Obamacare 2023 Rates for McDowell County

Obamacare > Rates > North Carolina > McDowell County

Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for McDowell County, NC.

The health insurance rates listed below are for calendar year 2023.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

Contact a licensed health insurance agent
Complete an application at Healthcare.gov
Contact the provider directly

Obamacare Providers, 149 Plans and 2023 Rates for McDowell County, North Carolina

Below, you’ll find a summary of the 149 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.

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 Simple | $0 Deductible | 3 Free PCP | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$540.34
$613.29
$690.55
$965.05
$1,466.48

$953.70
$1,026.65
$1,103.91
$1,378.41

$1,367.06
$1,440.01
$1,517.27
$1,791.77

$1,780.42
$1,853.37
$1,930.63
$2,205.13

$413.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,080.68
$1,226.58
$1,381.10
$1,930.10
$2,932.96

$1,494.04
$1,639.94
$1,794.46
$2,343.46

$1,907.40
$2,053.30
$2,207.82
$2,756.82

$2,320.76
$2,466.66
$2,621.18
$3,170.18

$413.36

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

Silver

(PPO) Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$3,100 $6,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$500.28
$567.82
$639.36
$893.50
$1,357.76

$882.99
$950.53
$1,022.07
$1,276.21

$1,265.70
$1,333.24
$1,404.78
$1,658.92

$1,648.41
$1,715.95
$1,787.49
$2,041.63

$382.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,000.56
$1,135.64
$1,278.72
$1,787.00
$2,715.52

$1,383.27
$1,518.35
$1,661.43
$2,169.71

$1,765.98
$1,901.06
$2,044.14
$2,552.42

$2,148.69
$2,283.77
$2,426.85
$2,935.13

$382.71

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

Silver

(PPO) Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$520.20
$590.43
$664.82
$929.08
$1,411.82

$918.15
$988.38
$1,062.77
$1,327.03

$1,316.10
$1,386.33
$1,460.72
$1,724.98

$1,714.05
$1,784.28
$1,858.67
$2,122.93

$397.95

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,040.40
$1,180.86
$1,329.64
$1,858.16
$2,823.64

$1,438.35
$1,578.81
$1,727.59
$2,256.11

$1,836.30
$1,976.76
$2,125.54
$2,654.06

$2,234.25
$2,374.71
$2,523.49
$3,052.01

$397.95

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

Expanded Bronze

(PPO) Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$365.18
$414.48
$466.70
$652.21
$991.10

$644.54
$693.84
$746.06
$931.57

$923.90
$973.20
$1,025.42
$1,210.93

$1,203.26
$1,252.56
$1,304.78
$1,490.29

$279.36

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$730.36
$828.96
$933.40
$1,304.42
$1,982.20

$1,009.72
$1,108.32
$1,212.76
$1,583.78

$1,289.08
$1,387.68
$1,492.12
$1,863.14

$1,568.44
$1,667.04
$1,771.48
$2,142.50

$279.36

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

Gold

(PPO) Blue Advantage Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$1,800 $3,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$513.97
$583.36
$656.85
$917.95
$1,394.91

$907.16
$976.55
$1,050.04
$1,311.14

$1,300.35
$1,369.74
$1,443.23
$1,704.33

$1,693.54
$1,762.93
$1,836.42
$2,097.52

$393.19

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,027.94
$1,166.72
$1,313.70
$1,835.90
$2,789.82

$1,421.13
$1,559.91
$1,706.89
$2,229.09

$1,814.32
$1,953.10
$2,100.08
$2,622.28

$2,207.51
$2,346.29
$2,493.27
$3,015.47

$393.19

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

Silver

(PPO) Blue Advantage Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$528.32
$599.64
$675.19
$943.58
$1,433.86

$932.48
$1,003.80
$1,079.35
$1,347.74

$1,336.64
$1,407.96
$1,483.51
$1,751.90

$1,740.80
$1,812.12
$1,887.67
$2,156.06

$404.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,056.64
$1,199.28
$1,350.38
$1,887.16
$2,867.72

$1,460.80
$1,603.44
$1,754.54
$2,291.32

$1,864.96
$2,007.60
$2,158.70
$2,695.48

$2,269.12
$2,411.76
$2,562.86
$3,099.64

$404.16

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

Expanded Bronze

(PPO) Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$383.21
$434.94
$489.74
$684.41
$1,040.03

$676.37
$728.10
$782.90
$977.57

$969.53
$1,021.26
$1,076.06
$1,270.73

$1,262.69
$1,314.42
$1,369.22
$1,563.89

$293.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$766.42
$869.88
$979.48
$1,368.82
$2,080.06

$1,059.58
$1,163.04
$1,272.64
$1,661.98

$1,352.74
$1,456.20
$1,565.80
$1,955.14

$1,645.90
$1,749.36
$1,858.96
$2,248.30

$293.16

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

Catastrophic

(PPO) Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$268.34
$304.57
$342.94
$479.26
$728.27

$473.62
$509.85
$548.22
$684.54

$678.90
$715.13
$753.50
$889.82

$884.18
$920.41
$958.78
$1,095.10

$205.28

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$536.68
$609.14
$685.88
$958.52
$1,456.54

$741.96
$814.42
$891.16
$1,163.80

$947.24
$1,019.70
$1,096.44
$1,369.08

$1,152.52
$1,224.98
$1,301.72
$1,574.36

$205.28

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

Silver

(PPO) Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$522.31
$592.82
$667.51
$932.85
$1,417.55

$921.88
$992.39
$1,067.08
$1,332.42

$1,321.45
$1,391.96
$1,466.65
$1,731.99

$1,721.02
$1,791.53
$1,866.22
$2,131.56

$399.57

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,044.62
$1,185.64
$1,335.02
$1,865.70
$2,835.10

$1,444.19
$1,585.21
$1,734.59
$2,265.27

$1,843.76
$1,984.78
$2,134.16
$2,664.84

$2,243.33
$2,384.35
$2,533.73
$3,064.41

$399.57

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

Expanded Bronze

(PPO) Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$385.91
$438.01
$493.19
$689.24
$1,047.36

$681.13
$733.23
$788.41
$984.46

$976.35
$1,028.45
$1,083.63
$1,279.68

$1,271.57
$1,323.67
$1,378.85
$1,574.90

$295.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$771.82
$876.02
$986.38
$1,378.48
$2,094.72

$1,067.04
$1,171.24
$1,281.60
$1,673.70

$1,362.26
$1,466.46
$1,576.82
$1,968.92

$1,657.48
$1,761.68
$1,872.04
$2,264.14

$295.22

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

Bronze

(PPO) Blue Advantage Bronze 9100 | Integrated | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$365.88
$415.27
$467.59
$653.46
$993.00

$645.78
$695.17
$747.49
$933.36

$925.68
$975.07
$1,027.39
$1,213.26

$1,205.58
$1,254.97
$1,307.29
$1,493.16

$279.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$731.76
$830.54
$935.18
$1,306.92
$1,986.00

$1,011.66
$1,110.44
$1,215.08
$1,586.82

$1,291.56
$1,390.34
$1,494.98
$1,866.72

$1,571.46
$1,670.24
$1,774.88
$2,146.62

$279.90

Toc - Plan #12 Blue Cross and Blue Shield of NC

Gold

(PPO) Blue Advantage Gold Standard 2000 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$512.08
$581.21
$654.44
$914.57
$1,389.79

$903.82
$972.95
$1,046.18
$1,306.31

$1,295.56
$1,364.69
$1,437.92
$1,698.05

$1,687.30
$1,756.43
$1,829.66
$2,089.79

$391.74

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,024.16
$1,162.42
$1,308.88
$1,829.14
$2,779.58

$1,415.90
$1,554.16
$1,700.62
$2,220.88

$1,807.64
$1,945.90
$2,092.36
$2,612.62

$2,199.38
$2,337.64
$2,484.10
$3,004.36

$391.74

Toc - Plan #13 Blue Cross and Blue Shield of NC

Silver

(PPO) Blue Advantage Silver Standard 5800 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$518.04
$587.98
$662.06
$925.22
$1,405.96

$914.34
$984.28
$1,058.36
$1,321.52

$1,310.64
$1,380.58
$1,454.66
$1,717.82

$1,706.94
$1,776.88
$1,850.96
$2,114.12

$396.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,036.08
$1,175.96
$1,324.12
$1,850.44
$2,811.92

$1,432.38
$1,572.26
$1,720.42
$2,246.74

$1,828.68
$1,968.56
$2,116.72
$2,643.04

$2,224.98
$2,364.86
$2,513.02
$3,039.34

$396.30

Toc - Plan #14 Blue Cross and Blue Shield of NC

Expanded Bronze

(PPO) Blue Advantage Bronze Standard 7500 | Nationwide Doctors

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-324-4973

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$365.62
$414.98
$467.26
$653.00
$992.29

$645.32
$694.68
$746.96
$932.70

$925.02
$974.38
$1,026.66
$1,212.40

$1,204.72
$1,254.08
$1,306.36
$1,492.10

$279.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$731.24
$829.96
$934.52
$1,306.00
$1,984.58

$1,010.94
$1,109.66
$1,214.22
$1,585.70

$1,290.64
$1,389.36
$1,493.92
$1,865.40

$1,570.34
$1,669.06
$1,773.62
$2,145.10

$279.70

CareSource

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

Toc - Plan #15 CareSource

Expanded Bronze

(HMO) CareSource Marketplace Bronze HSA Eligible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 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

$395.43
$448.81
$505.36
$706.24
$1,073.20

$697.93
$751.31
$807.86
$1,008.74

$1,000.43
$1,053.81
$1,110.36
$1,311.24

$1,302.93
$1,356.31
$1,412.86
$1,613.74

$302.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$790.86
$897.62
$1,010.72
$1,412.48
$2,146.40

$1,093.36
$1,200.12
$1,313.22
$1,714.98

$1,395.86
$1,502.62
$1,615.72
$2,017.48

$1,698.36
$1,805.12
$1,918.22
$2,319.98

$302.50

Toc - Plan #16 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

$8,000 $16,000 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

$354.77
$402.66
$453.40
$633.62
$962.85

$626.17
$674.06
$724.80
$905.02

$897.57
$945.46
$996.20
$1,176.42

$1,168.97
$1,216.86
$1,267.60
$1,447.82

$271.40

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$709.54
$805.32
$906.80
$1,267.24
$1,925.70

$980.94
$1,076.72
$1,178.20
$1,538.64

$1,252.34
$1,348.12
$1,449.60
$1,810.04

$1,523.74
$1,619.52
$1,721.00
$2,081.44

$271.40

Toc - Plan #17 CareSource

Bronze

(HMO) CareSource Marketplace Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$343.48
$389.85
$438.97
$613.46
$932.20

$606.24
$652.61
$701.73
$876.22

$869.00
$915.37
$964.49
$1,138.98

$1,131.76
$1,178.13
$1,227.25
$1,401.74

$262.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$686.96
$779.70
$877.94
$1,226.92
$1,864.40

$949.72
$1,042.46
$1,140.70
$1,489.68

$1,212.48
$1,305.22
$1,403.46
$1,752.44

$1,475.24
$1,567.98
$1,666.22
$2,015.20

$262.76

Toc - Plan #18 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

$481.19
$546.15
$614.96
$859.41
$1,305.95

$849.30
$914.26
$983.07
$1,227.52

$1,217.41
$1,282.37
$1,351.18
$1,595.63

$1,585.52
$1,650.48
$1,719.29
$1,963.74

$368.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$962.38
$1,092.30
$1,229.92
$1,718.82
$2,611.90

$1,330.49
$1,460.41
$1,598.03
$2,086.93

$1,698.60
$1,828.52
$1,966.14
$2,455.04

$2,066.71
$2,196.63
$2,334.25
$2,823.15

$368.11

Toc - Plan #19 CareSource

Silver

(HMO) CareSource Marketplace Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$492.71
$559.23
$629.68
$879.98
$1,337.21

$869.63
$936.15
$1,006.60
$1,256.90

$1,246.55
$1,313.07
$1,383.52
$1,633.82

$1,623.47
$1,689.99
$1,760.44
$2,010.74

$376.92

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$985.42
$1,118.46
$1,259.36
$1,759.96
$2,674.42

$1,362.34
$1,495.38
$1,636.28
$2,136.88

$1,739.26
$1,872.30
$2,013.20
$2,513.80

$2,116.18
$2,249.22
$2,390.12
$2,890.72

$376.92

Toc - Plan #20 CareSource

Silver

(HMO) CareSource Marketplace Low Deductible Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$520.43
$590.69
$665.11
$929.49
$1,412.45

$918.56
$988.82
$1,063.24
$1,327.62

$1,316.69
$1,386.95
$1,461.37
$1,725.75

$1,714.82
$1,785.08
$1,859.50
$2,123.88

$398.13

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,040.86
$1,181.38
$1,330.22
$1,858.98
$2,824.90

$1,438.99
$1,579.51
$1,728.35
$2,257.11

$1,837.12
$1,977.64
$2,126.48
$2,655.24

$2,235.25
$2,375.77
$2,524.61
$3,053.37

$398.13

Toc - Plan #21 CareSource

Silver

(HMO) CareSource Marketplace Essential Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,150 $12,300 Annual Deductible

$6,150 $12,300 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

$544.15
$617.61
$695.42
$971.85
$1,476.82

$960.42
$1,033.88
$1,111.69
$1,388.12

$1,376.69
$1,450.15
$1,527.96
$1,804.39

$1,792.96
$1,866.42
$1,944.23
$2,220.66

$416.27

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,088.30
$1,235.22
$1,390.84
$1,943.70
$2,953.64

