McDowell County, North Carolina Obamacare 2024 Rates

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

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

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

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

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

Below, you’ll find a summary of the 110 plans for McDowell County, North Carolina and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

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



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Blue Cross and Blue Shield of NC

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

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

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$476.52
$540.85
$608.99
$851.06
$1,293.28
$841.06
$905.39
$973.53
$1,215.60
$1,205.60
$1,269.93
$1,338.07
$1,580.14
$1,570.14
$1,634.47
$1,702.61
$1,944.68
$364.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$953.04
$1,081.70
$1,217.98
$1,702.12
$2,586.56
$1,317.58
$1,446.24
$1,582.52
$2,066.66
$1,682.12
$1,810.78
$1,947.06
$2,431.20
$2,046.66
$2,175.32
$2,311.60
$2,795.74
$364.54
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,600 $3,200 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$496.49
$563.52
$634.51
$886.73
$1,347.47
$876.30
$943.33
$1,014.32
$1,266.54
$1,256.11
$1,323.14
$1,394.13
$1,646.35
$1,635.92
$1,702.95
$1,773.94
$2,026.16
$379.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992.98
$1,127.04
$1,269.02
$1,773.46
$2,694.94
$1,372.79
$1,506.85
$1,648.83
$2,153.27
$1,752.60
$1,886.66
$2,028.64
$2,533.08
$2,132.41
$2,266.47
$2,408.45
$2,912.89
$379.81
Toc - Plan #3 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$360.84
$409.55
$461.15
$644.46
$979.32
$636.88
$685.59
$737.19
$920.50
$912.92
$961.63
$1,013.23
$1,196.54
$1,188.96
$1,237.67
$1,289.27
$1,472.58
$276.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$721.68
$819.10
$922.30
$1,288.92
$1,958.64
$997.72
$1,095.14
$1,198.34
$1,564.96
$1,273.76
$1,371.18
$1,474.38
$1,841.00
$1,549.80
$1,647.22
$1,750.42
$2,117.04
$276.04
Toc - Plan #4 Blue Cross and Blue Shield of NC
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$494.19
$560.91
$631.57
$882.62
$1,341.23
$872.25
$938.97
$1,009.63
$1,260.68
$1,250.31
$1,317.03
$1,387.69
$1,638.74
$1,628.37
$1,695.09
$1,765.75
$2,016.80
$378.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$988.38
$1,121.82
$1,263.14
$1,765.24
$2,682.46
$1,366.44
$1,499.88
$1,641.20
$2,143.30
$1,744.50
$1,877.94
$2,019.26
$2,521.36
$2,122.56
$2,256.00
$2,397.32
$2,899.42
$378.06
Toc - Plan #5 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$8,050 $16,100 Annual Deductible
$8,050 $16,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.97
$410.84
$462.60
$646.48
$982.39
$638.88
$687.75
$739.51
$923.39
$915.79
$964.66
$1,016.42
$1,200.30
$1,192.70
$1,241.57
$1,293.33
$1,477.21
$276.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.94
$821.68
$925.20
$1,292.96
$1,964.78
$1,000.85
$1,098.59
$1,202.11
$1,569.87
$1,277.76
$1,375.50
$1,479.02
$1,846.78
$1,554.67
$1,652.41
$1,755.93
$2,123.69
$276.91
Toc - Plan #6 Blue Cross and Blue Shield of NC
Catastrophic

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.91
$324.51
$365.39
$510.64
$775.96
$504.63
$543.23
$584.11
$729.36
$723.35
$761.95
$802.83
$948.08
$942.07
$980.67
$1,021.55
$1,166.80
$218.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$571.82
$649.02
$730.78
$1,021.28
$1,551.92
$790.54
$867.74
$949.50
$1,240.00
$1,009.26
$1,086.46
$1,168.22
$1,458.72
$1,227.98
$1,305.18
$1,386.94
$1,677.44
$218.72
Toc - Plan #7 Blue Cross and Blue Shield of NC
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$499.88
$567.36
$638.85
$892.79
$1,356.67
$882.29
$949.77
$1,021.26
$1,275.20
$1,264.70
$1,332.18
$1,403.67
$1,657.61
$1,647.11
$1,714.59
$1,786.08
$2,040.02
$382.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$999.76
$1,134.72
$1,277.70
$1,785.58
$2,713.34
$1,382.17
$1,517.13
$1,660.11
$2,167.99
$1,764.58
$1,899.54
$2,042.52
$2,550.40
$2,146.99
$2,281.95
$2,424.93
$2,932.81
$382.41
Toc - Plan #8 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$382.27
$433.88
$488.54
$682.73
$1,037.48
$674.71
$726.32
$780.98
$975.17
$967.15
$1,018.76
$1,073.42
$1,267.61
$1,259.59
$1,311.20
$1,365.86
$1,560.05
$292.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$764.54
$867.76
$977.08
$1,365.46
$2,074.96
$1,056.98
$1,160.20
$1,269.52
$1,657.90
$1,349.42
$1,452.64
$1,561.96
$1,950.34
$1,641.86
$1,745.08
$1,854.40
$2,242.78
$292.44
Toc - Plan #9 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold Standard | Nationwide Doctors

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$494.24
$560.96
$631.64
$882.71
$1,341.37
$872.33
$939.05
$1,009.73
$1,260.80
$1,250.42
$1,317.14
$1,387.82
$1,638.89
$1,628.51
$1,695.23
$1,765.91
$2,016.98
$378.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$988.48
$1,121.92
$1,263.28
$1,765.42
$2,682.74
$1,366.57
$1,500.01
$1,641.37
$2,143.51
$1,744.66
$1,878.10
$2,019.46
$2,521.60
$2,122.75
$2,256.19
$2,397.55
$2,899.69
$378.09
Toc - Plan #10 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Standard | Nationwide Doctors

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$483.60
$548.89
$618.04
$863.71
$1,312.49
$853.55
$918.84
$987.99
$1,233.66
$1,223.50
$1,288.79
$1,357.94
$1,603.61
$1,593.45
$1,658.74
$1,727.89
$1,973.56
$369.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$967.20
$1,097.78
$1,236.08
$1,727.42
$2,624.98
$1,337.15
$1,467.73
$1,606.03
$2,097.37
$1,707.10
$1,837.68
$1,975.98
$2,467.32
$2,077.05
$2,207.63
$2,345.93
$2,837.27
$369.95
Toc - Plan #11 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze Standard | Nationwide Doctors

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$370.18
$420.15
$473.09
$661.14
$1,004.67
$653.37
$703.34
$756.28
$944.33
$936.56
$986.53
$1,039.47
$1,227.52
$1,219.75
$1,269.72
$1,322.66
$1,510.71
$283.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$740.36
$840.30
$946.18
$1,322.28
$2,009.34
$1,023.55
$1,123.49
$1,229.37
$1,605.47
$1,306.74
$1,406.68
$1,512.56
$1,888.66
$1,589.93
$1,689.87
$1,795.75
$2,171.85
$283.19

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CareSource

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

Toc - Plan #12 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.84
$401.60
$452.20
$631.95
$960.31
$624.52
$672.28
$722.88
$902.63
$895.20
$942.96
$993.56
$1,173.31
$1,165.88
$1,213.64
$1,264.24
$1,443.99
$270.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.68
$803.20
$904.40
$1,263.90
$1,920.62
$978.36
$1,073.88
$1,175.08
$1,534.58
$1,249.04
$1,344.56
$1,445.76
$1,805.26
$1,519.72
$1,615.24
$1,716.44
$2,075.94
$270.68
Toc - Plan #13 CareSource
Silver

(HMO) CareSource Marketplace Low Premium Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$438.45
$497.63
$560.33
$783.06
$1,189.94
$773.86
$833.04
$895.74
$1,118.47
$1,109.27
$1,168.45
$1,231.15
$1,453.88
$1,444.68
$1,503.86
$1,566.56
$1,789.29
$335.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$876.90
$995.26
$1,120.66
$1,566.12
$2,379.88
$1,212.31
$1,330.67
$1,456.07
$1,901.53
$1,547.72
$1,666.08
$1,791.48
$2,236.94
$1,883.13
$2,001.49
$2,126.89
$2,572.35
$335.41
Toc - Plan #14 CareSource
Silver

