Connect Silver 4500 Indiv Med Deductible

81. Silver Connect Silver 3500 Indiv Med Deductible

82. Silver Connect Silver 1500 Indiv Med Deductible

83. Silver Connect Silver 2500 Indiv Med Deductible Enhanced Diabetes Care

84. Expanded Bronze Connect Bronze CMS Standard

85. Expanded Bronze Connect Bronze 0 Indiv Med Deductible

86. Silver Connect Silver CMS Standard

87. Gold Connect Gold CMS Standard

Ambetter of North Carolina

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

88. Expanded Bronze Choice Bronze HSA

89. Silver Complete Silver

90. Gold Complete Gold

91. Expanded Bronze Everyday Bronze

92. Expanded Bronze Elite Bronze

93. Silver Clear Silver

94. Silver Focused Silver

95. Expanded Bronze Standard Expanded Bronze

96. Silver Standard Silver

97. Gold Standard Gold

98. Expanded Bronze Choice Bronze HSA + Vision + Adult Dental

99. Silver Complete Silver + Vision + Adult Dental

100. Gold Complete Gold + Vision + Adult Dental

101. Expanded Bronze Everyday Bronze + Vision + Adult Dental

102. Expanded Bronze Elite Bronze + Vision + Adult Dental

103. Silver Focused Silver + Vision + Adult Dental

104. Silver Clear Silver + Vision + Adult Dental

105. Expanded Bronze Standard Expanded Bronze + Vision + Adult Dental

106. Silver Standard Silver + Vision + Adult Dental

107. Gold Standard Gold + Vision + Adult Dental

108. Expanded Bronze Ambetter Virtual Access Bronze (Virtual PCP selection required)

109. Silver Ambetter Virtual Access Silver (Virtual PCP selection required)

110. Gold Ambetter Virtual Access Gold (Virtual PCP selection required)

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North Carolina Expanded Medicaid as of December 1, 2023

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More Information

Blue Cross and Blue Shield of NC

(PPO) Blue Advantage Silver Preferred | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

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:

(PPO) Blue Advantage Silver Secure | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

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:

(PPO) Blue Advantage Bronze | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

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:

(PPO) Blue Advantage Gold | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors

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:

(PPO) Blue Advantage Bronze | HSA Eligible | Integrated | Nationwide Doctors

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:

(PPO) Blue Advantage Catastrophic | 3 PCP $35 | Integrated | Nationwide Doctors

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:

(PPO) Blue Advantage Silver Choice | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

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:

(PPO) Blue Advantage Bronze | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

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:

(PPO) Blue Advantage Gold Standard | Nationwide Doctors

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:

(PPO) Blue Advantage Silver Standard | Nationwide Doctors

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:

(PPO) Blue Advantage Bronze Standard | Nationwide Doctors

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:

CareSource

(HMO) CareSource Marketplace Bronze First

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:

(HMO) CareSource Marketplace Low Premium Silver

Annual Out of Pocket Expenses:

Individual Family $6,500 $13,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) CareSource Marketplace Silver

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:

(HMO) CareSource Marketplace Gold

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:

(HMO) CareSource Marketplace Diabetes Silver

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:

(HMO) CareSource Marketplace Diabetes Gold

Annual Out of Pocket Expenses:

Individual Family $1,000 $2,000 Annual Deductible $7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$2,750 $5,500 Annual Deductible

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

Individual Family

$1,600 $3,200 Annual Deductible

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

Individual Family

$7,000 $14,000 Annual Deductible

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

Individual Family

$1,800 $3,600 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$8,050 $16,100 Annual Deductible

$8,050 $16,100 Maximum Out of Pocket Per Year

Individual Family

$9,450 $18,900 Annual Deductible

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

Individual Family

$3,500 $7,000 Annual Deductible

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

Individual Family

$5,500 $11,000 Annual Deductible

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

Individual Family

$1,500 $3,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,900 $11,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,400 $18,800 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,400 $18,800 Maximum Out of Pocket Per Year

Individual Family

$6,500 $13,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,900 $11,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$3,500 $7,000 Annual Deductible

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

Individual Family

$1,000 $2,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,400 $18,800 Maximum Out of Pocket Per Year

Individual Family

$6,500 $13,000 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$5,900 $11,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$3,500 $7,000 Annual Deductible

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

Individual Family

$1,000 $2,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$9,450 $18,900 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

$9,400 $18,800 Maximum Out of Pocket Per Year

Individual Family

$5,900 $11,800 Annual Deductible

$9,100 $18,200 Maximum Out of Pocket Per Year

Individual Family

$1,500 $3,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$3,500 $7,000 Annual Deductible

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

Individual Family

$0 $0 Annual Deductible

$9,400 $18,800 Maximum Out of Pocket Per Year

Individual Family

$7,100 $14,200 Annual Deductible

$9,250 $18,500 Maximum Out of Pocket Per Year