$1,504.57
$1,651.49
$1,807.11
$2,359.97

$1,920.84
$2,067.76
$2,223.38
$2,776.24

$2,337.11
$2,484.03
$2,639.65
$3,192.51

$416.27

Toc - Plan #22 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

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$516.39
$586.10
$659.95
$922.27
$1,401.48

$911.43
$981.14
$1,054.99
$1,317.31

$1,306.47
$1,376.18
$1,450.03
$1,712.35

$1,701.51
$1,771.22
$1,845.07
$2,107.39

$395.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,032.78
$1,172.20
$1,319.90
$1,844.54
$2,802.96

$1,427.82
$1,567.24
$1,714.94
$2,239.58

$1,822.86
$1,962.28
$2,109.98
$2,634.62

$2,217.90
$2,357.32
$2,505.02
$3,029.66

$395.04

Toc - Plan #23 CareSource

Expanded Bronze

(HMO) CareSource Marektplace 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

$8,000 $16,000 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

$361.73
$410.56
$462.29
$646.05
$981.74

$638.45
$687.28
$739.01
$922.77

$915.17
$964.00
$1,015.73
$1,199.49

$1,191.89
$1,240.72
$1,292.45
$1,476.21

$276.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$723.46
$821.12
$924.58
$1,292.10
$1,963.48

$1,000.18
$1,097.84
$1,201.30
$1,568.82

$1,276.90
$1,374.56
$1,478.02
$1,845.54

$1,553.62
$1,651.28
$1,754.74
$2,122.26

$276.72

Toc - Plan #24 CareSource

Bronze

(HMO) CareSource Marektplace Bronze Dental, Vision, & Fitness

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$350.06
$397.32
$447.38
$625.21
$950.06

$617.86
$665.12
$715.18
$893.01

$885.66
$932.92
$982.98
$1,160.81

$1,153.46
$1,200.72
$1,250.78
$1,428.61

$267.80

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$700.12
$794.64
$894.76
$1,250.42
$1,900.12

$967.92
$1,062.44
$1,162.56
$1,518.22

$1,235.72
$1,330.24
$1,430.36
$1,786.02

$1,503.52
$1,598.04
$1,698.16
$2,053.82

$267.80

Toc - Plan #25 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

$488.01
$553.89
$623.68
$871.59
$1,324.46

$861.34
$927.22
$997.01
$1,244.92

$1,234.67
$1,300.55
$1,370.34
$1,618.25

$1,608.00
$1,673.88
$1,743.67
$1,991.58

$373.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$976.02
$1,107.78
$1,247.36
$1,743.18
$2,648.92

$1,349.35
$1,481.11
$1,620.69
$2,116.51

$1,722.68
$1,854.44
$1,994.02
$2,489.84

$2,096.01
$2,227.77
$2,367.35
$2,863.17

$373.33

Toc - Plan #26 CareSource

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$499.53
$566.97
$638.40
$892.16
$1,355.72

$881.67
$949.11
$1,020.54
$1,274.30

$1,263.81
$1,331.25
$1,402.68
$1,656.44

$1,645.95
$1,713.39
$1,784.82
$2,038.58

$382.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$999.06
$1,133.94
$1,276.80
$1,784.32
$2,711.44

$1,381.20
$1,516.08
$1,658.94
$2,166.46

$1,763.34
$1,898.22
$2,041.08
$2,548.60

$2,145.48
$2,280.36
$2,423.22
$2,930.74

$382.14

Toc - Plan #27 CareSource

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$527.25
$598.43
$673.83
$941.67
$1,430.96

$930.60
$1,001.78
$1,077.18
$1,345.02

$1,333.95
$1,405.13
$1,480.53
$1,748.37

$1,737.30
$1,808.48
$1,883.88
$2,151.72

$403.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,054.50
$1,196.86
$1,347.66
$1,883.34
$2,861.92

$1,457.85
$1,600.21
$1,751.01
$2,286.69

$1,861.20
$2,003.56
$2,154.36
$2,690.04

$2,264.55
$2,406.91
$2,557.71
$3,093.39

$403.35

Toc - Plan #28 CareSource

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family

$6,150 $12,300 Annual Deductible

$6,150 $12,300 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

$550.77
$625.12
$703.88
$983.68
$1,494.79

$972.11
$1,046.46
$1,125.22
$1,405.02

$1,393.45
$1,467.80
$1,546.56
$1,826.36

$1,814.79
$1,889.14
$1,967.90
$2,247.70

$421.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,101.54
$1,250.24
$1,407.76
$1,967.36
$2,989.58

$1,522.88
$1,671.58
$1,829.10
$2,388.70

$1,944.22
$2,092.92
$2,250.44
$2,810.04

$2,365.56
$2,514.26
$2,671.78
$3,231.38

$421.34

Toc - Plan #29 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

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$523.68
$594.38
$669.26
$935.29
$1,421.27

$924.30
$995.00
$1,069.88
$1,335.91

$1,324.92
$1,395.62
$1,470.50
$1,736.53

$1,725.54
$1,796.24
$1,871.12
$2,137.15

$400.62

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,047.36
$1,188.76
$1,338.52
$1,870.58
$2,842.54

$1,447.98
$1,589.38
$1,739.14
$2,271.20

$1,848.60
$1,990.00
$2,139.76
$2,671.82

$2,249.22
$2,390.62
$2,540.38
$3,072.44

$400.62

AmeriHealth Caritas Next

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

Toc - Plan #30 AmeriHealth Caritas Next

Bronze

(HMO) AmeriHealth Caritas Next Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$309.57
$351.36
$395.62
$552.88
$840.15

$546.39
$588.18
$632.44
$789.70

$783.21
$825.00
$869.26
$1,026.52

$1,020.03
$1,061.82
$1,106.08
$1,263.34

$236.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$619.14
$702.72
$791.24
$1,105.76
$1,680.30

$855.96
$939.54
$1,028.06
$1,342.58

$1,092.78
$1,176.36
$1,264.88
$1,579.40

$1,329.60
$1,413.18
$1,501.70
$1,816.22

$236.82

Toc - Plan #31 AmeriHealth Caritas Next

Expanded Bronze

(HMO) AmeriHealth Caritas Next Expanded Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

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

$9,000 $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

$348.56
$395.61
$445.45
$622.52
$945.97

$615.21
$662.26
$712.10
$889.17

$881.86
$928.91
$978.75
$1,155.82

$1,148.51
$1,195.56
$1,245.40
$1,422.47

$266.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$697.12
$791.22
$890.90
$1,245.04
$1,891.94

$963.77
$1,057.87
$1,157.55
$1,511.69

$1,230.42
$1,324.52
$1,424.20
$1,778.34

$1,497.07
$1,591.17
$1,690.85
$2,044.99

$266.65

Toc - Plan #32 AmeriHealth Caritas Next

Silver

(HMO) AmeriHealth Caritas Next Silver + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$474.94
$539.06
$606.98
$848.24
$1,288.99

$838.27
$902.39
$970.31
$1,211.57

$1,201.60
$1,265.72
$1,333.64
$1,574.90

$1,564.93
$1,629.05
$1,696.97
$1,938.23

$363.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$949.88
$1,078.12
$1,213.96
$1,696.48
$2,577.98

$1,313.21
$1,441.45
$1,577.29
$2,059.81

$1,676.54
$1,804.78
$1,940.62
$2,423.14

$2,039.87
$2,168.11
$2,303.95
$2,786.47

$363.33

Toc - Plan #33 AmeriHealth Caritas Next

Gold

(HMO) AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-613-2262

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$582.99
$661.69
$745.06
$1,041.22
$1,582.23

$1,028.98
$1,107.68
$1,191.05
$1,487.21

$1,474.97
$1,553.67
$1,637.04
$1,933.20

$1,920.96
$1,999.66
$2,083.03
$2,379.19

$445.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,165.98
$1,323.38
$1,490.12
$2,082.44
$3,164.46

$1,611.97
$1,769.37
$1,936.11
$2,528.43

$2,057.96
$2,215.36
$2,382.10
$2,974.42

$2,503.95
$2,661.35
$2,828.09
$3,420.41

$445.99

WellCare of North Carolina

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

Toc - Plan #34 WellCare of North Carolina

Expanded Bronze

(PPO) WellCare Secure Health Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family

$7,100 $14,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$564.18
$640.33
$721.01
$1,007.60
$1,531.15

$995.77
$1,071.92
$1,152.60
$1,439.19

$1,427.36
$1,503.51
$1,584.19
$1,870.78

$1,858.95
$1,935.10
$2,015.78
$2,302.37

$431.59

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,128.36
$1,280.66
$1,442.02
$2,015.20
$3,062.30

$1,559.95
$1,712.25
$1,873.61
$2,446.79

$1,991.54
$2,143.84
$2,305.20
$2,878.38

$2,423.13
$2,575.43
$2,736.79
$3,309.97

$431.59

Toc - Plan #35 WellCare of North Carolina

Silver

(PPO) WellCare Secure Health Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family

$8,100 $16,200 Annual Deductible

$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$723.77
$821.46
$924.96
$1,292.63
$1,964.28

$1,277.44
$1,375.13
$1,478.63
$1,846.30

$1,831.11
$1,928.80
$2,032.30
$2,399.97

$2,384.78
$2,482.47
$2,585.97
$2,953.64

$553.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,447.54
$1,642.92
$1,849.92
$2,585.26
$3,928.56

$2,001.21
$2,196.59
$2,403.59
$3,138.93

$2,554.88
$2,750.26
$2,957.26
$3,692.60

$3,108.55
$3,303.93
$3,510.93
$4,246.27

$553.67

Toc - Plan #36 WellCare of North Carolina

Gold

(PPO) WellCare Secure Health Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family

$1,850 $3,700 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$748.88
$849.97
$957.06
$1,337.48
$2,032.44

$1,321.77
$1,422.86
$1,529.95
$1,910.37

$1,894.66
$1,995.75
$2,102.84
$2,483.26

$2,467.55
$2,568.64
$2,675.73
$3,056.15

$572.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,497.76
$1,699.94
$1,914.12
$2,674.96
$4,064.88

$2,070.65
$2,272.83
$2,487.01
$3,247.85

$2,643.54
$2,845.72
$3,059.90
$3,820.74

$3,216.43
$3,418.61
$3,632.79
$4,393.63

$572.89

Toc - Plan #37 WellCare of North Carolina

Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$565.12
$641.40
$722.21
$1,009.28
$1,533.71

$997.43
$1,073.71
$1,154.52
$1,441.59

$1,429.74
$1,506.02
$1,586.83
$1,873.90

$1,862.05
$1,938.33
$2,019.14
$2,306.21

$432.31

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,130.24
$1,282.80
$1,444.42
$2,018.56
$3,067.42

$1,562.55
$1,715.11
$1,876.73
$2,450.87

$1,994.86
$2,147.42
$2,309.04
$2,883.18

$2,427.17
$2,579.73
$2,741.35
$3,315.49

$432.31

Toc - Plan #38 WellCare of North Carolina

Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$715.01
$811.52
$913.77
$1,276.99
$1,940.51

$1,261.98
$1,358.49
$1,460.74
$1,823.96

$1,808.95
$1,905.46
$2,007.71
$2,370.93

$2,355.92
$2,452.43
$2,554.68
$2,917.90

$546.97

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,430.02
$1,623.04
$1,827.54
$2,553.98
$3,881.02

$1,976.99
$2,170.01
$2,374.51
$3,100.95

$2,523.96
$2,716.98
$2,921.48
$3,647.92

$3,070.93
$3,263.95
$3,468.45
$4,194.89

$546.97

Toc - Plan #39 WellCare of North Carolina

Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$728.18
$826.47
$930.60
$1,300.51
$1,976.26

$1,285.23
$1,383.52
$1,487.65
$1,857.56

$1,842.28
$1,940.57
$2,044.70
$2,414.61

$2,399.33
$2,497.62
$2,601.75
$2,971.66

$557.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,456.36
$1,652.94
$1,861.20
$2,601.02
$3,952.52

$2,013.41
$2,209.99
$2,418.25
$3,158.07

$2,570.46
$2,767.04
$2,975.30
$3,715.12

$3,127.51
$3,324.09
$3,532.35
$4,272.17

$557.05

UnitedHealthcare

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

Toc - Plan #40 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$1,900 $3,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$608.41
$690.55
$777.55
$1,086.62
$1,651.23

$1,073.84
$1,155.98
$1,242.98
$1,552.05

$1,539.27
$1,621.41
$1,708.41
$2,017.48

$2,004.70
$2,086.84
$2,173.84
$2,482.91

$465.43

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,216.82
$1,381.10
$1,555.10
$2,173.24
$3,302.46

$1,682.25
$1,846.53
$2,020.53
$2,638.67

$2,147.68
$2,311.96
$2,485.96
$3,104.10

$2,613.11
$2,777.39
$2,951.39
$3,569.53

$465.43

Toc - Plan #41 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$600.65
$681.74
$767.63
$1,072.77
$1,630.17

$1,060.15
$1,141.24
$1,227.13
$1,532.27

$1,519.65
$1,600.74
$1,686.63
$1,991.77

$1,979.15
$2,060.24
$2,146.13
$2,451.27

$459.50

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,201.30
$1,363.48
$1,535.26
$2,145.54
$3,260.34

$1,660.80
$1,822.98
$1,994.76
$2,605.04

$2,120.30
$2,282.48
$2,454.26
$3,064.54

$2,579.80
$2,741.98
$2,913.76
$3,524.04

$459.50

Toc - Plan #42 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$3,350 $6,700 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$599.69
$680.65
$766.40
$1,071.04
$1,627.55

$1,058.45
$1,139.41
$1,225.16
$1,529.80

$1,517.21
$1,598.17
$1,683.92
$1,988.56

$1,975.97
$2,056.93
$2,142.68
$2,447.32

$458.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,199.38
$1,361.30
$1,532.80
$2,142.08
$3,255.10