(HMO) CareSource Marketplace Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.73
$492.28
$554.30
$774.63
$1,177.13
$765.53
$824.08
$886.10
$1,106.43
$1,097.33
$1,155.88
$1,217.90
$1,438.23
$1,429.13
$1,487.68
$1,549.70
$1,770.03
$331.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$867.46
$984.56
$1,108.60
$1,549.26
$2,354.26
$1,199.26
$1,316.36
$1,440.40
$1,881.06
$1,531.06
$1,648.16
$1,772.20
$2,212.86
$1,862.86
$1,979.96
$2,104.00
$2,544.66
$331.80
Toc - Plan #15 CareSource
Gold

(HMO) CareSource Marketplace Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$505.43
$573.66
$645.93
$902.69
$1,371.72
$892.08
$960.31
$1,032.58
$1,289.34
$1,278.73
$1,346.96
$1,419.23
$1,675.99
$1,665.38
$1,733.61
$1,805.88
$2,062.64
$386.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,010.86
$1,147.32
$1,291.86
$1,805.38
$2,743.44
$1,397.51
$1,533.97
$1,678.51
$2,192.03
$1,784.16
$1,920.62
$2,065.16
$2,578.68
$2,170.81
$2,307.27
$2,451.81
$2,965.33
$386.65
Toc - Plan #16 CareSource
Silver

(HMO) CareSource Marketplace Diabetes Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$454.82
$516.22
$581.26
$812.30
$1,234.38
$802.76
$864.16
$929.20
$1,160.24
$1,150.70
$1,212.10
$1,277.14
$1,508.18
$1,498.64
$1,560.04
$1,625.08
$1,856.12
$347.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$909.64
$1,032.44
$1,162.52
$1,624.60
$2,468.76
$1,257.58
$1,380.38
$1,510.46
$1,972.54
$1,605.52
$1,728.32
$1,858.40
$2,320.48
$1,953.46
$2,076.26
$2,206.34
$2,668.42
$347.94
Toc - Plan #17 CareSource
Gold

(HMO) CareSource Marketplace Diabetes Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$516.85
$586.63
$660.54
$923.10
$1,402.73
$912.24
$982.02
$1,055.93
$1,318.49
$1,307.63
$1,377.41
$1,451.32
$1,713.88
$1,703.02
$1,772.80
$1,846.71
$2,109.27
$395.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,033.70
$1,173.26
$1,321.08
$1,846.20
$2,805.46
$1,429.09
$1,568.65
$1,716.47
$2,241.59
$1,824.48
$1,964.04
$2,111.86
$2,636.98
$2,219.87
$2,359.43
$2,507.25
$3,032.37
$395.39
Toc - Plan #18 CareSource
Gold

(HMO) CareSource Marketplace Core Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$475.80
$540.03
$608.07
$849.77
$1,291.31
$839.78
$904.01
$972.05
$1,213.75
$1,203.76
$1,267.99
$1,336.03
$1,577.73
$1,567.74
$1,631.97
$1,700.01
$1,941.71
$363.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$951.60
$1,080.06
$1,216.14
$1,699.54
$2,582.62
$1,315.58
$1,444.04
$1,580.12
$2,063.52
$1,679.56
$1,808.02
$1,944.10
$2,427.50
$2,043.54
$2,172.00
$2,308.08
$2,791.48
$363.98
Toc - Plan #19 CareSource
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$361.90
$410.75
$462.50
$646.34
$982.18
$638.75
$687.60
$739.35
$923.19
$915.60
$964.45
$1,016.20
$1,200.04
$1,192.45
$1,241.30
$1,293.05
$1,476.89
$276.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.80
$821.50
$925.00
$1,292.68
$1,964.36
$1,000.65
$1,098.35
$1,201.85
$1,569.53
$1,277.50
$1,375.20
$1,478.70
$1,846.38
$1,554.35
$1,652.05
$1,755.55
$2,123.23
$276.85
Toc - Plan #20 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.34
$506.59
$570.42
$797.15
$1,211.35
$787.79
$848.04
$911.87
$1,138.60
$1,129.24
$1,189.49
$1,253.32
$1,480.05
$1,470.69
$1,530.94
$1,594.77
$1,821.50
$341.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.68
$1,013.18
$1,140.84
$1,594.30
$2,422.70
$1,234.13
$1,354.63
$1,482.29
$1,935.75
$1,575.58
$1,696.08
$1,823.74
$2,277.20
$1,917.03
$2,037.53
$2,165.19
$2,618.65
$341.45
Toc - Plan #21 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.62
$501.24
$564.39
$788.73
$1,198.55
$779.46
$839.08
$902.23
$1,126.57
$1,117.30
$1,176.92
$1,240.07
$1,464.41
$1,455.14
$1,514.76
$1,577.91
$1,802.25
$337.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.24
$1,002.48
$1,128.78
$1,577.46
$2,397.10
$1,221.08
$1,340.32
$1,466.62
$1,915.30
$1,558.92
$1,678.16
$1,804.46
$2,253.14
$1,896.76
$2,016.00
$2,142.30
$2,590.98
$337.84
Toc - Plan #22 CareSource
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$513.87
$583.24
$656.72
$917.76
$1,394.63
$906.98
$976.35
$1,049.83
$1,310.87
$1,300.09
$1,369.46
$1,442.94
$1,703.98
$1,693.20
$1,762.57
$1,836.05
$2,097.09
$393.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,027.74
$1,166.48
$1,313.44
$1,835.52
$2,789.26
$1,420.85
$1,559.59
$1,706.55
$2,228.63
$1,813.96
$1,952.70
$2,099.66
$2,621.74
$2,207.07
$2,345.81
$2,492.77
$3,014.85
$393.11
Toc - Plan #23 CareSource
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$462.72
$525.19
$591.36
$826.42
$1,255.82
$816.70
$879.17
$945.34
$1,180.40
$1,170.68
$1,233.15
$1,299.32
$1,534.38
$1,524.66
$1,587.13
$1,653.30
$1,888.36
$353.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$925.44
$1,050.38
$1,182.72
$1,652.84
$2,511.64
$1,279.42
$1,404.36
$1,536.70
$2,006.82
$1,633.40
$1,758.34
$1,890.68
$2,360.80
$1,987.38
$2,112.32
$2,244.66
$2,714.78
$353.98
Toc - Plan #24 CareSource
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$525.31
$596.22
$671.34
$938.19
$1,425.67
$927.17
$998.08
$1,073.20
$1,340.05
$1,329.03
$1,399.94
$1,475.06
$1,741.91
$1,730.89
$1,801.80
$1,876.92
$2,143.77
$401.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,050.62
$1,192.44
$1,342.68
$1,876.38
$2,851.34
$1,452.48
$1,594.30
$1,744.54
$2,278.24
$1,854.34
$1,996.16
$2,146.40
$2,680.10
$2,256.20
$2,398.02
$2,548.26
$3,081.96
$401.86
Toc - Plan #25 CareSource
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-230-2099

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$484.25
$549.62
$618.87
$864.87
$1,314.25
$854.70
$920.07
$989.32
$1,235.32
$1,225.15
$1,290.52
$1,359.77
$1,605.77
$1,595.60
$1,660.97
$1,730.22
$1,976.22
$370.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$968.50
$1,099.24
$1,237.74
$1,729.74
$2,628.50
$1,338.95
$1,469.69
$1,608.19
$2,100.19
$1,709.40
$1,840.14
$1,978.64
$2,470.64
$2,079.85
$2,210.59
$2,349.09
$2,841.09
$370.45