$1,658.14
$1,820.06
$1,991.56
$2,600.84

$2,116.90
$2,278.82
$2,450.32
$3,059.60

$2,575.66
$2,737.58
$2,909.08
$3,518.36

$458.76

Toc - Plan #43 UnitedHealthcare

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$423.71
$480.91
$541.50
$756.74
$1,149.95

$747.85
$805.05
$865.64
$1,080.88

$1,071.99
$1,129.19
$1,189.78
$1,405.02

$1,396.13
$1,453.33
$1,513.92
$1,729.16

$324.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$847.42
$961.82
$1,083.00
$1,513.48
$2,299.90

$1,171.56
$1,285.96
$1,407.14
$1,837.62

$1,495.70
$1,610.10
$1,731.28
$2,161.76

$1,819.84
$1,934.24
$2,055.42
$2,485.90

$324.14

Toc - Plan #44 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$1,200 $2,400 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$631.95
$717.26
$807.63
$1,128.66
$1,715.10

$1,115.39
$1,200.70
$1,291.07
$1,612.10

$1,598.83
$1,684.14
$1,774.51
$2,095.54

$2,082.27
$2,167.58
$2,257.95
$2,578.98

$483.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,263.90
$1,434.52
$1,615.26
$2,257.32
$3,430.20

$1,747.34
$1,917.96
$2,098.70
$2,740.76

$2,230.78
$2,401.40
$2,582.14
$3,224.20

$2,714.22
$2,884.84
$3,065.58
$3,707.64

$483.44

Toc - Plan #45 UnitedHealthcare

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$1,200 $2,400 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$655.45
$743.93
$837.66
$1,170.63
$1,778.88

$1,156.87
$1,245.35
$1,339.08
$1,672.05

$1,658.29
$1,746.77
$1,840.50
$2,173.47

$2,159.71
$2,248.19
$2,341.92
$2,674.89

$501.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,310.90
$1,487.86
$1,675.32
$2,341.26
$3,557.76

$1,812.32
$1,989.28
$2,176.74
$2,842.68

$2,313.74
$2,490.70
$2,678.16
$3,344.10

$2,815.16
$2,992.12
$3,179.58
$3,845.52

$501.42

Toc - Plan #46 UnitedHealthcare

Expanded Bronze

(HMO) UHC Bronze Value HSA (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$6,700 $13,400 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$450.63
$511.46
$575.90
$804.82
$1,223.01

$795.36
$856.19
$920.63
$1,149.55

$1,140.09
$1,200.92
$1,265.36
$1,494.28

$1,484.82
$1,545.65
$1,610.09
$1,839.01

$344.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$901.26
$1,022.92
$1,151.80
$1,609.64
$2,446.02

$1,245.99
$1,367.65
$1,496.53
$1,954.37

$1,590.72
$1,712.38
$1,841.26
$2,299.10

$1,935.45
$2,057.11
$2,185.99
$2,643.83

$344.73

Toc - Plan #47 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$4,000 $8,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$600.07
$681.08
$766.89
$1,071.72
$1,628.59

$1,059.12
$1,140.13
$1,225.94
$1,530.77

$1,518.17
$1,599.18
$1,684.99
$1,989.82

$1,977.22
$2,058.23
$2,144.04
$2,448.87

$459.05

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,200.14
$1,362.16
$1,533.78
$2,143.44
$3,257.18

$1,659.19
$1,821.21
$1,992.83
$2,602.49

$2,118.24
$2,280.26
$2,451.88
$3,061.54

$2,577.29
$2,739.31
$2,910.93
$3,520.59

$459.05

Toc - Plan #48 UnitedHealthcare

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$428.90
$486.81
$548.14
$766.02
$1,164.05

$757.01
$814.92
$876.25
$1,094.13

$1,085.12
$1,143.03
$1,204.36
$1,422.24

$1,413.23
$1,471.14
$1,532.47
$1,750.35

$328.11

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$857.80
$973.62
$1,096.28
$1,532.04
$2,328.10

$1,185.91
$1,301.73
$1,424.39
$1,860.15

$1,514.02
$1,629.84
$1,752.50
$2,188.26

$1,842.13
$1,957.95
$2,080.61
$2,516.37

$328.11

Toc - Plan #49 UnitedHealthcare

Gold

(HMO) UHC Gold Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$619.28
$702.88
$791.44
$1,106.03
$1,680.72

$1,093.03
$1,176.63
$1,265.19
$1,579.78

$1,566.78
$1,650.38
$1,738.94
$2,053.53

$2,040.53
$2,124.13
$2,212.69
$2,527.28

$473.75

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,238.56
$1,405.76
$1,582.88
$2,212.06
$3,361.44

$1,712.31
$1,879.51
$2,056.63
$2,685.81

$2,186.06
$2,353.26
$2,530.38
$3,159.56

$2,659.81
$2,827.01
$3,004.13
$3,633.31

$473.75

Toc - Plan #50 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$609.05
$691.28
$778.37
$1,087.77
$1,652.97

$1,074.98
$1,157.21
$1,244.30
$1,553.70

$1,540.91
$1,623.14
$1,710.23
$2,019.63

$2,006.84
$2,089.07
$2,176.16
$2,485.56

$465.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,218.10
$1,382.56
$1,556.74
$2,175.54
$3,305.94

$1,684.03
$1,848.49
$2,022.67
$2,641.47

$2,149.96
$2,314.42
$2,488.60
$3,107.40

$2,615.89
$2,780.35
$2,954.53
$3,573.33

$465.93

Toc - Plan #51 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$594.68
$674.96
$760.00
$1,062.10
$1,613.97

$1,049.61
$1,129.89
$1,214.93
$1,517.03

$1,504.54
$1,584.82
$1,669.86
$1,971.96

$1,959.47
$2,039.75
$2,124.79
$2,426.89

$454.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,189.36
$1,349.92
$1,520.00
$2,124.20
$3,227.94

$1,644.29
$1,804.85
$1,974.93
$2,579.13

$2,099.22
$2,259.78
$2,429.86
$3,034.06

$2,554.15
$2,714.71
$2,884.79
$3,488.99

$454.93

Toc - Plan #52 UnitedHealthcare

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$627.00
$711.65
$801.31
$1,119.82
$1,701.68

$1,106.66
$1,191.31
$1,280.97
$1,599.48

$1,586.32
$1,670.97
$1,760.63
$2,079.14

$2,065.98
$2,150.63
$2,240.29
$2,558.80

$479.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,254.00
$1,423.30
$1,602.62
$2,239.64
$3,403.36

$1,733.66
$1,902.96
$2,082.28
$2,719.30

$2,213.32
$2,382.62
$2,561.94
$3,198.96

$2,692.98
$2,862.28
$3,041.60
$3,678.62

$479.66

Toc - Plan #53 UnitedHealthcare

Silver

(HMO) UHC Silver Standard (No Referrals)

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$598.02
$678.75
$764.27
$1,068.06
$1,623.02

$1,055.50
$1,136.23
$1,221.75
$1,525.54

$1,512.98
$1,593.71
$1,679.23
$1,983.02

$1,970.46
$2,051.19
$2,136.71
$2,440.50

$457.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,196.04
$1,357.50
$1,528.54
$2,136.12
$3,246.04

$1,653.52
$1,814.98
$1,986.02
$2,593.60

$2,111.00
$2,272.46
$2,443.50
$3,051.08

$2,568.48
$2,729.94
$2,900.98
$3,508.56

$457.48

Toc - Plan #54 UnitedHealthcare

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$409.84
$465.17
$523.77
$731.97
$1,112.30

$723.37
$778.70
$837.30
$1,045.50

$1,036.90
$1,092.23
$1,150.83
$1,359.03

$1,350.43
$1,405.76
$1,464.36
$1,672.56

$313.53

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$819.68
$930.34
$1,047.54
$1,463.94
$2,224.60

$1,133.21
$1,243.87
$1,361.07
$1,777.47

$1,446.74
$1,557.40
$1,674.60
$2,091.00

$1,760.27
$1,870.93
$1,988.13
$2,404.53

$313.53

Toc - Plan #55 UnitedHealthcare

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$408.42
$463.56
$521.96
$729.44
$1,108.45

$720.86
$776.00
$834.40
$1,041.88

$1,033.30
$1,088.44
$1,146.84
$1,354.32

$1,345.74
$1,400.88
$1,459.28
$1,666.76

$312.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$816.84
$927.12
$1,043.92
$1,458.88
$2,216.90

$1,129.28
$1,239.56
$1,356.36
$1,771.32

$1,441.72
$1,552.00
$1,668.80
$2,083.76

$1,754.16
$1,864.44
$1,981.24
$2,396.20

$312.44

Toc - Plan #56 UnitedHealthcare

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$429.61
$487.60
$549.04
$767.28
$1,165.96

$758.26
$816.25
$877.69
$1,095.93

$1,086.91
$1,144.90
$1,206.34
$1,424.58

$1,415.56
$1,473.55
$1,534.99
$1,753.23

$328.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$859.22
$975.20
$1,098.08
$1,534.56
$2,331.92

$1,187.87
$1,303.85
$1,426.73
$1,863.21

$1,516.52
$1,632.50
$1,755.38
$2,191.86

$1,845.17
$1,961.15
$2,084.03
$2,520.51

$328.65

Toc - Plan #57 UnitedHealthcare

Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-800-980-5357

Annual Out of Pocket Expenses:

Individual Family

$6,350 $12,700 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$418.33
$474.81
$534.63
$747.15
$1,135.36

$738.36
$794.84
$854.66
$1,067.18

$1,058.39
$1,114.87
$1,174.69
$1,387.21

$1,378.42
$1,434.90
$1,494.72
$1,707.24

$320.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$836.66
$949.62
$1,069.26
$1,494.30
$2,270.72

$1,156.69
$1,269.65
$1,389.29
$1,814.33

$1,476.72
$1,589.68
$1,709.32
$2,134.36

$1,796.75
$1,909.71
$2,029.35
$2,454.39

$320.03

Aetna CVS Health

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

Toc - Plan #58 Aetna CVS Health

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$6,000 $12,000 Annual Deductible

$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$339.14
$384.92
$433.42
$605.70
$920.42

$598.58
$644.36
$692.86
$865.14

$858.02
$903.80
$952.30
$1,124.58

$1,117.46
$1,163.24
$1,211.74
$1,384.02

$259.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$678.28
$769.84
$866.84
$1,211.40
$1,840.84

$937.72
$1,029.28
$1,126.28
$1,470.84

$1,197.16
$1,288.72
$1,385.72
$1,730.28

$1,456.60
$1,548.16
$1,645.16
$1,989.72

$259.44

Toc - Plan #59 Aetna CVS Health

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$8,800 $17,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$305.17
$346.37
$390.01
$545.04
$828.24

$538.63
$579.83
$623.47
$778.50

$772.09
$813.29
$856.93
$1,011.96

$1,005.55
$1,046.75
$1,090.39
$1,245.42

$233.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$610.34
$692.74
$780.02
$1,090.08
$1,656.48

$843.80
$926.20
$1,013.48
$1,323.54

$1,077.26
$1,159.66
$1,246.94
$1,557.00

$1,310.72
$1,393.12
$1,480.40
$1,790.46

$233.46

Toc - Plan #60 Aetna CVS Health

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$1,500 $3,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$500.49
$568.05
$639.62
$893.87
$1,358.32

$883.36
$950.92
$1,022.49
$1,276.74

$1,266.23
$1,333.79
$1,405.36
$1,659.61

$1,649.10
$1,716.66
$1,788.23
$2,042.48

$382.87

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,000.98
$1,136.10
$1,279.24
$1,787.74
$2,716.64

$1,383.85
$1,518.97
$1,662.11
$2,170.61

$1,766.72
$1,901.84
$2,044.98
$2,553.48

$2,149.59
$2,284.71
$2,427.85
$2,936.35

$382.87

Toc - Plan #61 Aetna CVS Health

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$4,300 $8,600 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$469.67
$533.08
$600.24
$838.83
$1,274.69

$828.97
$892.38
$959.54
$1,198.13

$1,188.27
$1,251.68
$1,318.84
$1,557.43

$1,547.57
$1,610.98
$1,678.14
$1,916.73

$359.30

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$939.34
$1,066.16
$1,200.48
$1,677.66
$2,549.38

$1,298.64
$1,425.46
$1,559.78
$2,036.96

$1,657.94
$1,784.76
$1,919.08
$2,396.26

$2,017.24
$2,144.06
$2,278.38
$2,755.56

$359.30

Toc - Plan #62 Aetna CVS Health

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$445.80
$505.98
$569.73
$796.19
$1,209.89

$786.83
$847.01
$910.76
$1,137.22

$1,127.86
$1,188.04
$1,251.79
$1,478.25

$1,468.89
$1,529.07
$1,592.82
$1,819.28

$341.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$891.60
$1,011.96
$1,139.46
$1,592.38
$2,419.78

$1,232.63
$1,352.99
$1,480.49
$1,933.41

$1,573.66
$1,694.02
$1,821.52
$2,274.44

$1,914.69
$2,035.05
$2,162.55
$2,615.47

$341.03

Toc - Plan #63 Aetna CVS Health

Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$316.29
$358.99
$404.22
$564.90
$858.42

$558.25
$600.95
$646.18
$806.86

$800.21
$842.91
$888.14
$1,048.82

$1,042.17
$1,084.87
$1,130.10
$1,290.78

$241.96

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$632.58
$717.98
$808.44
$1,129.80
$1,716.84

$874.54
$959.94
$1,050.40
$1,371.76

$1,116.50
$1,201.90
$1,292.36
$1,613.72

$1,358.46
$1,443.86
$1,534.32
$1,855.68

$241.96

Toc - Plan #64 Aetna CVS Health

Gold

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$491.27
$557.59
$627.84
$877.41
$1,333.31

$867.09
$933.41
$1,003.66
$1,253.23

$1,242.91
$1,309.23
$1,379.48
$1,629.05

$1,618.73
$1,685.05
$1,755.30
$2,004.87

$375.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$982.54
$1,115.18
$1,255.68
$1,754.82
$2,666.62

$1,358.36
$1,491.00
$1,631.50
$2,130.64

$1,734.18
$1,866.82
$2,007.32
$2,506.46

$2,110.00
$2,242.64
$2,383.14
$2,882.28

$375.82

Toc - Plan #65 Aetna CVS Health

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$8,850 $17,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$461.12
$523.37
$589.31
$823.56
$1,251.48

$813.88
$876.13
$942.07
$1,176.32

$1,166.64
$1,228.89
$1,294.83
$1,529.08

$1,519.40
$1,581.65
$1,647.59
$1,881.84

$352.76

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$922.24
$1,046.74
$1,178.62
$1,647.12
$2,502.96

$1,275.00
$1,399.50
$1,531.38
$1,999.88

$1,627.76
$1,752.26
$1,884.14
$2,352.64

$1,980.52
$2,105.02
$2,236.90
$2,705.40

$352.76

Toc - Plan #66 Aetna CVS Health

Silver

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

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-336-3915

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$435.37
$494.15
$556.41
$777.58
$1,181.60

$768.43
$827.21
$889.47
$1,110.64

$1,101.49
$1,160.27
$1,222.53
$1,443.70

$1,434.55
$1,493.33
$1,555.59
$1,776.76

$333.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$870.74
$988.30
$1,112.82
$1,555.16
$2,363.20

$1,203.80
$1,321.36
$1,445.88
$1,888.22

$1,536.86
$1,654.42
$1,778.94
$2,221.28

$1,869.92
$1,987.48
$2,112.00
$2,554.34

$333.06

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 #67 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

$383.63
$435.41
$490.26
$685.14
$1,041.14

$677.10
$728.88
$783.73
$978.61

$970.57
$1,022.35
$1,077.20
$1,272.08

$1,264.04
$1,315.82
$1,370.67
$1,565.55

$293.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$767.26
$870.82
$980.52
$1,370.28
$2,082.28

$1,060.73
$1,164.29
$1,273.99
$1,663.75

$1,354.20
$1,457.76
$1,567.46
$1,957.22

$1,647.67
$1,751.23
$1,860.93
$2,250.69

$293.47

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

Expanded Bronze

(HMO) Bronze Classic

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

$373.79
$424.24
$477.69
$667.57
$1,014.44

$659.73
$710.18
$763.63
$953.51

$945.67
$996.12
$1,049.57
$1,239.45

$1,231.61
$1,282.06
$1,335.51
$1,525.39

$285.94

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$747.58
$848.48
$955.38
$1,335.14
$2,028.88

$1,033.52
$1,134.42
$1,241.32
$1,621.08

$1,319.46
$1,420.36
$1,527.26
$1,907.02

$1,605.40
$1,706.30
$1,813.20
$2,192.96

$285.94

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

Expanded Bronze

(HMO) Bronze Elite- Deductible + 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

$9,100 $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

$454.28
$515.60
$580.56
$811.33
$1,232.90

$801.80
$863.12
$928.08
$1,158.85

$1,149.32
$1,210.64
$1,275.60
$1,506.37

$1,496.84
$1,558.16
$1,623.12
$1,853.89

$347.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$908.56
$1,031.20
$1,161.12
$1,622.66
$2,465.80

$1,256.08
$1,378.72
$1,508.64
$1,970.18

$1,603.60
$1,726.24
$1,856.16
$2,317.70

$1,951.12
$2,073.76
$2,203.68
$2,665.22

$347.52

Toc - Plan #70 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

$521.48
$591.87
$666.44
$931.35
$1,415.27

$920.41
$990.80
$1,065.37
$1,330.28

$1,319.34
$1,389.73
$1,464.30
$1,729.21

$1,718.27
$1,788.66
$1,863.23
$2,128.14

$398.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,042.96
$1,183.74
$1,332.88
$1,862.70
$2,830.54

$1,441.89
$1,582.67
$1,731.81
$2,261.63

$1,840.82
$1,981.60
$2,130.74
$2,660.56

$2,239.75
$2,380.53
$2,529.67
$3,059.49

$398.93

Toc - Plan #71 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

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$321.36
$364.74
$410.69
$573.94
$872.15

$567.20
$610.58
$656.53
$819.78

$813.04
$856.42
$902.37
$1,065.62

$1,058.88
$1,102.26
$1,148.21
$1,311.46

$245.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$642.72
$729.48
$821.38
$1,147.88
$1,744.30

$888.56
$975.32
$1,067.22
$1,393.72

$1,134.40
$1,221.16
$1,313.06
$1,639.56

$1,380.24
$1,467.00
$1,558.90
$1,885.40

$245.84

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

Expanded Bronze

(HMO) Bronze Elite- Deductible + Specialist 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

$452.16
$513.19
$577.84
$807.53
$1,227.13

$798.05
$859.08
$923.73
$1,153.42

$1,143.94
$1,204.97
$1,269.62
$1,499.31

$1,489.83
$1,550.86
$1,615.51
$1,845.20

$345.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$904.32
$1,026.38
$1,155.68
$1,615.06
$2,454.26

$1,250.21
$1,372.27
$1,501.57
$1,960.95

$1,596.10
$1,718.16
$1,847.46
$2,306.84

$1,941.99
$2,064.05
$2,193.35
$2,652.73

$345.89

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

Gold

(HMO) Gold Classic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 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

$543.29
$616.62
$694.31
$970.29
$1,474.45

$958.90
$1,032.23
$1,109.92
$1,385.90

$1,374.51
$1,447.84
$1,525.53
$1,801.51

$1,790.12
$1,863.45
$1,941.14
$2,217.12

$415.61

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,086.58
$1,233.24
$1,388.62
$1,940.58
$2,948.90

$1,502.19
$1,648.85
$1,804.23
$2,356.19

$1,917.80
$2,064.46
$2,219.84
$2,771.80

$2,333.41
$2,480.07
$2,635.45
$3,187.41

$415.61

Toc - Plan #74 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

$5,200 $10,400 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

$403.99
$458.52
$516.28
$721.51
$1,096.40

$713.03
$767.56
$825.32
$1,030.55

$1,022.07
$1,076.60
$1,134.36
$1,339.59

$1,331.11
$1,385.64
$1,443.40
$1,648.63

$309.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$807.98
$917.04
$1,032.56
$1,443.02
$2,192.80

$1,117.02
$1,226.08
$1,341.60
$1,752.06

$1,426.06
$1,535.12
$1,650.64
$2,061.10

$1,735.10
$1,844.16
$1,959.68
$2,370.14

$309.04

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

Silver

(HMO) Silver Simple- Specialist Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 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

$514.96
$584.47
$658.10
$919.70
$1,397.57

$908.89
$978.40
$1,052.03
$1,313.63

$1,302.82
$1,372.33
$1,445.96
$1,707.56

$1,696.75
$1,766.26
$1,839.89
$2,101.49

$393.93

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,029.92
$1,168.94
$1,316.20
$1,839.40
$2,795.14

$1,423.85
$1,562.87
$1,710.13
$2,233.33

$1,817.78
$1,956.80
$2,104.06
$2,627.26

$2,211.71
$2,350.73
$2,497.99
$3,021.19

$393.93

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

Silver

(HMO) Silver Classic- Deductible Saver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$9,000 $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

$548.75
$622.82
$701.29
$980.04
$1,489.27

$968.53
$1,042.60
$1,121.07
$1,399.82

$1,388.31
$1,462.38
$1,540.85
$1,819.60

$1,808.09
$1,882.16
$1,960.63
$2,239.38

$419.78

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,097.50
$1,245.64
$1,402.58
$1,960.08
$2,978.54

$1,517.28
$1,665.42
$1,822.36
$2,379.86

$1,937.06
$2,085.20
$2,242.14
$2,799.64

$2,356.84
$2,504.98
$2,661.92
$3,219.42

$419.78

Toc - Plan #77 Oscar Health Plan of North Carolina, Inc

Expanded Bronze

(HMO) Bronze Classic- Deductible Saver

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

$404.04
$458.58
$516.36
$721.61
$1,096.55

$713.13
$767.67
$825.45
$1,030.70

$1,022.22
$1,076.76
$1,134.54
$1,339.79

$1,331.31
$1,385.85
$1,443.63
$1,648.88

$309.09

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$808.08
$917.16
$1,032.72
$1,443.22
$2,193.10

$1,117.17
$1,226.25
$1,341.81
$1,752.31

$1,426.26
$1,535.34
$1,650.90
$2,061.40

$1,735.35
$1,844.43
$1,959.99
$2,370.49

$309.09

Toc - Plan #78 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

$501.96
$569.72
$641.49
$896.49
$1,362.30

$885.95
$953.71
$1,025.48
$1,280.48

$1,269.94
$1,337.70
$1,409.47
$1,664.47

$1,653.93
$1,721.69
$1,793.46
$2,048.46

$383.99

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,003.92
$1,139.44
$1,282.98
$1,792.98
$2,724.60

$1,387.91
$1,523.43
$1,666.97
$2,176.97

$1,771.90
$1,907.42
$2,050.96
$2,560.96

$2,155.89
$2,291.41
$2,434.95
$2,944.95

$383.99

Toc - Plan #79 Oscar Health Plan of North Carolina, Inc

Silver

(HMO) Silver Elite- Deductible 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

$529.20
$600.63
$676.31
$945.13
$1,436.22

$934.03
$1,005.46
$1,081.14
$1,349.96

$1,338.86
$1,410.29
$1,485.97
$1,754.79

$1,743.69
$1,815.12
$1,890.80
$2,159.62

$404.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,058.40
$1,201.26
$1,352.62
$1,890.26
$2,872.44

$1,463.23
$1,606.09
$1,757.45
$2,295.09

$1,868.06
$2,010.92
$2,162.28
$2,699.92

$2,272.89
$2,415.75
$2,567.11
$3,104.75

$404.83

Toc - Plan #80 Oscar Health Plan of North Carolina, Inc

Gold

(HMO) Gold Elite- Deductible 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

$610.28
$692.66
$779.93
$1,089.95
$1,656.28

$1,077.14
$1,159.52
$1,246.79
$1,556.81

$1,544.00
$1,626.38
$1,713.65
$2,023.67

$2,010.86
$2,093.24
$2,180.51
$2,490.53

$466.86

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,220.56
$1,385.32
$1,559.86
$2,179.90
$3,312.56

$1,687.42
$1,852.18
$2,026.72
$2,646.76

$2,154.28
$2,319.04
$2,493.58
$3,113.62

$2,621.14
$2,785.90
$2,960.44
$3,580.48

$466.86

Toc - Plan #81 Oscar Health Plan of North Carolina, Inc

Gold

(HMO) Gold Elite

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$500 $1,000 Annual Deductible

$5,500 $11,000 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

$568.51
$645.25
$726.55
$1,015.35
$1,542.92

$1,003.42
$1,080.16
$1,161.46
$1,450.26

$1,438.33
$1,515.07
$1,596.37
$1,885.17

$1,873.24
$1,949.98
$2,031.28
$2,320.08

$434.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,137.02
$1,290.50
$1,453.10
$2,030.70
$3,085.84

$1,571.93
$1,725.41
$1,888.01
$2,465.61

$2,006.84
$2,160.32
$2,322.92
$2,900.52

$2,441.75
$2,595.23
$2,757.83
$3,335.43

$434.91

Toc - Plan #82 Oscar Health Plan of North Carolina, Inc

Expanded Bronze

(HMO) Bronze Elite- Deductible 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

$449.33
$509.98
$574.23
$802.49
$1,219.45

$793.06
$853.71
$917.96
$1,146.22

$1,136.79
$1,197.44
$1,261.69
$1,489.95

$1,480.52
$1,541.17
$1,605.42
$1,833.68

$343.73

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$898.66
$1,019.96
$1,148.46
$1,604.98
$2,438.90

$1,242.39
$1,363.69
$1,492.19
$1,948.71

$1,586.12
$1,707.42
$1,835.92
$2,292.44

$1,929.85
$2,051.15
$2,179.65
$2,636.17

$343.73

Toc - Plan #83 Oscar Health Plan of North Carolina, Inc

Silver

(HMO) Silver Simple- For 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

$517.70
$587.58
$661.61
$924.59
$1,405.01

$913.73
$983.61
$1,057.64
$1,320.62

$1,309.76
$1,379.64
$1,453.67
$1,716.65

$1,705.79
$1,775.67
$1,849.70
$2,112.68

$396.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,035.40
$1,175.16
$1,323.22
$1,849.18
$2,810.02

$1,431.43
$1,571.19
$1,719.25
$2,245.21

$1,827.46
$1,967.22
$2,115.28
$2,641.24

$2,223.49
$2,363.25
$2,511.31
$3,037.27

$396.03

Toc - Plan #84 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

$9,000 $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

$395.71
$449.12
$505.71
$706.73
$1,073.94

$698.42
$751.83
$808.42
$1,009.44

$1,001.13
$1,054.54
$1,111.13
$1,312.15

$1,303.84
$1,357.25
$1,413.84
$1,614.86

$302.71

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$791.42
$898.24
$1,011.42
$1,413.46
$2,147.88

$1,094.13
$1,200.95
$1,314.13
$1,716.17

$1,396.84
$1,503.66
$1,616.84
$2,018.88

$1,699.55
$1,806.37
$1,919.55
$2,321.59

$302.71

Toc - Plan #85 Oscar Health Plan of North Carolina, Inc

Bronze

(HMO) Bronze Simple- Standard

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$353.87
$401.63
$452.23
$631.99
$960.38