ADVERTISEMENT

AmeriHealth Caritas Next

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

Toc - Plan #26 AmeriHealth Caritas Next
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.16
$362.25
$407.89
$570.02
$866.19
$563.32
$606.41
$652.05
$814.18
$807.48
$850.57
$896.21
$1,058.34
$1,051.64
$1,094.73
$1,140.37
$1,302.50
$244.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$638.32
$724.50
$815.78
$1,140.04
$1,732.38
$882.48
$968.66
$1,059.94
$1,384.20
$1,126.64
$1,212.82
$1,304.10
$1,628.36
$1,370.80
$1,456.98
$1,548.26
$1,872.52
$244.16
Toc - Plan #27 AmeriHealth Caritas Next
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$358.67
$407.10
$458.38
$640.59
$973.43
$633.06
$681.49
$732.77
$914.98
$907.45
$955.88
$1,007.16
$1,189.37
$1,181.84
$1,230.27
$1,281.55
$1,463.76
$274.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$717.34
$814.20
$916.76
$1,281.18
$1,946.86
$991.73
$1,088.59
$1,191.15
$1,555.57
$1,266.12
$1,362.98
$1,465.54
$1,829.96
$1,540.51
$1,637.37
$1,739.93
$2,104.35
$274.39
Toc - Plan #28 AmeriHealth Caritas Next
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$446.42
$506.68
$570.52
$797.30
$1,211.57
$787.93
$848.19
$912.03
$1,138.81
$1,129.44
$1,189.70
$1,253.54
$1,480.32
$1,470.95
$1,531.21
$1,595.05
$1,821.83
$341.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$892.84
$1,013.36
$1,141.04
$1,594.60
$2,423.14
$1,234.35
$1,354.87
$1,482.55
$1,936.11
$1,575.86
$1,696.38
$1,824.06
$2,277.62
$1,917.37
$2,037.89
$2,165.57
$2,619.13
$341.51
Toc - Plan #29 AmeriHealth Caritas Next
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$508.43
$577.07
$649.77
$908.05
$1,379.87
$897.38
$966.02
$1,038.72
$1,297.00
$1,286.33
$1,354.97
$1,427.67
$1,685.95
$1,675.28
$1,743.92
$1,816.62
$2,074.90
$388.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,016.86
$1,154.14
$1,299.54
$1,816.10
$2,759.74
$1,405.81
$1,543.09
$1,688.49
$2,205.05
$1,794.76
$1,932.04
$2,077.44
$2,594.00
$2,183.71
$2,320.99
$2,466.39
$2,982.95
$388.95
Toc - Plan #30 AmeriHealth Caritas Next
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$366.77
$416.29
$468.74
$655.05
$995.42
$647.35
$696.87
$749.32
$935.63
$927.93
$977.45
$1,029.90
$1,216.21
$1,208.51
$1,258.03
$1,310.48
$1,496.79
$280.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$733.54
$832.58
$937.48
$1,310.10
$1,990.84
$1,014.12
$1,113.16
$1,218.06
$1,590.68
$1,294.70
$1,393.74
$1,498.64
$1,871.26
$1,575.28
$1,674.32
$1,779.22
$2,151.84
$280.58
Toc - Plan #31 AmeriHealth Caritas Next
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$460.47
$522.63
$588.48
$822.39
$1,249.70
$812.73
$874.89
$940.74
$1,174.65
$1,164.99
$1,227.15
$1,293.00
$1,526.91
$1,517.25
$1,579.41
$1,645.26
$1,879.17
$352.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$920.94
$1,045.26
$1,176.96
$1,644.78
$2,499.40
$1,273.20
$1,397.52
$1,529.22
$1,997.04
$1,625.46
$1,749.78
$1,881.48
$2,349.30
$1,977.72
$2,102.04
$2,233.74
$2,701.56
$352.26

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #32 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$582.20
$660.78
$744.03
$1,039.78
$1,580.05
$1,027.57
$1,106.15
$1,189.40
$1,485.15
$1,472.94
$1,551.52
$1,634.77
$1,930.52
$1,918.31
$1,996.89
$2,080.14
$2,375.89
$445.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,164.40
$1,321.56
$1,488.06
$2,079.56
$3,160.10
$1,609.77
$1,766.93
$1,933.43
$2,524.93
$2,055.14
$2,212.30
$2,378.80
$2,970.30
$2,500.51
$2,657.67
$2,824.17
$3,415.67
$445.37
Toc - Plan #33 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

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

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$756.26
$858.34
$966.49
$1,350.66
$2,052.46
$1,334.79
$1,436.87
$1,545.02
$1,929.19
$1,913.32
$2,015.40
$2,123.55
$2,507.72
$2,491.85
$2,593.93
$2,702.08
$3,086.25
$578.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,512.52
$1,716.68
$1,932.98
$2,701.32
$4,104.92
$2,091.05
$2,295.21
$2,511.51
$3,279.85
$2,669.58
$2,873.74
$3,090.04
$3,858.38
$3,248.11
$3,452.27
$3,668.57
$4,436.91
$578.53
Toc - Plan #34 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,850 $3,700 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$790.14
$896.80
$1,009.79
$1,411.17
$2,144.41
$1,394.59
$1,501.25
$1,614.24
$2,015.62
$1,999.04
$2,105.70
$2,218.69
$2,620.07
$2,603.49
$2,710.15
$2,823.14
$3,224.52
$604.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,580.28
$1,793.60
$2,019.58
$2,822.34
$4,288.82
$2,184.73
$2,398.05
$2,624.03
$3,426.79
$2,789.18
$3,002.50
$3,228.48
$4,031.24
$3,393.63
$3,606.95
$3,832.93
$4,635.69
$604.45
Toc - Plan #35 WellCare of North Carolina
Expanded Bronze

(PPO) Standard Expanded Bronze WellCare

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$577.54
$655.49
$738.08
$1,031.46
$1,567.40
$1,019.35
$1,097.30
$1,179.89
$1,473.27
$1,461.16
$1,539.11
$1,621.70
$1,915.08
$1,902.97
$1,980.92
$2,063.51
$2,356.89
$441.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,155.08
$1,310.98
$1,476.16
$2,062.92
$3,134.80
$1,596.89
$1,752.79
$1,917.97
$2,504.73
$2,038.70
$2,194.60
$2,359.78
$2,946.54
$2,480.51
$2,636.41
$2,801.59
$3,388.35
$441.81
Toc - Plan #36 WellCare of North Carolina
Silver

(PPO) Standard Silver WellCare

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$739.76
$839.62
$945.41
$1,321.20
$2,007.69
$1,305.67
$1,405.53
$1,511.32
$1,887.11
$1,871.58
$1,971.44
$2,077.23
$2,453.02
$2,437.49
$2,537.35
$2,643.14
$3,018.93
$565.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,479.52
$1,679.24
$1,890.82
$2,642.40
$4,015.38
$2,045.43
$2,245.15
$2,456.73
$3,208.31
$2,611.34
$2,811.06
$3,022.64
$3,774.22
$3,177.25
$3,376.97
$3,588.55
$4,340.13
$565.91
Toc - Plan #37 WellCare of North Carolina
Gold

(PPO) Standard Gold WellCare

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$767.58
$871.19
$980.95
$1,370.88
$2,083.18
$1,354.77
$1,458.38
$1,568.14
$1,958.07
$1,941.96
$2,045.57
$2,155.33
$2,545.26
$2,529.15
$2,632.76
$2,742.52
$3,132.45
$587.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,535.16
$1,742.38
$1,961.90
$2,741.76
$4,166.36
$2,122.35
$2,329.57
$2,549.09
$3,328.95
$2,709.54
$2,916.76
$3,136.28
$3,916.14
$3,296.73
$3,503.95
$3,723.47
$4,503.33
$587.19

ADVERTISEMENT

UnitedHealthcare

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

Toc - Plan #38 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$526.58
$597.67
$672.97
$940.48
$1,429.15
$929.42
$1,000.51
$1,075.81
$1,343.32
$1,332.26
$1,403.35
$1,478.65
$1,746.16
$1,735.10
$1,806.19
$1,881.49
$2,149.00
$402.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,053.16
$1,195.34
$1,345.94
$1,880.96
$2,858.30
$1,456.00
$1,598.18
$1,748.78
$2,283.80
$1,858.84
$2,001.02
$2,151.62
$2,686.64
$2,261.68
$2,403.86
$2,554.46
$3,089.48
$402.84
Toc - Plan #39 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$597.59
$678.26
$763.72
$1,067.29
$1,621.85
$1,054.74
$1,135.41
$1,220.87
$1,524.44
$1,511.89
$1,592.56
$1,678.02
$1,981.59
$1,969.04
$2,049.71
$2,135.17
$2,438.74
$457.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,195.18
$1,356.52
$1,527.44
$2,134.58
$3,243.70
$1,652.33
$1,813.67
$1,984.59
$2,591.73
$2,109.48
$2,270.82
$2,441.74
$3,048.88
$2,566.63
$2,727.97
$2,898.89
$3,506.03
$457.15
Toc - Plan #40 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA (No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$8,050 $16,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.88
$460.67
$518.71
$724.90
$1,101.56
$716.38
$771.17
$829.21
$1,035.40
$1,026.88
$1,081.67
$1,139.71
$1,345.90
$1,337.38
$1,392.17
$1,450.21
$1,656.40
$310.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$811.76
$921.34
$1,037.42
$1,449.80
$2,203.12
$1,122.26
$1,231.84
$1,347.92
$1,760.30
$1,432.76
$1,542.34
$1,658.42
$2,070.80
$1,743.26
$1,852.84
$1,968.92
$2,381.30
$310.50
Toc - Plan #41 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$531.50
$603.25
$679.25
$949.25
$1,442.48
$938.09
$1,009.84
$1,085.84
$1,355.84
$1,344.68
$1,416.43
$1,492.43
$1,762.43
$1,751.27
$1,823.02
$1,899.02
$2,169.02
$406.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,063.00
$1,206.50
$1,358.50
$1,898.50
$2,884.96
$1,469.59
$1,613.09
$1,765.09
$2,305.09
$1,876.18
$2,019.68
$2,171.68
$2,711.68
$2,282.77
$2,426.27
$2,578.27
$3,118.27
$406.59
Toc - Plan #42 UnitedHealthcare
Gold

(HMO) UHC Gold Standard (No Referrals)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$601.64
$682.86
$768.89
$1,074.52
$1,632.84
$1,061.89
$1,143.11
$1,229.14
$1,534.77
$1,522.14
$1,603.36
$1,689.39
$1,995.02
$1,982.39
$2,063.61
$2,149.64
$2,455.27
$460.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,203.28
$1,365.72
$1,537.78
$2,149.04
$3,265.68
$1,663.53
$1,825.97
$1,998.03
$2,609.29
$2,123.78
$2,286.22
$2,458.28
$3,069.54
$2,584.03
$2,746.47
$2,918.53
$3,529.79
$460.25
Toc - Plan #43 UnitedHealthcare
Silver

(HMO) UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $5 Tier 2 Rx, No Referrals)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$537.47
$610.03
$686.89
$959.93
$1,458.70
$948.64
$1,021.20
$1,098.06
$1,371.10
$1,359.81
$1,432.37
$1,509.23
$1,782.27
$1,770.98
$1,843.54
$1,920.40
$2,193.44
$411.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,074.94
$1,220.06
$1,373.78
$1,919.86
$2,917.40
$1,486.11
$1,631.23
$1,784.95
$2,331.03
$1,897.28
$2,042.40
$2,196.12
$2,742.20
$2,308.45
$2,453.57
$2,607.29
$3,153.37
$411.17
Toc - Plan #44 UnitedHealthcare
Silver

(HMO) UHC Silver Standard (No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$533.41
$605.42
$681.70
$952.68
$1,447.68
$941.47
$1,013.48
$1,089.76
$1,360.74
$1,349.53
$1,421.54
$1,497.82
$1,768.80
$1,757.59
$1,829.60
$1,905.88
$2,176.86
$408.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,066.82
$1,210.84
$1,363.40
$1,905.36
$2,895.36
$1,474.88
$1,618.90
$1,771.46
$2,313.42
$1,882.94
$2,026.96
$2,179.52
$2,721.48
$2,291.00
$2,435.02
$2,587.58
$3,129.54
$408.06
Toc - Plan #45 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard (No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.27
$452.04
$508.99
$711.31
$1,080.90
$702.95
$756.72
$813.67
$1,015.99
$1,007.63
$1,061.40
$1,118.35
$1,320.67
$1,312.31
$1,366.08
$1,423.03
$1,625.35
$304.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.54
$904.08
$1,017.98
$1,422.62
$2,161.80
$1,101.22
$1,208.76
$1,322.66
$1,727.30
$1,405.90
$1,513.44
$1,627.34
$2,031.98
$1,710.58
$1,818.12
$1,932.02
$2,336.66
$304.68
Toc - Plan #46 UnitedHealthcare
Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,350 $12,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.71
$433.24
$487.83
$681.74
$1,035.96
$673.72
$725.25
$779.84
$973.75
$965.73
$1,017.26
$1,071.85
$1,265.76
$1,257.74
$1,309.27
$1,363.86
$1,557.77
$292.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.42
$866.48
$975.66
$1,363.48
$2,071.92
$1,055.43
$1,158.49
$1,267.67
$1,655.49
$1,347.44
$1,450.50
$1,559.68
$1,947.50
$1,639.45
$1,742.51
$1,851.69
$2,239.51
$292.01
Toc - Plan #47 UnitedHealthcare
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$390.75
$443.51
$499.38
$697.89
$1,060.51
$689.68
$742.44
$798.31
$996.82
$988.61
$1,041.37
$1,097.24
$1,295.75
$1,287.54
$1,340.30
$1,396.17
$1,594.68
$298.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$781.50
$887.02
$998.76
$1,395.78
$2,121.02
$1,080.43
$1,185.95
$1,297.69
$1,694.71
$1,379.36
$1,484.88
$1,596.62
$1,993.64
$1,678.29
$1,783.81
$1,895.55
$2,292.57
$298.93
Toc - Plan #48 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$412.84
$468.57
$527.61
$737.33
$1,120.45
$728.66
$784.39
$843.43
$1,053.15
$1,044.48
$1,100.21
$1,159.25
$1,368.97
$1,360.30
$1,416.03
$1,475.07
$1,684.79
$315.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825.68
$937.14
$1,055.22
$1,474.66
$2,240.90
$1,141.50
$1,252.96
$1,371.04
$1,790.48
$1,457.32
$1,568.78
$1,686.86
$2,106.30
$1,773.14
$1,884.60
$2,002.68
$2,422.12
$315.82
Toc - Plan #49 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$529.38
$600.84
$676.54
$945.47
$1,436.73
$934.35
$1,005.81
$1,081.51
$1,350.44
$1,339.32
$1,410.78
$1,486.48
$1,755.41
$1,744.29
$1,815.75
$1,891.45
$2,160.38
$404.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,058.76
$1,201.68
$1,353.08
$1,890.94
$2,873.46
$1,463.73
$1,606.65
$1,758.05
$2,295.91
$1,868.70
$2,011.62
$2,163.02
$2,700.88
$2,273.67
$2,416.59
$2,567.99
$3,105.85
$404.97
Toc - Plan #50 UnitedHealthcare
Gold

(HMO) UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 Tier 2 Rx, No Referrals)