$624.57
$672.33
$722.93
$902.69

$895.27
$943.03
$993.63
$1,173.39

$1,165.97
$1,213.73
$1,264.33
$1,444.09

$270.70

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$707.74
$803.26
$904.46
$1,263.98
$1,920.76

$978.44
$1,073.96
$1,175.16
$1,534.68

$1,249.14
$1,344.66
$1,445.86
$1,805.38

$1,519.84
$1,615.36
$1,716.56
$2,076.08

$270.70

Toc - Plan #86 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

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$506.77
$575.17
$647.64
$905.07
$1,375.35

$894.44
$962.84
$1,035.31
$1,292.74

$1,282.11
$1,350.51
$1,422.98
$1,680.41

$1,669.78
$1,738.18
$1,810.65
$2,068.08

$387.67

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,013.54
$1,150.34
$1,295.28
$1,810.14
$2,750.70

$1,401.21
$1,538.01
$1,682.95
$2,197.81

$1,788.88
$1,925.68
$2,070.62
$2,585.48

$2,176.55
$2,313.35
$2,458.29
$2,973.15

$387.67

Toc - Plan #87 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

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$514.83
$584.32
$657.94
$919.47
$1,397.22

$908.67
$978.16
$1,051.78
$1,313.31

$1,302.51
$1,372.00
$1,445.62
$1,707.15

$1,696.35
$1,765.84
$1,839.46
$2,100.99

$393.84

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,029.66
$1,168.64
$1,315.88
$1,838.94
$2,794.44

$1,423.50
$1,562.48
$1,709.72
$2,232.78

$1,817.34
$1,956.32
$2,103.56
$2,626.62

$2,211.18
$2,350.16
$2,497.40
$3,020.46

$393.84

Cigna Healthcare

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

Toc - Plan #88 Cigna Healthcare

Gold

(HMO) Cigna Connect 2100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$2,100 $4,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$758.75
$861.18
$969.68
$1,355.13
$2,059.25

$1,339.19
$1,441.62
$1,550.12
$1,935.57

$1,919.63
$2,022.06
$2,130.56
$2,516.01

$2,500.07
$2,602.50
$2,711.00
$3,096.45

$580.44

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,517.50
$1,722.36
$1,939.36
$2,710.26
$4,118.50

$2,097.94
$2,302.80
$2,519.80
$3,290.70

$2,678.38
$2,883.24
$3,100.24
$3,871.14

$3,258.82
$3,463.68
$3,680.68
$4,451.58

$580.44

Toc - Plan #89 Cigna Healthcare

Bronze

(HMO) Cigna Connect 8700

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$8,700 $17,400 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$446.40
$506.66
$570.50
$797.27
$1,211.52

$787.89
$848.15
$911.99
$1,138.76

$1,129.38
$1,189.64
$1,253.48
$1,480.25

$1,470.87
$1,531.13
$1,594.97
$1,821.74

$341.49

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$892.80
$1,013.32
$1,141.00
$1,594.54
$2,423.04

$1,234.29
$1,354.81
$1,482.49
$1,936.03

$1,575.78
$1,696.30
$1,823.98
$2,277.52

$1,917.27
$2,037.79
$2,165.47
$2,619.01

$341.49

Toc - Plan #90 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Connect 7800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,800 $15,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$469.91
$533.35
$600.54
$839.26
$1,275.33

$829.39
$892.83
$960.02
$1,198.74

$1,188.87
$1,252.31
$1,319.50
$1,558.22

$1,548.35
$1,611.79
$1,678.98
$1,917.70

$359.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$939.82
$1,066.70
$1,201.08
$1,678.52
$2,550.66

$1,299.30
$1,426.18
$1,560.56
$2,038.00

$1,658.78
$1,785.66
$1,920.04
$2,397.48

$2,018.26
$2,145.14
$2,279.52
$2,756.96

$359.48

Toc - Plan #91 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Connect 5900

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,900 $11,800 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$463.83
$526.44
$592.77
$828.40
$1,258.83

$818.66
$881.27
$947.60
$1,183.23

$1,173.49
$1,236.10
$1,302.43
$1,538.06

$1,528.32
$1,590.93
$1,657.26
$1,892.89

$354.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$927.66
$1,052.88
$1,185.54
$1,656.80
$2,517.66

$1,282.49
$1,407.71
$1,540.37
$2,011.63

$1,637.32
$1,762.54
$1,895.20
$2,366.46

$1,992.15
$2,117.37
$2,250.03
$2,721.29

$354.83

Toc - Plan #92 Cigna Healthcare

Silver

(HMO) Cigna Connect 5500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,500 $11,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$547.59
$621.51
$699.82
$977.99
$1,486.16

$966.50
$1,040.42
$1,118.73
$1,396.90

$1,385.41
$1,459.33
$1,537.64
$1,815.81

$1,804.32
$1,878.24
$1,956.55
$2,234.72

$418.91

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,095.18
$1,243.02
$1,399.64
$1,955.98
$2,972.32

$1,514.09
$1,661.93
$1,818.55
$2,374.89

$1,933.00
$2,080.84
$2,237.46
$2,793.80

$2,351.91
$2,499.75
$2,656.37
$3,212.71

$418.91

Toc - Plan #93 Cigna Healthcare

Silver

(HMO) Cigna Connect 4500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,500 $9,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$546.84
$620.66
$698.86
$976.65
$1,484.12

$965.17
$1,038.99
$1,117.19
$1,394.98

$1,383.50
$1,457.32
$1,535.52
$1,813.31

$1,801.83
$1,875.65
$1,953.85
$2,231.64

$418.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,093.68
$1,241.32
$1,397.72
$1,953.30
$2,968.24

$1,512.01
$1,659.65
$1,816.05
$2,371.63

$1,930.34
$2,077.98
$2,234.38
$2,789.96

$2,348.67
$2,496.31
$2,652.71
$3,208.29

$418.33

Toc - Plan #94 Cigna Healthcare

Silver

(HMO) Cigna Connect 3500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$3,500 $7,000 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$549.16
$623.29
$701.82
$980.79
$1,490.41

$969.26
$1,043.39
$1,121.92
$1,400.89

$1,389.36
$1,463.49
$1,542.02
$1,820.99

$1,809.46
$1,883.59
$1,962.12
$2,241.09

$420.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,098.32
$1,246.58
$1,403.64
$1,961.58
$2,980.82

$1,518.42
$1,666.68
$1,823.74
$2,381.68

$1,938.52
$2,086.78
$2,243.84
$2,801.78

$2,358.62
$2,506.88
$2,663.94
$3,221.88

$420.10

Toc - Plan #95 Cigna Healthcare

Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$3,800 $7,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$551.98
$626.50
$705.43
$985.83
$1,498.07

$974.24
$1,048.76
$1,127.69
$1,408.09

$1,396.50
$1,471.02
$1,549.95
$1,830.35

$1,818.76
$1,893.28
$1,972.21
$2,252.61

$422.26

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,103.96
$1,253.00
$1,410.86
$1,971.66
$2,996.14

$1,526.22
$1,675.26
$1,833.12
$2,393.92

$1,948.48
$2,097.52
$2,255.38
$2,816.18

$2,370.74
$2,519.78
$2,677.64
$3,238.44

$422.26

Toc - Plan #96 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Connect HSA 7050

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,050 $14,100 Annual Deductible

$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$466.02
$528.93
$595.58
$832.31
$1,264.78

$822.53
$885.44
$952.09
$1,188.82

$1,179.04
$1,241.95
$1,308.60
$1,545.33

$1,535.55
$1,598.46
$1,665.11
$1,901.84

$356.51

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$932.04
$1,057.86
$1,191.16
$1,664.62
$2,529.56

$1,288.55
$1,414.37
$1,547.67
$2,021.13

$1,645.06
$1,770.88
$1,904.18
$2,377.64

$2,001.57
$2,127.39
$2,260.69
$2,734.15

$356.51

Toc - Plan #97 Cigna Healthcare

Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$4,200 $8,400 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$550.35
$624.65
$703.34
$982.92
$1,493.64

$971.37
$1,045.67
$1,124.36
$1,403.94

$1,392.39
$1,466.69
$1,545.38
$1,824.96

$1,813.41
$1,887.71
$1,966.40
$2,245.98

$421.02

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,100.70
$1,249.30
$1,406.68
$1,965.84
$2,987.28

$1,521.72
$1,670.32
$1,827.70
$2,386.86

$1,942.74
$2,091.34
$2,248.72
$2,807.88

$2,363.76
$2,512.36
$2,669.74
$3,228.90

$421.02

Toc - Plan #98 Cigna Healthcare

Bronze

(HMO) Cigna Simple Choice 9100

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$442.01
$501.68
$564.89
$789.43
$1,199.61

$780.15
$839.82
$903.03
$1,127.57

$1,118.29
$1,177.96
$1,241.17
$1,465.71

$1,456.43
$1,516.10
$1,579.31
$1,803.85

$338.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$884.02
$1,003.36
$1,129.78
$1,578.86
$2,399.22

$1,222.16
$1,341.50
$1,467.92
$1,917.00

$1,560.30
$1,679.64
$1,806.06
$2,255.14

$1,898.44
$2,017.78
$2,144.20
$2,593.28

$338.14

Toc - Plan #99 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Simple Choice 7500

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$460.76
$522.96
$588.84
$822.91
$1,250.49

$813.24
$875.44
$941.32
$1,175.39

$1,165.72
$1,227.92
$1,293.80
$1,527.87

$1,518.20
$1,580.40
$1,646.28
$1,880.35

$352.48

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$921.52
$1,045.92
$1,177.68
$1,645.82
$2,500.98

$1,274.00
$1,398.40
$1,530.16
$1,998.30

$1,626.48
$1,750.88
$1,882.64
$2,350.78

$1,978.96
$2,103.36
$2,235.12
$2,703.26

$352.48

Toc - Plan #100 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Connect 0A

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$492.54
$559.04
$629.47
$879.68
$1,336.76

$869.33
$935.83
$1,006.26
$1,256.47

$1,246.12
$1,312.62
$1,383.05
$1,633.26

$1,622.91
$1,689.41
$1,759.84
$2,010.05

$376.79

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$985.08
$1,118.08
$1,258.94
$1,759.36
$2,673.52

$1,361.87
$1,494.87
$1,635.73
$2,136.15

$1,738.66
$1,871.66
$2,012.52
$2,512.94

$2,115.45
$2,248.45
$2,389.31
$2,889.73

$376.79

Toc - Plan #101 Cigna Healthcare

Silver

(HMO) Cigna Simple Choice 5800

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$547.09
$620.94
$699.18
$977.10
$1,484.80

$965.61
$1,039.46
$1,117.70
$1,395.62

$1,384.13
$1,457.98
$1,536.22
$1,814.14

$1,802.65
$1,876.50
$1,954.74
$2,232.66

$418.52

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,094.18
$1,241.88
$1,398.36
$1,954.20
$2,969.60

$1,512.70
$1,660.40
$1,816.88
$2,372.72

$1,931.22
$2,078.92
$2,235.40
$2,791.24

$2,349.74
$2,497.44
$2,653.92
$3,209.76

$418.52

Toc - Plan #102 Cigna Healthcare

Gold

(HMO) Cigna Simple Choice 2000

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$762.70
$865.66
$974.73
$1,362.18
$2,069.97

$1,346.17
$1,449.13
$1,558.20
$1,945.65

$1,929.64
$2,032.60
$2,141.67
$2,529.12

$2,513.11
$2,616.07
$2,725.14
$3,112.59

$583.47

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,525.40
$1,731.32
$1,949.46
$2,724.36
$4,139.94

$2,108.87
$2,314.79
$2,532.93
$3,307.83

$2,692.34
$2,898.26
$3,116.40
$3,891.30

$3,275.81
$3,481.73
$3,699.87
$4,474.77

$583.47

Toc - Plan #103 Cigna Healthcare

Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-877-900-1237

Annual Out of Pocket Expenses:

Individual Family

$6,800 $13,600 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$464.20
$526.87
$593.25
$829.07
$1,259.85

$819.32
$881.99
$948.37
$1,184.19

$1,174.44
$1,237.11
$1,303.49
$1,539.31

$1,529.56
$1,592.23
$1,658.61
$1,894.43

$355.12

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$928.40
$1,053.74
$1,186.50
$1,658.14
$2,519.70

$1,283.52
$1,408.86
$1,541.62
$2,013.26

$1,638.64
$1,763.98
$1,896.74
$2,368.38

$1,993.76
$2,119.10
$2,251.86
$2,723.50

$355.12

Ambetter of North Carolina

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

Toc - Plan #104 Ambetter of North Carolina

Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$397.43
$451.07
$507.90
$709.79
$1,078.59

$701.46
$755.10
$811.93
$1,013.82

$1,005.49
$1,059.13
$1,115.96
$1,317.85

$1,309.52
$1,363.16
$1,419.99
$1,621.88

$304.03

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$794.86
$902.14
$1,015.80
$1,419.58
$2,157.18

$1,098.89
$1,206.17
$1,319.83
$1,723.61

$1,402.92
$1,510.20
$1,623.86
$2,027.64

$1,706.95
$1,814.23
$1,927.89
$2,331.67

$304.03

Toc - Plan #105 Ambetter of North Carolina

Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$437.04
$496.03
$558.53
$780.54
$1,186.10

$771.37
$830.36
$892.86
$1,114.87

$1,105.70
$1,164.69
$1,227.19
$1,449.20

$1,440.03
$1,499.02
$1,561.52
$1,783.53

$334.33

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$874.08
$992.06
$1,117.06
$1,561.08
$2,372.20