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$604.69
$686.32
$772.79
$1,079.98
$1,641.13
$1,067.28
$1,148.91
$1,235.38
$1,542.57
$1,529.87
$1,611.50
$1,697.97
$2,005.16
$1,992.46
$2,074.09
$2,160.56
$2,467.75
$462.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,209.38
$1,372.64
$1,545.58
$2,159.96
$3,282.26
$1,671.97
$1,835.23
$2,008.17
$2,622.55
$2,134.56
$2,297.82
$2,470.76
$3,085.14
$2,597.15
$2,760.41
$2,933.35
$3,547.73
$462.59
Toc - Plan #51 UnitedHealthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$552.42
$627.00
$705.99
$986.63
$1,499.27
$975.02
$1,049.60
$1,128.59
$1,409.23
$1,397.62
$1,472.20
$1,551.19
$1,831.83
$1,820.22
$1,894.80
$1,973.79
$2,254.43
$422.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,104.84
$1,254.00
$1,411.98
$1,973.26
$2,998.54
$1,527.44
$1,676.60
$1,834.58
$2,395.86
$1,950.04
$2,099.20
$2,257.18
$2,818.46
$2,372.64
$2,521.80
$2,679.78
$3,241.06
$422.60
Toc - Plan #52 UnitedHealthcare
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$622.03
$706.00
$794.95
$1,110.94
$1,688.19
$1,097.88
$1,181.85
$1,270.80
$1,586.79
$1,573.73
$1,657.70
$1,746.65
$2,062.64
$2,049.58
$2,133.55
$2,222.50
$2,538.49
$475.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,244.06
$1,412.00
$1,589.90
$2,221.88
$3,376.38
$1,719.91
$1,887.85
$2,065.75
$2,697.73
$2,195.76
$2,363.70
$2,541.60
$3,173.58
$2,671.61
$2,839.55
$3,017.45
$3,649.43
$475.85

ADVERTISEMENT

Aetna CVS Health

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

Toc - Plan #53 Aetna CVS Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,200 $12,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$347.45
$394.36
$444.04
$620.55
$942.98
$613.25
$660.16
$709.84
$886.35
$879.05
$925.96
$975.64
$1,152.15
$1,144.85
$1,191.76
$1,241.44
$1,417.95
$265.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$694.90
$788.72
$888.08
$1,241.10
$1,885.96
$960.70
$1,054.52
$1,153.88
$1,506.90
$1,226.50
$1,320.32
$1,419.68
$1,772.70
$1,492.30
$1,586.12
$1,685.48
$2,038.50
$265.80
Toc - Plan #54 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$476.79
$541.15
$609.34
$851.54
$1,294.00
$841.53
$905.89
$974.08
$1,216.28
$1,206.27
$1,270.63
$1,338.82
$1,581.02
$1,571.01
$1,635.37
$1,703.56
$1,945.76
$364.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$953.58
$1,082.30
$1,218.68
$1,703.08
$2,588.00
$1,318.32
$1,447.04
$1,583.42
$2,067.82
$1,683.06
$1,811.78
$1,948.16
$2,432.56
$2,047.80
$2,176.52
$2,312.90
$2,797.30
$364.74
Toc - Plan #55 Aetna CVS Health
Silver

(HMO) Silver 2: Aetna network of doctors & hospitals + $0 MinuteClinic + $0 CVS Health Virtual Care 24/7

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$483.39
$548.64
$617.77
$863.33
$1,311.90
$853.18
$918.43
$987.56
$1,233.12
$1,222.97
$1,288.22
$1,357.35
$1,602.91
$1,592.76
$1,658.01
$1,727.14
$1,972.70
$369.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$966.78
$1,097.28
$1,235.54
$1,726.66
$2,623.80
$1,336.57
$1,467.07
$1,605.33
$2,096.45
$1,706.36
$1,836.86
$1,975.12
$2,466.24
$2,076.15
$2,206.65
$2,344.91
$2,836.03
$369.79
Toc - Plan #56 Aetna CVS Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.65
$401.39
$451.96
$631.61
$959.80
$624.19
$671.93
$722.50
$902.15
$894.73
$942.47
$993.04
$1,172.69
$1,165.27
$1,213.01
$1,263.58
$1,443.23
$270.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.30
$802.78
$903.92
$1,263.22
$1,919.60
$977.84
$1,073.32
$1,174.46
$1,533.76
$1,248.38
$1,343.86
$1,445.00
$1,804.30
$1,518.92
$1,614.40
$1,715.54
$2,074.84
$270.54
Toc - Plan #57 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$477.56
$542.03
$610.32
$852.92
$1,296.10
$842.90
$907.37
$975.66
$1,218.26
$1,208.24
$1,272.71
$1,341.00
$1,583.60
$1,573.58
$1,638.05
$1,706.34
$1,948.94
$365.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$955.12
$1,084.06
$1,220.64
$1,705.84
$2,592.20
$1,320.46
$1,449.40
$1,585.98
$2,071.18
$1,685.80
$1,814.74
$1,951.32
$2,436.52
$2,051.14
$2,180.08
$2,316.66
$2,801.86
$365.34
Toc - Plan #58 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$466.67
$529.67
$596.41
$833.47
$1,266.54
$823.68
$886.68
$953.42
$1,190.48
$1,180.69
$1,243.69
$1,310.43
$1,547.49
$1,537.70
$1,600.70
$1,667.44
$1,904.50
$357.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$933.34
$1,059.34
$1,192.82
$1,666.94
$2,533.08
$1,290.35
$1,416.35
$1,549.83
$2,023.95
$1,647.36
$1,773.36
$1,906.84
$2,380.96
$2,004.37
$2,130.37
$2,263.85
$2,737.97
$357.01
Toc - Plan #59 Aetna CVS Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.79
$444.69
$500.71
$699.74
$1,063.32
$691.51
$744.41
$800.43
$999.46
$991.23
$1,044.13
$1,100.15
$1,299.18
$1,290.95
$1,343.85
$1,399.87
$1,598.90
$299.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$783.58
$889.38
$1,001.42
$1,399.48
$2,126.64
$1,083.30
$1,189.10
$1,301.14
$1,699.20
$1,383.02
$1,488.82
$1,600.86
$1,998.92
$1,682.74
$1,788.54
$1,900.58
$2,298.64
$299.72
Toc - Plan #60 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$478.35
$542.93
$611.33
$854.33
$1,298.24
$844.29
$908.87
$977.27
$1,220.27
$1,210.23
$1,274.81
$1,343.21
$1,586.21
$1,576.17
$1,640.75
$1,709.15
$1,952.15
$365.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$956.70
$1,085.86
$1,222.66
$1,708.66
$2,596.48
$1,322.64
$1,451.80
$1,588.60
$2,074.60
$1,688.58
$1,817.74
$1,954.54
$2,440.54
$2,054.52
$2,183.68
$2,320.48
$2,806.48
$365.94
Toc - Plan #61 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$482.66
$547.82
$616.83
$862.02
$1,309.92
$851.89
$917.05
$986.06
$1,231.25
$1,221.12
$1,286.28
$1,355.29
$1,600.48
$1,590.35
$1,655.51
$1,724.52
$1,969.71
$369.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$965.32
$1,095.64
$1,233.66
$1,724.04
$2,619.84
$1,334.55
$1,464.87
$1,602.89
$2,093.27
$1,703.78
$1,834.10
$1,972.12
$2,462.50
$2,073.01
$2,203.33
$2,341.35
$2,831.73
$369.23
Toc - Plan #62 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$466.86
$529.88
$596.64
$833.80
$1,267.04
$824.01
$887.03
$953.79
$1,190.95
$1,181.16
$1,244.18
$1,310.94
$1,548.10
$1,538.31
$1,601.33
$1,668.09
$1,905.25
$357.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$933.72
$1,059.76
$1,193.28
$1,667.60
$2,534.08
$1,290.87
$1,416.91
$1,550.43
$2,024.75
$1,648.02
$1,774.06
$1,907.58
$2,381.90
$2,005.17
$2,131.21
$2,264.73
$2,739.05
$357.15
Toc - Plan #63 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$476.83
$541.20
$609.39
$851.62
$1,294.12
$841.61
$905.98
$974.17
$1,216.40
$1,206.39
$1,270.76
$1,338.95
$1,581.18
$1,571.17
$1,635.54
$1,703.73
$1,945.96
$364.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$953.66
$1,082.40
$1,218.78
$1,703.24
$2,588.24
$1,318.44
$1,447.18
$1,583.56
$2,068.02
$1,683.22
$1,811.96
$1,948.34
$2,432.80
$2,048.00
$2,176.74
$2,313.12
$2,797.58
$364.78