$1,208.41
$1,326.39
$1,451.39
$1,895.41

$1,542.74
$1,660.72
$1,785.72
$2,229.74

$1,877.07
$1,995.05
$2,120.05
$2,564.07

$334.33

Toc - Plan #106 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

$538.96
$611.70
$688.77
$962.56
$1,462.70

$951.25
$1,023.99
$1,101.06
$1,374.85

$1,363.54
$1,436.28
$1,513.35
$1,787.14

$1,775.83
$1,848.57
$1,925.64
$2,199.43

$412.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,077.92
$1,223.40
$1,377.54
$1,925.12
$2,925.40

$1,490.21
$1,635.69
$1,789.83
$2,337.41

$1,902.50
$2,047.98
$2,202.12
$2,749.70

$2,314.79
$2,460.27
$2,614.41
$3,161.99

$412.29

Toc - Plan #107 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

$562.24
$638.13
$718.53
$1,004.14
$1,525.89

$992.34
$1,068.23
$1,148.63
$1,434.24

$1,422.44
$1,498.33
$1,578.73
$1,864.34

$1,852.54
$1,928.43
$2,008.83
$2,294.44

$430.10

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,124.48
$1,276.26
$1,437.06
$2,008.28
$3,051.78

$1,554.58
$1,706.36
$1,867.16
$2,438.38

$1,984.68
$2,136.46
$2,297.26
$2,868.48

$2,414.78
$2,566.56
$2,727.36
$3,298.58

$430.10

Toc - Plan #108 Ambetter of North Carolina

Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$533.94
$606.01
$682.37
$953.61
$1,449.10

$942.40
$1,014.47
$1,090.83
$1,362.07

$1,350.86
$1,422.93
$1,499.29
$1,770.53

$1,759.32
$1,831.39
$1,907.75
$2,178.99

$408.46

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,067.88
$1,212.02
$1,364.74
$1,907.22
$2,898.20

$1,476.34
$1,620.48
$1,773.20
$2,315.68

$1,884.80
$2,028.94
$2,181.66
$2,724.14

$2,293.26
$2,437.40
$2,590.12
$3,132.60

$408.46

Toc - Plan #109 Ambetter of North Carolina

Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$424.05
$481.29
$541.93
$757.34
$1,150.85

$748.44
$805.68
$866.32
$1,081.73

$1,072.83
$1,130.07
$1,190.71
$1,406.12

$1,397.22
$1,454.46
$1,515.10
$1,730.51

$324.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$848.10
$962.58
$1,083.86
$1,514.68
$2,301.70

$1,172.49
$1,286.97
$1,408.25
$1,839.07

$1,496.88
$1,611.36
$1,732.64
$2,163.46

$1,821.27
$1,935.75
$2,057.03
$2,487.85

$324.39

Toc - Plan #110 Ambetter of North Carolina

Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$477.19
$541.60
$609.84
$852.25
$1,295.07

$842.23
$906.64
$974.88
$1,217.29

$1,207.27
$1,271.68
$1,339.92
$1,582.33

$1,572.31
$1,636.72
$1,704.96
$1,947.37

$365.04

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$954.38
$1,083.20
$1,219.68
$1,704.50
$2,590.14

$1,319.42
$1,448.24
$1,584.72
$2,069.54

$1,684.46
$1,813.28
$1,949.76
$2,434.58

$2,049.50
$2,178.32
$2,314.80
$2,799.62

$365.04

Toc - Plan #111 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

$532.54
$604.42
$680.58
$951.10
$1,445.29

$939.93
$1,011.81
$1,087.97
$1,358.49

$1,347.32
$1,419.20
$1,495.36
$1,765.88

$1,754.71
$1,826.59
$1,902.75
$2,173.27

$407.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,065.08
$1,208.84
$1,361.16
$1,902.20
$2,890.58

$1,472.47
$1,616.23
$1,768.55
$2,309.59

$1,879.86
$2,023.62
$2,175.94
$2,716.98

$2,287.25
$2,431.01
$2,583.33
$3,124.37

$407.39

Toc - Plan #112 Ambetter of North Carolina

Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$532.76
$604.67
$680.85
$951.49
$1,445.88

$940.31
$1,012.22
$1,088.40
$1,359.04

$1,347.86
$1,419.77
$1,495.95
$1,766.59

$1,755.41
$1,827.32
$1,903.50
$2,174.14

$407.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,065.52
$1,209.34
$1,361.70
$1,902.98
$2,891.76

$1,473.07
$1,616.89
$1,769.25
$2,310.53

$1,880.62
$2,024.44
$2,176.80
$2,718.08

$2,288.17
$2,431.99
$2,584.35
$3,125.63

$407.55

Toc - Plan #113 Ambetter of North Carolina

Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$415.81
$471.93
$531.39
$742.61
$1,128.47

$733.89
$790.01
$849.47
$1,060.69

$1,051.97
$1,108.09
$1,167.55
$1,378.77

$1,370.05
$1,426.17
$1,485.63
$1,696.85

$318.08

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$831.62
$943.86
$1,062.78
$1,485.22
$2,256.94

$1,149.70
$1,261.94
$1,380.86
$1,803.30

$1,467.78
$1,580.02
$1,698.94
$2,121.38

$1,785.86
$1,898.10
$2,017.02
$2,439.46

$318.08

Toc - Plan #114 Ambetter of North Carolina

Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$527.31
$598.49
$673.90
$941.77
$1,431.11

$930.70
$1,001.88
$1,077.29
$1,345.16

$1,334.09
$1,405.27
$1,480.68
$1,748.55

$1,737.48
$1,808.66
$1,884.07
$2,151.94

$403.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,054.62
$1,196.98
$1,347.80
$1,883.54
$2,862.22

$1,458.01
$1,600.37
$1,751.19
$2,286.93

$1,861.40
$2,003.76
$2,154.58
$2,690.32

$2,264.79
$2,407.15
$2,557.97
$3,093.71

$403.39

Toc - Plan #115 Ambetter of North Carolina

Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$533.62
$605.65
$681.95
$953.03
$1,448.22

$941.83
$1,013.86
$1,090.16
$1,361.24

$1,350.04
$1,422.07
$1,498.37
$1,769.45

$1,758.25
$1,830.28
$1,906.58
$2,177.66

$408.21

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,067.24
$1,211.30
$1,363.90
$1,906.06
$2,896.44

$1,475.45
$1,619.51
$1,772.11
$2,314.27

$1,883.66
$2,027.72
$2,180.32
$2,722.48

$2,291.87
$2,435.93
$2,588.53
$3,130.69

$408.21

Toc - Plan #116 Ambetter of North Carolina

Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$8,600 $17,200 Annual Deductible

$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$414.17
$470.07
$529.29
$739.69
$1,124.02

$731.00
$786.90
$846.12
$1,056.52

$1,047.83
$1,103.73
$1,162.95
$1,373.35

$1,364.66
$1,420.56
$1,479.78
$1,690.18

$316.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$828.34
$940.14
$1,058.58
$1,479.38
$2,248.04

$1,145.17
$1,256.97
$1,375.41
$1,796.21

$1,462.00
$1,573.80
$1,692.24
$2,113.04

$1,778.83
$1,890.63
$2,009.07
$2,429.87

$316.83

Toc - Plan #117 Ambetter of North Carolina

Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$6,900 $13,800 Annual Deductible

$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$455.45
$516.92
$582.05
$813.41
$1,236.06

$803.86
$865.33
$930.46
$1,161.82

$1,152.27
$1,213.74
$1,278.87
$1,510.23

$1,500.68
$1,562.15
$1,627.28
$1,858.64

$348.41

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$910.90
$1,033.84
$1,164.10
$1,626.82
$2,472.12

$1,259.31
$1,382.25
$1,512.51
$1,975.23

$1,607.72
$1,730.66
$1,860.92
$2,323.64

$1,956.13
$2,079.07
$2,209.33
$2,672.05

$348.41

Toc - Plan #118 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

$561.66
$637.47
$717.78
$1,003.10
$1,524.31

$991.32
$1,067.13
$1,147.44
$1,432.76

$1,420.98
$1,496.79
$1,577.10
$1,862.42

$1,850.64
$1,926.45
$2,006.76
$2,292.08

$429.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,123.32
$1,274.94
$1,435.56
$2,006.20
$3,048.62

$1,552.98
$1,704.60
$1,865.22
$2,435.86

$1,982.64
$2,134.26
$2,294.88
$2,865.52

$2,412.30
$2,563.92
$2,724.54
$3,295.18

$429.66

Toc - Plan #119 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

$585.92
$665.01
$748.79
$1,046.43
$1,590.16

$1,034.14
$1,113.23
$1,197.01
$1,494.65

$1,482.36
$1,561.45
$1,645.23
$1,942.87

$1,930.58
$2,009.67
$2,093.45
$2,391.09

$448.22

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,171.84
$1,330.02
$1,497.58
$2,092.86
$3,180.32

$1,620.06
$1,778.24
$1,945.80
$2,541.08

$2,068.28
$2,226.46
$2,394.02
$2,989.30

$2,516.50
$2,674.68
$2,842.24
$3,437.52

$448.22

Toc - Plan #120 Ambetter of North Carolina

Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$6,500 $13,000 Annual Deductible

$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$556.43
$631.54
$711.11
$993.77
$1,510.13

$982.09
$1,057.20
$1,136.77
$1,419.43

$1,407.75
$1,482.86
$1,562.43
$1,845.09

$1,833.41
$1,908.52
$1,988.09
$2,270.75

$425.66

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,112.86
$1,263.08
$1,422.22
$1,987.54
$3,020.26

$1,538.52
$1,688.74
$1,847.88
$2,413.20

$1,964.18
$2,114.40
$2,273.54
$2,838.86

$2,389.84
$2,540.06
$2,699.20
$3,264.52

$425.66

Toc - Plan #121 Ambetter of North Carolina

Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$8,300 $16,600 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$441.91
$501.56
$564.75
$789.24
$1,199.33

$779.97
$839.62
$902.81
$1,127.30

$1,118.03
$1,177.68
$1,240.87
$1,465.36

$1,456.09
$1,515.74
$1,578.93
$1,803.42

$338.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$883.82
$1,003.12
$1,129.50
$1,578.48
$2,398.66

$1,221.88
$1,341.18
$1,467.56
$1,916.54

$1,559.94
$1,679.24
$1,805.62
$2,254.60

$1,898.00
$2,017.30
$2,143.68
$2,592.66

$338.06

Toc - Plan #122 Ambetter of North Carolina

Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$497.29
$564.41
$635.53
$888.15
$1,349.62

$877.71
$944.83
$1,015.95
$1,268.57

$1,258.13
$1,325.25
$1,396.37
$1,648.99

$1,638.55
$1,705.67
$1,776.79
$2,029.41

$380.42

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$994.58
$1,128.82
$1,271.06
$1,776.30
$2,699.24

$1,375.00
$1,509.24
$1,651.48
$2,156.72

$1,755.42
$1,889.66
$2,031.90
$2,537.14

$2,135.84
$2,270.08
$2,412.32
$2,917.56

$380.42

Toc - Plan #123 Ambetter of North Carolina

Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-833-863-1310

Annual Out of Pocket Expenses:

Individual Family

$6,100 $12,200 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$555.20
$630.14
$709.53
$991.56
$1,506.78

$979.92
$1,054.86
$1,134.25
$1,416.28

$1,404.64
$1,479.58
$1,558.97
$1,841.00

$1,829.36
$1,904.30
$1,983.69
$2,265.72

$424.72

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,110.40
$1,260.28
$1,419.06
$1,983.12
$3,013.56

$1,535.12
$1,685.00
$1,843.78
$2,407.84

$1,959.84
$2,109.72
$2,268.50
$2,832.56

$2,384.56
$2,534.44
$2,693.22
$3,257.28

$424.72

Toc - Plan #124 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

$554.97
$629.88
$709.24
$991.16
$1,506.17

$979.52
$1,054.43
$1,133.79
$1,415.71

$1,404.07
$1,478.98
$1,558.34
$1,840.26

$1,828.62
$1,903.53
$1,982.89
$2,264.81

$424.55

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,109.94
$1,259.76
$1,418.48
$1,982.32
$3,012.34

$1,534.49
$1,684.31
$1,843.03
$2,406.87

$1,959.04
$2,108.86
$2,267.58
$2,831.42

$2,383.59
$2,533.41
$2,692.13
$3,255.97

$424.55

Toc - Plan #125 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

$414.08
$469.97
$529.18
$739.53
$1,123.79

$730.85
$786.74
$845.95
$1,056.30

$1,047.62
$1,103.51
$1,162.72
$1,373.07

$1,364.39
$1,420.28
$1,479.49
$1,689.84

$316.77

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$828.16
$939.94
$1,058.36
$1,479.06
$2,247.58

$1,144.93
$1,256.71
$1,375.13
$1,795.83

$1,461.70
$1,573.48
$1,691.90
$2,112.60

$1,778.47
$1,890.25
$2,008.67
$2,429.37

$316.77

Toc - Plan #126 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

$521.12
$591.46
$665.97
$930.70
$1,414.28

$919.77
$990.11
$1,064.62
$1,329.35

$1,318.42
$1,388.76
$1,463.27
$1,728.00

$1,717.07
$1,787.41
$1,861.92
$2,126.65

$398.65

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,042.24
$1,182.92
$1,331.94
$1,861.40
$2,828.56

$1,440.89
$1,581.57
$1,730.59
$2,260.05

$1,839.54
$1,980.22
$2,129.24
$2,658.70

$2,238.19
$2,378.87
$2,527.89
$3,057.35

$398.65

Toc - Plan #127 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

$546.29
$620.02
$698.14
$975.65
$1,482.59

$964.19
$1,037.92
$1,116.04
$1,393.55

$1,382.09
$1,455.82
$1,533.94
$1,811.45

$1,799.99
$1,873.72
$1,951.84
$2,229.35

$417.90

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,092.58
$1,240.04
$1,396.28
$1,951.30
$2,965.18

$1,510.48
$1,657.94
$1,814.18
$2,369.20

$1,928.38
$2,075.84
$2,232.08
$2,787.10

$2,346.28
$2,493.74
$2,649.98
$3,205.00

$417.90

Friday Health Plans

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

Toc - Plan #128 Friday Health Plans

Catastrophic

(HMO) Friday Catastrophic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$272.11
$308.84
$347.76
$485.99
$738.51

$480.27
$517.00
$555.92
$694.15

$688.43
$725.16
$764.08
$902.31

$896.59
$933.32
$972.24
$1,110.47

$208.16

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$544.22
$617.68
$695.52
$971.98
$1,477.02

$752.38
$825.84
$903.68
$1,180.14

$960.54
$1,034.00
$1,111.84
$1,388.30

$1,168.70
$1,242.16
$1,320.00
$1,596.46

$208.16

Toc - Plan #129 Friday Health Plans

Bronze

(HMO) Friday Bronze Basic + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$356.72
$404.88
$455.89
$637.10
$968.13

$629.61
$677.77
$728.78
$909.99

$902.50
$950.66
$1,001.67
$1,182.88

$1,175.39
$1,223.55
$1,274.56
$1,455.77

$272.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$713.44
$809.76
$911.78
$1,274.20
$1,936.26

$986.33
$1,082.65
$1,184.67
$1,547.09

$1,259.22
$1,355.54
$1,457.56
$1,819.98

$1,532.11
$1,628.43
$1,730.45
$2,092.87

$272.89

Toc - Plan #130 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze Plus + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$360.31
$408.95
$460.47
$643.50
$977.87

$635.94
$684.58
$736.10
$919.13

$911.57
$960.21
$1,011.73
$1,194.76

$1,187.20
$1,235.84
$1,287.36
$1,470.39

$275.63

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$720.62
$817.90
$920.94
$1,287.00
$1,955.74

$996.25
$1,093.53
$1,196.57
$1,562.63

$1,271.88
$1,369.16
$1,472.20
$1,838.26

$1,547.51
$1,644.79
$1,747.83
$2,113.89

$275.63

Toc - Plan #131 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$7,000 $14,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$380.90
$432.32
$486.79
$680.28
$1,033.75

$672.29
$723.71
$778.18
$971.67

$963.68
$1,015.10
$1,069.57
$1,263.06

$1,255.07
$1,306.49
$1,360.96
$1,554.45

$291.39

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$761.80
$864.64
$973.58
$1,360.56
$2,067.50

$1,053.19
$1,156.03
$1,264.97
$1,651.95

$1,344.58
$1,447.42
$1,556.36
$1,943.34

$1,635.97
$1,738.81
$1,847.75
$2,234.73

$291.39

Toc - Plan #132 Friday Health Plans

Silver

(HMO) Friday Silver + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$496.96
$564.05
$635.11
$887.57
$1,348.74

$877.13
$944.22
$1,015.28
$1,267.74

$1,257.30
$1,324.39
$1,395.45
$1,647.91

$1,637.47
$1,704.56
$1,775.62
$2,028.08

$380.17

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$993.92
$1,128.10
$1,270.22
$1,775.14
$2,697.48

$1,374.09
$1,508.27
$1,650.39
$2,155.31

$1,754.26
$1,888.44
$2,030.56
$2,535.48

$2,134.43
$2,268.61
$2,410.73
$2,915.65

$380.17

Toc - Plan #133 Friday Health Plans

Gold

(HMO) Friday Gold + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$522.46
$593.00
$667.71
$933.12
$1,417.96

$922.14
$992.68
$1,067.39
$1,332.80

$1,321.82
$1,392.36
$1,467.07
$1,732.48

$1,721.50
$1,792.04
$1,866.75
$2,132.16

$399.68

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,044.92
$1,186.00
$1,335.42
$1,866.24
$2,835.92

$1,444.60
$1,585.68
$1,735.10
$2,265.92

$1,844.28
$1,985.36
$2,134.78
$2,665.60

$2,243.96
$2,385.04
$2,534.46
$3,065.28

$399.68

Toc - Plan #134 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$356.46
$404.58
$455.56
$636.64
$967.44

$629.15
$677.27
$728.25
$909.33

$901.84
$949.96
$1,000.94
$1,182.02

$1,174.53
$1,222.65
$1,273.63
$1,454.71

$272.69

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$712.92
$809.16
$911.12
$1,273.28
$1,934.88

$985.61
$1,081.85
$1,183.81
$1,545.97

$1,258.30
$1,354.54
$1,456.50
$1,818.66

$1,530.99
$1,627.23
$1,729.19
$2,091.35

$272.69

Toc - Plan #135 Friday Health Plans

Silver

(HMO) Friday Silver Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$510.11
$578.98
$651.92
$911.06
$1,384.45

$900.35
$969.22
$1,042.16
$1,301.30

$1,290.59
$1,359.46
$1,432.40
$1,691.54

$1,680.83
$1,749.70
$1,822.64
$2,081.78

$390.24

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,020.22
$1,157.96
$1,303.84
$1,822.12
$2,768.90

$1,410.46
$1,548.20
$1,694.08
$2,212.36

$1,800.70
$1,938.44
$2,084.32
$2,602.60

$2,190.94
$2,328.68
$2,474.56
$2,992.84

$390.24

Toc - Plan #136 Friday Health Plans

Gold

(HMO) Friday Gold Copay + Vision Exam

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$542.78
$616.06
$693.67
$969.41
$1,473.11

$958.01
$1,031.29
$1,108.90
$1,384.64

$1,373.24
$1,446.52
$1,524.13
$1,799.87

$1,788.47
$1,861.75
$1,939.36
$2,215.10

$415.23

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,085.56
$1,232.12
$1,387.34
$1,938.82
$2,946.22

$1,500.79
$1,647.35
$1,802.57
$2,354.05

$1,916.02
$2,062.58
$2,217.80
$2,769.28

$2,331.25
$2,477.81
$2,633.03
$3,184.51

$415.23

Toc - Plan #137 Friday Health Plans

Bronze

(HMO) Friday Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$356.27
$404.36
$455.31
$636.29
$966.91

$628.81
$676.90
$727.85
$908.83

$901.35
$949.44
$1,000.39
$1,181.37

$1,173.89
$1,221.98
$1,272.93
$1,453.91

$272.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$712.54
$808.72
$910.62
$1,272.58
$1,933.82

$985.08
$1,081.26
$1,183.16
$1,545.12

$1,257.62
$1,353.80
$1,455.70
$1,817.66

$1,530.16
$1,626.34
$1,728.24
$2,090.20

$272.54

Toc - Plan #138 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze Plus

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$359.85
$408.43
$459.89
$642.70
$976.64

$635.14
$683.72
$735.18
$917.99

$910.43
$959.01
$1,010.47
$1,193.28

$1,185.72
$1,234.30
$1,285.76
$1,468.57

$275.29

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$719.70
$816.86
$919.78
$1,285.40
$1,953.28

$994.99
$1,092.15
$1,195.07
$1,560.69

$1,270.28
$1,367.44
$1,470.36
$1,835.98

$1,545.57
$1,642.73
$1,745.65
$2,111.27

$275.29

Toc - Plan #139 Friday Health Plans

Expanded Bronze

(HMO) Friday Bronze Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$356.01
$404.07
$454.98
$635.83
$966.21

$628.36
$676.42
$727.33
$908.18

$900.71
$948.77
$999.68
$1,180.53

$1,173.06
$1,221.12
$1,272.03
$1,452.88

$272.35

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$712.02
$808.14
$909.96
$1,271.66
$1,932.42

$984.37
$1,080.49
$1,182.31
$1,544.01

$1,256.72
$1,352.84
$1,454.66
$1,816.36

$1,529.07
$1,625.19
$1,727.01
$2,088.71

$272.35

Toc - Plan #140 Friday Health Plans

Silver

(HMO) Friday Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$496.51
$563.53
$634.53
$886.76
$1,347.52

$876.34
$943.36
$1,014.36
$1,266.59

$1,256.17
$1,323.19
$1,394.19
$1,646.42

$1,636.00
$1,703.02
$1,774.02
$2,026.25

$379.83

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$993.02
$1,127.06
$1,269.06
$1,773.52
$2,695.04

$1,372.85
$1,506.89
$1,648.89
$2,153.35

$1,752.68
$1,886.72
$2,028.72
$2,533.18

$2,132.51
$2,266.55
$2,408.55
$2,913.01

$379.83

Toc - Plan #141 Friday Health Plans

Silver

(HMO) Friday Silver HSA

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$3,000 $6,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$502.55
$570.39
$642.25
$897.55
$1,363.91

$887.00
$954.84
$1,026.70
$1,282.00

$1,271.45
$1,339.29
$1,411.15
$1,666.45

$1,655.90
$1,723.74
$1,795.60
$2,050.90

$384.45

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,005.10
$1,140.78
$1,284.50
$1,795.10
$2,727.82

$1,389.55
$1,525.23
$1,668.95
$2,179.55

$1,774.00
$1,909.68
$2,053.40
$2,564.00

$2,158.45
$2,294.13
$2,437.85
$2,948.45

$384.45

Toc - Plan #142 Friday Health Plans

Silver

(HMO) Friday Silver Zero Deductible

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$0 $0 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$512.91
$582.15
$655.50
$916.06
$1,392.04

$905.29
$974.53
$1,047.88
$1,308.44

$1,297.67
$1,366.91
$1,440.26
$1,700.82

$1,690.05
$1,759.29
$1,832.64
$2,093.20

$392.38

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,025.82
$1,164.30
$1,311.00
$1,832.12
$2,784.08

$1,418.20
$1,556.68
$1,703.38
$2,224.50

$1,810.58
$1,949.06
$2,095.76
$2,616.88

$2,202.96
$2,341.44
$2,488.14
$3,009.26

$392.38

Toc - Plan #143 Friday Health Plans

Silver

(HMO) Friday Silver Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$5,000 $10,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$509.66
$578.47
$651.35
$910.25
$1,383.22

$899.55
$968.36
$1,041.24
$1,300.14

$1,289.44
$1,358.25
$1,431.13
$1,690.03

$1,679.33
$1,748.14
$1,821.02
$2,079.92

$389.89

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,019.32
$1,156.94
$1,302.70
$1,820.50
$2,766.44

$1,409.21
$1,546.83
$1,692.59
$2,210.39

$1,799.10
$1,936.72
$2,082.48
$2,600.28

$2,188.99
$2,326.61
$2,472.37
$2,990.17

$389.89

Toc - Plan #144 Friday Health Plans

Gold

(HMO) Friday Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$522.01
$592.48
$667.13
$932.31
$1,416.74

$921.35
$991.82
$1,066.47
$1,331.65

$1,320.69
$1,391.16
$1,465.81
$1,730.99

$1,720.03
$1,790.50
$1,865.15
$2,130.33

$399.34

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,044.02
$1,184.96
$1,334.26
$1,864.62
$2,833.48

$1,443.36
$1,584.30
$1,733.60
$2,263.96

$1,842.70
$1,983.64
$2,132.94
$2,663.30

$2,242.04
$2,382.98
$2,532.28
$3,062.64

$399.34

Toc - Plan #145 Friday Health Plans

Gold

(HMO) Friday Gold Copay

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$2,300 $4,600 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$542.33
$615.54
$693.10
$968.60
$1,471.88

$957.21
$1,030.42
$1,107.98
$1,383.48

$1,372.09
$1,445.30
$1,522.86
$1,798.36

$1,786.97
$1,860.18
$1,937.74
$2,213.24

$414.88

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,084.66
$1,231.08
$1,386.20
$1,937.20
$2,943.76

$1,499.54
$1,645.96
$1,801.08
$2,352.08

$1,914.42
$2,060.84
$2,215.96
$2,766.96

$2,329.30
$2,475.72
$2,630.84
$3,181.84

$414.88

Toc - Plan #146 Friday Health Plans

Bronze

(HMO) Friday Standard Bronze Basic

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$9,100 $18,200 Annual Deductible

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

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$356.27
$404.36
$455.31
$636.29
$966.91

$628.81
$676.90
$727.85
$908.83

$901.35
$949.44
$1,000.39
$1,181.37

$1,173.89
$1,221.98
$1,272.93
$1,453.91

$272.54

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$712.54
$808.72
$910.62
$1,272.58
$1,933.82

$985.08
$1,081.26
$1,183.16
$1,545.12

$1,257.62
$1,353.80
$1,455.70
$1,817.66

$1,530.16
$1,626.34
$1,728.24
$2,090.20

$272.54

Toc - Plan #147 Friday Health Plans

Expanded Bronze

(HMO) Friday Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$354.32
$402.16
$452.82
$632.82
$961.63

$625.38
$673.22
$723.88
$903.88

$896.44
$944.28
$994.94
$1,174.94

$1,167.50
$1,215.34
$1,266.00
$1,446.00

$271.06

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$708.64
$804.32
$905.64
$1,265.64
$1,923.26

$979.70
$1,075.38
$1,176.70
$1,536.70

$1,250.76
$1,346.44
$1,447.76
$1,807.76

$1,521.82
$1,617.50
$1,718.82
$2,078.82

$271.06

Toc - Plan #148 Friday Health Plans

Silver

(HMO) Friday Standard Silver

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$492.58
$559.07
$629.51
$879.74
$1,336.85

$869.40
$935.89
$1,006.33
$1,256.56

$1,246.22
$1,312.71
$1,383.15
$1,633.38

$1,623.04
$1,689.53
$1,759.97
$2,010.20

$376.82

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$985.16
$1,118.14
$1,259.02
$1,759.48
$2,673.70

$1,361.98
$1,494.96
$1,635.84
$2,136.30

$1,738.80
$1,871.78
$2,012.66
$2,513.12

$2,115.62
$2,248.60
$2,389.48
$2,889.94

$376.82

Toc - Plan #149 Friday Health Plans

Gold

(HMO) Friday Standard Gold

Benefits & Coverage Plan Brochure Provider Directory

Customer Service Phone: 1-844-465-5500

Annual Out of Pocket Expenses:

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]

Age

Individual

Individual
1 Child

Individual
2 Children

Individual
3+ Children

Child
0-14

21
30
40
50
60

$540.06
$612.97
$690.19
$964.54
$1,465.72

$953.20
$1,026.11
$1,103.33
$1,377.68

$1,366.34
$1,439.25
$1,516.47
$1,790.82

$1,779.48
$1,852.39
$1,929.61
$2,203.96

$413.14

Age

Couple

Couple
1 Child

Couple
2 Chidren

Couple
3+ Children

Child
0-14

21
30
40
50
60

$1,080.12
$1,225.94
$1,380.38
$1,929.08
$2,931.44

$1,493.26
$1,639.08
$1,793.52
$2,342.22

$1,906.40
$2,052.22
$2,206.66
$2,755.36

$2,319.54
$2,465.36
$2,619.80
$3,168.50

$413.14

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

McDowell County is in “” of North Carolina.