ADVERTISEMENT

Oscar Health Plan of North Carolina, Inc

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

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

(HMO) Bronze Classic PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$405.47
$460.20
$518.18
$724.16
$1,100.43
$715.65
$770.38
$828.36
$1,034.34
$1,025.83
$1,080.56
$1,138.54
$1,344.52
$1,336.01
$1,390.74
$1,448.72
$1,654.70
$310.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$810.94
$920.40
$1,036.36
$1,448.32
$2,200.86
$1,121.12
$1,230.58
$1,346.54
$1,758.50
$1,431.30
$1,540.76
$1,656.72
$2,068.68
$1,741.48
$1,850.94
$1,966.90
$2,378.86
$310.18
Toc - Plan #65 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Elite + PCP Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$483.78
$549.08
$618.26
$864.02
$1,312.96
$853.87
$919.17
$988.35
$1,234.11
$1,223.96
$1,289.26
$1,358.44
$1,604.20
$1,594.05
$1,659.35
$1,728.53
$1,974.29
$370.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$967.56
$1,098.16
$1,236.52
$1,728.04
$2,625.92
$1,337.65
$1,468.25
$1,606.61
$2,098.13
$1,707.74
$1,838.34
$1,976.70
$2,468.22
$2,077.83
$2,208.43
$2,346.79
$2,838.31
$370.09
Toc - Plan #66 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Classic

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$543.43
$616.78
$694.49
$970.54
$1,474.84
$959.14
$1,032.49
$1,110.20
$1,386.25
$1,374.85
$1,448.20
$1,525.91
$1,801.96
$1,790.56
$1,863.91
$1,941.62
$2,217.67
$415.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,086.86
$1,233.56
$1,388.98
$1,941.08
$2,949.68
$1,502.57
$1,649.27
$1,804.69
$2,356.79
$1,918.28
$2,064.98
$2,220.40
$2,772.50
$2,333.99
$2,480.69
$2,636.11
$3,188.21
$415.71
Toc - Plan #67 Oscar Health Plan of North Carolina, Inc
Catastrophic

(HMO) Secure

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.82
$362.99
$408.72
$571.19
$867.97
$564.48
$607.65
$653.38
$815.85
$809.14
$852.31
$898.04
$1,060.51
$1,053.80
$1,096.97
$1,142.70
$1,305.17
$244.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.64
$725.98
$817.44
$1,142.38
$1,735.94
$884.30
$970.64
$1,062.10
$1,387.04
$1,128.96
$1,215.30
$1,306.76
$1,631.70
$1,373.62
$1,459.96
$1,551.42
$1,876.36
$244.66
Toc - Plan #68 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Simple HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$396.36
$449.86
$506.54
$707.89
$1,075.70
$699.57
$753.07
$809.75
$1,011.10
$1,002.78
$1,056.28
$1,112.96
$1,314.31
$1,305.99
$1,359.49
$1,416.17
$1,617.52
$303.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$792.72
$899.72
$1,013.08
$1,415.78
$2,151.40
$1,095.93
$1,202.93
$1,316.29
$1,718.99
$1,399.14
$1,506.14
$1,619.50
$2,022.20
$1,702.35
$1,809.35
$1,922.71
$2,325.41
$303.21
Toc - Plan #69 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Classic 4700

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$4,700 $9,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.29
$487.23
$548.62
$766.69
$1,165.06
$757.69
$815.63
$877.02
$1,095.09
$1,086.09
$1,144.03
$1,205.42
$1,423.49
$1,414.49
$1,472.43
$1,533.82
$1,751.89
$328.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$858.58
$974.46
$1,097.24
$1,533.38
$2,330.12
$1,186.98
$1,302.86
$1,425.64
$1,861.78
$1,515.38
$1,631.26
$1,754.04
$2,190.18
$1,843.78
$1,959.66
$2,082.44
$2,518.58
$328.40
Toc - Plan #70 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Simple PCP Saver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$527.02
$598.16
$673.52
$941.25
$1,430.32
$930.19
$1,001.33
$1,076.69
$1,344.42
$1,333.36
$1,404.50
$1,479.86
$1,747.59
$1,736.53
$1,807.67
$1,883.03
$2,150.76
$403.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,054.04
$1,196.32
$1,347.04
$1,882.50
$2,860.64
$1,457.21
$1,599.49
$1,750.21
$2,285.67
$1,860.38
$2,002.66
$2,153.38
$2,688.84
$2,263.55
$2,405.83
$2,556.55
$3,092.01
$403.17
Toc - Plan #71 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Elite Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$567.53
$644.14
$725.29
$1,013.60
$1,540.26
$1,001.68
$1,078.29
$1,159.44
$1,447.75
$1,435.83
$1,512.44
$1,593.59
$1,881.90
$1,869.98
$1,946.59
$2,027.74
$2,316.05
$434.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,135.06
$1,288.28
$1,450.58
$2,027.20
$3,080.52
$1,569.21
$1,722.43
$1,884.73
$2,461.35
$2,003.36
$2,156.58
$2,318.88
$2,895.50
$2,437.51
$2,590.73
$2,753.03
$3,329.65
$434.15
Toc - Plan #72 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) Gold Elite Saver Plus

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$655.00
$743.42
$837.08
$1,169.82
$1,777.65
$1,156.07
$1,244.49
$1,338.15
$1,670.89
$1,657.14
$1,745.56
$1,839.22
$2,171.96
$2,158.21
$2,246.63
$2,340.29
$2,673.03
$501.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,310.00
$1,486.84
$1,674.16
$2,339.64
$3,555.30
$1,811.07
$1,987.91
$2,175.23
$2,840.71
$2,312.14
$2,488.98
$2,676.30
$3,341.78
$2,813.21
$2,990.05
$3,177.37
$3,842.85
$501.07
Toc - Plan #73 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Simple Diabetes

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$6,450 $12,900 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$547.04
$620.88
$699.10
$976.99
$1,484.63
$965.52
$1,039.36
$1,117.58
$1,395.47
$1,384.00
$1,457.84
$1,536.06
$1,813.95
$1,802.48
$1,876.32
$1,954.54
$2,232.43
$418.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,094.08
$1,241.76
$1,398.20
$1,953.98
$2,969.26
$1,512.56
$1,660.24
$1,816.68
$2,372.46
$1,931.04
$2,078.72
$2,235.16
$2,790.94
$2,349.52
$2,497.20
$2,653.64
$3,209.42
$418.48
Toc - Plan #74 Oscar Health Plan of North Carolina, Inc
Expanded Bronze

(HMO) Bronze Classic Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$414.14
$470.04
$529.26
$739.64
$1,123.96
$730.95
$786.85
$846.07
$1,056.45
$1,047.76
$1,103.66
$1,162.88
$1,373.26
$1,364.57
$1,420.47
$1,479.69
$1,690.07
$316.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$828.28
$940.08
$1,058.52
$1,479.28
$2,247.92
$1,145.09
$1,256.89
$1,375.33
$1,796.09
$1,461.90
$1,573.70
$1,692.14
$2,112.90
$1,778.71
$1,890.51
$2,008.95
$2,429.71
$316.81
Toc - Plan #75 Oscar Health Plan of North Carolina, Inc
Silver

(HMO) Silver Classic Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$521.59
$591.99
$666.58
$931.54
$1,415.56
$920.60
$991.00
$1,065.59
$1,330.55
$1,319.61
$1,390.01
$1,464.60
$1,729.56
$1,718.62
$1,789.02
$1,863.61
$2,128.57
$399.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,043.18
$1,183.98
$1,333.16
$1,863.08
$2,831.12
$1,442.19
$1,582.99
$1,732.17
$2,262.09
$1,841.20
$1,982.00
$2,131.18
$2,661.10
$2,240.21
$2,381.01
$2,530.19
$3,060.11
$399.01
Toc - Plan #76 Oscar Health Plan of North Carolina, Inc
Gold