Currently, there are 149 plans offered in .

Top

2023 Obamacare Plans for McDowell County, NC

Plan Browser: 149 Plans

Blue Cross and Blue Shield of NC

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

1. Silver Blue Advantage Silver Simple | $0 Deductible | 3 Free PCP | Nationwide Doctors

2. Silver Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

3. Silver Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

4. Expanded Bronze Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

5. Gold Blue Advantage Gold 1800 | 3 Free PCP | $10 Tier 1 Rx | Nationwide Doctors

6. Silver Blue Advantage Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

7. Expanded Bronze Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide Doctors

8. Catastrophic Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide Doctors

9. Silver Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

10. Expanded Bronze Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

11. Bronze Blue Advantage Bronze 9100 | Integrated | Nationwide Doctors

12. Gold Blue Advantage Gold Standard 2000 | Nationwide Doctors

13. Silver Blue Advantage Silver Standard 5800 | Nationwide Doctors

14. Expanded Bronze Blue Advantage Bronze Standard 7500 | Nationwide Doctors

CareSource

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

15. Expanded Bronze CareSource Marketplace Bronze HSA Eligible

16. Expanded Bronze CareSource Marketplace Bronze First

17. Bronze CareSource Marketplace Bronze

18. Silver CareSource Marketplace Low Premium Silver

19. Silver CareSource Marketplace Standard Silver

20. Silver CareSource Marketplace Low Deductible Silver

21. Silver CareSource Marketplace Essential Silver

22. Gold CareSource Marketplace Gold

23. Expanded Bronze CareSource Marektplace Bronze First Dental, Vision, & Fitness

24. Bronze CareSource Marektplace Bronze Dental, Vision, & Fitness

25. Silver CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness

26. Silver CareSource Marketplace Standard Silver Dental, Vision, & Fitness

27. Silver CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness

28. Silver CareSource Marketplace Essential Silver Dental, Vision, & Fitness

29. Gold CareSource Marketplace Gold Dental, Vision, & Fitness

AmeriHealth Caritas Next

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

30. Bronze AmeriHealth Caritas Next Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

31. Expanded Bronze AmeriHealth Caritas Next Expanded Bronze + Free Telemedicine + Free Preventive Care + Healthy Rewards

32. Silver AmeriHealth Caritas Next Silver + Free Telemedicine + Free Preventive Care + Healthy Rewards

33. Gold AmeriHealth Caritas Next Gold + Free Telemedicine + Free Preventive Care + Healthy Rewards

WellCare of North Carolina

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

34. Expanded Bronze WellCare Secure Health Bronze

35. Silver WellCare Secure Health Silver

36. Gold WellCare Secure Health Gold

37. Expanded Bronze CMS Standard Expanded Bronze

38. Silver CMS Standard Silver

39. Gold CMS Standard Gold

UnitedHealthcare

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

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

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

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

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

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

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

46. Expanded Bronze UHC Bronze Value HSA (No Referrals)

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

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

49. Gold UHC Gold Standard (No Referrals)

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

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

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

53. Silver UHC Silver Standard (No Referrals)

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

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

56. Expanded Bronze UHC Bronze Standard $7,500 Indiv Ded (No Referrals)

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

Aetna CVS Health

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

58. Expanded Bronze Bronze: Aetna network of doctors & hospitals+ Low-cost MinuteClinic+ $0 Telehealth 24/7

59. Expanded Bronze Bronze: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

60. Gold Gold: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

61. Silver Silver 1: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

62. Silver Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

63. Expanded Bronze Bronze S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

64. Gold Gold S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

65. Silver Silver 3: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 24/7

66. Silver Silver S: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 Telehealth 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

67. Expanded Bronze Bronze Classic- PCP Saver

68. Expanded Bronze Bronze Classic

69. Expanded Bronze Bronze Elite- Deductible + PCP Saver Plus

70. Silver Silver Classic

71. Catastrophic Secure

72. Expanded Bronze Bronze Elite- Deductible + Specialist Saver Plus

73. Gold Gold Classic

74. Expanded Bronze Bronze Simple- HSA

75. Silver Silver Simple- Specialist Saver

76. Silver Silver Classic- Deductible Saver

77. Expanded Bronze Bronze Classic- Deductible Saver

78. Silver Silver Simple- PCP Saver

79. Silver Silver Elite- Deductible Saver Plus

80. Gold Gold Elite- Deductible Saver Plus

81. Gold Gold Elite

82. Expanded Bronze Bronze Elite- Deductible Saver Plus

83. Silver Silver Simple- For Diabetes

84. Expanded Bronze Bronze Classic- Standard

85. Bronze Bronze Simple- Standard

86. Silver Silver Classic- Standard

87. Gold Gold Classic- Standard

Cigna Healthcare

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

88. Gold Cigna Connect 2100

89. Bronze Cigna Connect 8700

90. Expanded Bronze Cigna Connect 7800

91. Expanded Bronze Cigna Connect 5900

92. Silver Cigna Connect 5500

93. Silver Cigna Connect 4500

94. Silver Cigna Connect 3500

95. Silver Cigna Connect 3800 Enhanced Diabetes Care

96. Expanded Bronze Cigna Connect HSA 7050

97. Silver Cigna Connect 4200 Enhanced Asthma COPD Care

98. Bronze Cigna Simple Choice 9100

99. Expanded Bronze Cigna Simple Choice 7500

100. Expanded Bronze Cigna Connect 0A

101. Silver Cigna Simple Choice 5800

102. Gold Cigna Simple Choice 2000

103. Expanded Bronze Cigna Connect 6800 Enhanced Diabetes Care

Ambetter of North Carolina

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

104. Bronze Clear Bronze

105. Expanded Bronze Choice Bronze HSA

106. Silver Complete Silver

107. Gold Complete Gold

108. Silver Everyday Silver

109. Expanded Bronze Everyday Bronze

110. Expanded Bronze Elite Bronze

111. Silver Clear Silver

112. Silver Focused Silver

113. Expanded Bronze CMS Standard Expanded Bronze

114. Silver CMS Standard Silver

115. Gold CMS Standard Gold

116. Bronze Clear Bronze + Vision + Adult Dental

117. Expanded Bronze Choice Bronze HSA + Vision + Adult Dental

118. Silver Complete Silver + Vision + Adult Dental

119. Gold Complete Gold + Vision + Adult Dental

120. Silver Everyday Silver + Vision + Adult Dental

121. Expanded Bronze Everyday Bronze + Vision + Adult Dental

122. Expanded Bronze Elite Bronze + Vision + Adult Dental

123. Silver Focused Silver + Vision + Adult Dental

124. Silver Clear Silver + Vision + Adult Dental

125. Expanded Bronze Ambetter Virtual Access Bronze - Virtual PCP selection required

126. Silver Ambetter Virtual Access Silver - Virtual PCP selection required

127. Gold Ambetter Virtual Access Gold - Virtual PCP selection required

Friday Health Plans

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

128. Catastrophic Friday Catastrophic

129. Bronze Friday Bronze Basic + Vision Exam

130. Expanded Bronze Friday Bronze Plus + Vision Exam

131. Expanded Bronze Friday Bronze HSA

132. Silver Friday Silver + Vision Exam

133. Gold Friday Gold + Vision Exam

134. Expanded Bronze Friday Bronze Copay + Vision Exam

135. Silver Friday Silver Copay + Vision Exam

136. Gold Friday Gold Copay + Vision Exam

137. Bronze Friday Bronze Basic

138. Expanded Bronze Friday Bronze Plus

139. Expanded Bronze Friday Bronze Copay

140. Silver Friday Silver

141. Silver Friday Silver HSA

142. Silver Friday Silver Zero Deductible

143. Silver Friday Silver Copay

144. Gold Friday Gold

145. Gold Friday Gold Copay

146. Bronze Friday Standard Bronze Basic

147. Expanded Bronze Friday Standard Expanded Bronze

148. Silver Friday Standard Silver

149. Gold Friday Standard Gold

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For information on subsidies to make your coverage affordable, you must take one of the following actions:

Obamacare Providers, 149 Plans and 2023 Rates for McDowell County, North Carolina

You may also be interested in:

Obamacare Rates and Providers for Other Years

How To Sign Up for Obamacare in North Carolina for 2023

Where's the North Carolina Health Care Exchange?

North Carolina Medicaid Expansion: Do I Qualify for Medicaid Under the ACA?

North Carolina Has Not Expanded Medicaid

The Medicaid Coverage Gap

Get Help Finding a Health Insurance Plan in North Carolina

Get Help From North Carolina's Health Insurance Exchange

Get Help From a Licensed Insurance Broker

More Information

Blue Cross and Blue Shield of NC

(PPO) Blue Advantage Silver Simple | $0 Deductible | 3 Free PCP | Nationwide Doctors

Annual Out of Pocket Expenses:

Individual Family $0 $0 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(PPO) Blue Advantage Silver Preferred 3100 | 3 Free PCP | $10 Tier 1 Rx | Integrated | Nationwide Doctors

Annual Out of Pocket Expenses:

Individual Family $3,100 $6,200 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(PPO) Blue Advantage Silver Secure 1900 | $15 PCP | $15 Tier 1 Rx | Nationwide Doctors

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(PPO) Blue Advantage Bronze 7000 | 3 Free PCP | $20 Tier 1 Rx | Integrated | Nationwide Doctors

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(PPO) Blue Advantage Gold 1800 | 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 Silver Total 3500 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(PPO) Blue Advantage Bronze 7500 | HSA Eligible | Integrated | Nationwide Doctors

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(PPO) Blue Advantage Catastrophic 9100 | 3 PCP $35 | Integrated | Nationwide Doctors

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(PPO) Blue Advantage Silver Choice 4000 | 3 Free PCP | $15 Tier 1 Rx | Nationwide Doctors

Annual Out of Pocket Expenses:

Individual Family $4,000 $8,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(PPO) Blue Advantage Bronze 5500 | $60 PCP | $20 Tier 1 Rx | Nationwide Doctors

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(PPO) Blue Advantage Bronze 9100 | Integrated | Nationwide Doctors

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(PPO) Blue Advantage Gold Standard 2000 | Nationwide Doctors

Annual Out of Pocket Expenses:

Individual Family $2,000 $4,000 Annual Deductible $8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

(PPO) Blue Advantage Silver Standard 5800 | Nationwide Doctors

Annual Out of Pocket Expenses:

Individual Family $5,800 $11,600 Annual Deductible $8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

(PPO) Blue Advantage Bronze Standard 7500 | Nationwide Doctors

Annual Out of Pocket Expenses:

Individual Family $7,500 $15,000 Annual Deductible $9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

CareSource

(HMO) CareSource Marketplace Bronze HSA Eligible

Annual Out of Pocket Expenses:

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

Monthly Premiums:

(HMO) CareSource Marketplace Bronze First

Annual Out of Pocket Expenses:

Individual Family $8,000 $16,000 Annual Deductible $9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

(HMO) CareSource Marketplace Bronze

Individual Family

$0 $0 Annual Deductible

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

Individual Family

$3,100 $6,200 Annual Deductible

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

Individual Family

$1,900 $3,800 Annual Deductible

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

Individual Family

$7,000 $14,000 Annual Deductible

$9,100 $18,200 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

$3,500 $7,000 Annual Deductible

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

Individual Family

$7,500 $15,000 Annual Deductible

$7,500 $15,000 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$4,000 $8,000 Annual Deductible

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

Individual Family

$5,500 $11,000 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

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

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$7,500 $15,000 Annual Deductible

$9,000 $18,000 Maximum Out of Pocket Per Year

Individual Family

$6,000 $12,000 Annual Deductible

$7,000 $14,000 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 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

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$4,000 $8,000 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Individual Family

$6,150 $12,300 Annual Deductible

$6,150 $12,300 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$8,000 $16,000 Annual Deductible

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

Individual Family

$9,100 $18,200 Annual Deductible

$9,100 $18,200 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

$5,800 $11,600 Annual Deductible

$8,900 $17,800 Maximum Out of Pocket Per Year

Individual Family

$4,000 $8,000 Annual Deductible

$8,250 $16,500 Maximum Out of Pocket Per Year

Individual Family

$6,150 $12,300 Annual Deductible

$6,150 $12,300 Maximum Out of Pocket Per Year

Individual Family

$2,000 $4,000 Annual Deductible

$8,700 $17,400 Maximum Out of Pocket Per Year

Individual Family

$9,100 $18,200 Annual Deductible

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