(HMO) Gold Classic Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-672-2755

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$546.92
$620.75
$698.95
$976.79
$1,484.32
$965.31
$1,039.14
$1,117.34
$1,395.18
$1,383.70
$1,457.53
$1,535.73
$1,813.57
$1,802.09
$1,875.92
$1,954.12
$2,231.96
$418.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,093.84
$1,241.50
$1,397.90
$1,953.58
$2,968.64
$1,512.23
$1,659.89
$1,816.29
$2,371.97
$1,930.62
$2,078.28
$2,234.68
$2,790.36
$2,349.01
$2,496.67
$2,653.07
$3,208.75
$418.39

ADVERTISEMENT

Cigna Healthcare

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

Toc - Plan #77 Cigna Healthcare
Bronze

(HMO) Connect Bronze 9450 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$490.96
$557.24
$627.44
$876.85
$1,332.46
$866.54
$932.82
$1,003.02
$1,252.43
$1,242.12
$1,308.40
$1,378.60
$1,628.01
$1,617.70
$1,683.98
$1,754.18
$2,003.59
$375.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$981.92
$1,114.48
$1,254.88
$1,753.70
$2,664.92
$1,357.50
$1,490.06
$1,630.46
$2,129.28
$1,733.08
$1,865.64
$2,006.04
$2,504.86
$2,108.66
$2,241.22
$2,381.62
$2,880.44
$375.58
Toc - Plan #78 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 6500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$519.07
$589.15
$663.38
$927.07
$1,408.77
$916.16
$986.24
$1,060.47
$1,324.16
$1,313.25
$1,383.33
$1,457.56
$1,721.25
$1,710.34
$1,780.42
$1,854.65
$2,118.34
$397.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,038.14
$1,178.30
$1,326.76
$1,854.14
$2,817.54
$1,435.23
$1,575.39
$1,723.85
$2,251.23
$1,832.32
$1,972.48
$2,120.94
$2,648.32
$2,229.41
$2,369.57
$2,518.03
$3,045.41
$397.09
Toc - Plan #79 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 5500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$514.74
$584.23
$657.84
$919.33
$1,397.01
$908.52
$978.01
$1,051.62
$1,313.11
$1,302.30
$1,371.79
$1,445.40
$1,706.89
$1,696.08
$1,765.57
$1,839.18
$2,100.67
$393.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,029.48
$1,168.46
$1,315.68
$1,838.66
$2,794.02
$1,423.26
$1,562.24
$1,709.46
$2,232.44
$1,817.04
$1,956.02
$2,103.24
$2,626.22
$2,210.82
$2,349.80
$2,497.02
$3,020.00
$393.78
Toc - Plan #80 Cigna Healthcare
Silver

(HMO) Connect Silver 4500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$600.19
$681.22
$767.04
$1,071.94
$1,628.91
$1,059.33
$1,140.36
$1,226.18
$1,531.08
$1,518.47
$1,599.50
$1,685.32
$1,990.22
$1,977.61
$2,058.64
$2,144.46
$2,449.36
$459.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,200.38
$1,362.44
$1,534.08
$2,143.88
$3,257.82
$1,659.52
$1,821.58
$1,993.22
$2,603.02
$2,118.66
$2,280.72
$2,452.36
$3,062.16
$2,577.80
$2,739.86
$2,911.50
$3,521.30
$459.14
Toc - Plan #81 Cigna Healthcare
Silver

(HMO) Connect Silver 3500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$600.05
$681.06
$766.87
$1,071.69
$1,628.54
$1,059.09
$1,140.10
$1,225.91
$1,530.73
$1,518.13
$1,599.14
$1,684.95
$1,989.77
$1,977.17
$2,058.18
$2,143.99
$2,448.81
$459.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,200.10
$1,362.12
$1,533.74
$2,143.38
$3,257.08
$1,659.14
$1,821.16
$1,992.78
$2,602.42
$2,118.18
$2,280.20
$2,451.82
$3,061.46
$2,577.22
$2,739.24
$2,910.86
$3,520.50
$459.04
Toc - Plan #82 Cigna Healthcare
Silver

(HMO) Connect Silver 1500 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$607.20
$689.17
$776.00
$1,084.46
$1,647.94
$1,071.71
$1,153.68
$1,240.51
$1,548.97
$1,536.22
$1,618.19
$1,705.02
$2,013.48
$2,000.73
$2,082.70
$2,169.53
$2,477.99
$464.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,214.40
$1,378.34
$1,552.00
$2,168.92
$3,295.88
$1,678.91
$1,842.85
$2,016.51
$2,633.43
$2,143.42
$2,307.36
$2,481.02
$3,097.94
$2,607.93
$2,771.87
$2,945.53
$3,562.45
$464.51
Toc - Plan #83 Cigna Healthcare
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$605.48
$687.22
$773.81
$1,081.39
$1,643.28
$1,068.67
$1,150.41
$1,237.00
$1,544.58
$1,531.86
$1,613.60
$1,700.19
$2,007.77
$1,995.05
$2,076.79
$2,163.38
$2,470.96
$463.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,210.96
$1,374.44
$1,547.62
$2,162.78
$3,286.56
$1,674.15
$1,837.63
$2,010.81
$2,625.97
$2,137.34
$2,300.82
$2,474.00
$3,089.16
$2,600.53
$2,764.01
$2,937.19
$3,552.35
$463.19
Toc - Plan #84 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze CMS Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$511.72
$580.80
$653.98
$913.93
$1,388.80
$903.18
$972.26
$1,045.44
$1,305.39
$1,294.64
$1,363.72
$1,436.90
$1,696.85
$1,686.10
$1,755.18
$1,828.36
$2,088.31
$391.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,023.44
$1,161.60
$1,307.96
$1,827.86
$2,777.60
$1,414.90
$1,553.06
$1,699.42
$2,219.32
$1,806.36
$1,944.52
$2,090.88
$2,610.78
$2,197.82
$2,335.98
$2,482.34
$3,002.24
$391.46
Toc - Plan #85 Cigna Healthcare
Expanded Bronze

(HMO) Connect Bronze 0 Indiv Med Deductible

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$546.16
$619.89
$697.99
$975.44
$1,482.27
$963.97
$1,037.70
$1,115.80
$1,393.25
$1,381.78
$1,455.51
$1,533.61
$1,811.06
$1,799.59
$1,873.32
$1,951.42
$2,228.87
$417.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,092.32
$1,239.78
$1,395.98
$1,950.88
$2,964.54
$1,510.13
$1,657.59
$1,813.79
$2,368.69
$1,927.94
$2,075.40
$2,231.60
$2,786.50
$2,345.75
$2,493.21
$2,649.41
$3,204.31
$417.81
Toc - Plan #86 Cigna Healthcare
Silver

(HMO) Connect Silver CMS Standard

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$599.50
$680.43
$766.16
$1,070.71
$1,627.05
$1,058.12
$1,139.05
$1,224.78
$1,529.33
$1,516.74
$1,597.67
$1,683.40
$1,987.95
$1,975.36
$2,056.29
$2,142.02
$2,446.57
$458.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,199.00
$1,360.86
$1,532.32
$2,141.42
$3,254.10
$1,657.62
$1,819.48
$1,990.94
$2,600.04
$2,116.24
$2,278.10
$2,449.56
$3,058.66
$2,574.86
$2,736.72
$2,908.18
$3,517.28
$458.62
Toc - Plan #87 Cigna Healthcare
Gold

(HMO) Connect Gold CMS Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$813.98
$923.87
$1,040.26
$1,453.77
$2,209.14
$1,436.67
$1,546.56
$1,662.95
$2,076.46
$2,059.36
$2,169.25
$2,285.64
$2,699.15
$2,682.05
$2,791.94
$2,908.33
$3,321.84
$622.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,627.96
$1,847.74
$2,080.52
$2,907.54
$4,418.28
$2,250.65
$2,470.43
$2,703.21
$3,530.23
$2,873.34
$3,093.12
$3,325.90
$4,152.92
$3,496.03
$3,715.81
$3,948.59
$4,775.61
$622.69

ADVERTISEMENT

Ambetter of North Carolina

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

Toc - Plan #88 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$433.48
$491.99
$553.97
$774.17
$1,176.43
$765.08
$823.59
$885.57
$1,105.77
$1,096.68
$1,155.19
$1,217.17
$1,437.37
$1,428.28
$1,486.79
$1,548.77
$1,768.97
$331.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$866.96
$983.98
$1,107.94
$1,548.34
$2,352.86
$1,198.56
$1,315.58
$1,439.54
$1,879.94
$1,530.16
$1,647.18
$1,771.14
$2,211.54
$1,861.76
$1,978.78
$2,102.74
$2,543.14
$331.60
Toc - Plan #89 Ambetter of North Carolina
Silver

(HMO) Complete Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$544.67
$618.19
$696.07
$972.76
$1,478.20
$961.33
$1,034.85
$1,112.73
$1,389.42
$1,377.99
$1,451.51
$1,529.39
$1,806.08
$1,794.65
$1,868.17
$1,946.05
$2,222.74
$416.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,089.34
$1,236.38
$1,392.14
$1,945.52
$2,956.40
$1,506.00
$1,653.04
$1,808.80
$2,362.18
$1,922.66
$2,069.70
$2,225.46
$2,778.84
$2,339.32
$2,486.36
$2,642.12
$3,195.50
$416.66
Toc - Plan #90 Ambetter of North Carolina
Gold

(HMO) Complete Gold

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$567.63
$644.25
$725.42
$1,013.77
$1,540.53
$1,001.86
$1,078.48
$1,159.65
$1,448.00
$1,436.09
$1,512.71
$1,593.88
$1,882.23
$1,870.32
$1,946.94
$2,028.11
$2,316.46
$434.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,135.26
$1,288.50
$1,450.84
$2,027.54
$3,081.06
$1,569.49
$1,722.73
$1,885.07
$2,461.77
$2,003.72
$2,156.96
$2,319.30
$2,896.00
$2,437.95
$2,591.19
$2,753.53
$3,330.23
$434.23
Toc - Plan #91 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.12
$482.50
$543.29
$759.25
$1,153.75
$750.33
$807.71
$868.50
$1,084.46
$1,075.54
$1,132.92
$1,193.71
$1,409.67
$1,400.75
$1,458.13
$1,518.92
$1,734.88
$325.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$850.24
$965.00
$1,086.58
$1,518.50
$2,307.50
$1,175.45
$1,290.21
$1,411.79
$1,843.71
$1,500.66
$1,615.42
$1,737.00
$2,168.92
$1,825.87
$1,940.63
$2,062.21
$2,494.13
$325.21
Toc - Plan #92 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$485.39
$550.91
$620.32
$866.90
$1,317.33
$856.71
$922.23
$991.64
$1,238.22
$1,228.03
$1,293.55
$1,362.96
$1,609.54
$1,599.35
$1,664.87
$1,734.28
$1,980.86
$371.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$970.78
$1,101.82
$1,240.64
$1,733.80
$2,634.66
$1,342.10
$1,473.14
$1,611.96
$2,105.12
$1,713.42
$1,844.46
$1,983.28
$2,476.44
$2,084.74
$2,215.78
$2,354.60
$2,847.76
$371.32
Toc - Plan #93 Ambetter of North Carolina
Silver

(HMO) Clear Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$529.06
$600.47
$676.13
$944.89
$1,435.85
$933.78
$1,005.19
$1,080.85
$1,349.61
$1,338.50
$1,409.91
$1,485.57
$1,754.33
$1,743.22
$1,814.63
$1,890.29
$2,159.05
$404.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,058.12
$1,200.94
$1,352.26
$1,889.78
$2,871.70
$1,462.84
$1,605.66
$1,756.98
$2,294.50
$1,867.56
$2,010.38
$2,161.70
$2,699.22
$2,272.28
$2,415.10
$2,566.42
$3,103.94
$404.72
Toc - Plan #94 Ambetter of North Carolina
Silver

(HMO) Focused Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$536.16
$608.53
$685.19
$957.56
$1,455.10
$946.31
$1,018.68
$1,095.34
$1,367.71
$1,356.46
$1,428.83
$1,505.49
$1,777.86
$1,766.61
$1,838.98
$1,915.64
$2,188.01
$410.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,072.32
$1,217.06
$1,370.38
$1,915.12
$2,910.20
$1,482.47
$1,627.21
$1,780.53
$2,325.27
$1,892.62
$2,037.36
$2,190.68
$2,735.42
$2,302.77
$2,447.51
$2,600.83
$3,145.57
$410.15
Toc - Plan #95 Ambetter of North Carolina
Expanded Bronze

(HMO) Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$417.66
$474.03
$533.76
$745.92
$1,133.50
$737.16
$793.53
$853.26
$1,065.42
$1,056.66
$1,113.03
$1,172.76
$1,384.92
$1,376.16
$1,432.53
$1,492.26
$1,704.42
$319.50
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$835.32
$948.06
$1,067.52
$1,491.84
$2,267.00
$1,154.82
$1,267.56
$1,387.02
$1,811.34
$1,474.32
$1,587.06
$1,706.52
$2,130.84
$1,793.82
$1,906.56
$2,026.02
$2,450.34
$319.50
Toc - Plan #96 Ambetter of North Carolina
Silver

(HMO) Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$525.49
$596.42
$671.56
$938.51
$1,426.15
$927.48
$998.41
$1,073.55
$1,340.50
$1,329.47
$1,400.40
$1,475.54
$1,742.49
$1,731.46
$1,802.39
$1,877.53
$2,144.48
$401.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,050.98
$1,192.84
$1,343.12
$1,877.02
$2,852.30
$1,452.97
$1,594.83
$1,745.11
$2,279.01
$1,854.96
$1,996.82
$2,147.10
$2,681.00
$2,256.95
$2,398.81
$2,549.09
$3,082.99
$401.99
Toc - Plan #97 Ambetter of North Carolina
Gold

(HMO) Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$544.83
$618.37
$696.28
$973.04
$1,478.63
$961.61
$1,035.15
$1,113.06
$1,389.82
$1,378.39
$1,451.93
$1,529.84
$1,806.60
$1,795.17
$1,868.71
$1,946.62
$2,223.38
$416.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,089.66
$1,236.74
$1,392.56
$1,946.08
$2,957.26
$1,506.44
$1,653.52
$1,809.34
$2,362.86
$1,923.22
$2,070.30
$2,226.12
$2,779.64
$2,340.00
$2,487.08
$2,642.90
$3,196.42
$416.78
Toc - Plan #98 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 Annual Deductible
$7,250 $14,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$450.63
$511.45
$575.89
$804.81
$1,222.98
$795.35
$856.17
$920.61
$1,149.53
$1,140.07
$1,200.89
$1,265.33
$1,494.25
$1,484.79
$1,545.61
$1,610.05
$1,838.97
$344.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.26
$1,022.90
$1,151.78
$1,609.62
$2,445.96
$1,245.98
$1,367.62
$1,496.50
$1,954.34
$1,590.70
$1,712.34
$1,841.22
$2,299.06
$1,935.42
$2,057.06
$2,185.94
$2,643.78
$344.72
Toc - Plan #99 Ambetter of North Carolina
Silver

(HMO) Complete Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$566.22
$642.65
$723.62
$1,011.25
$1,536.70
$999.37
$1,075.80
$1,156.77
$1,444.40
$1,432.52
$1,508.95
$1,589.92
$1,877.55
$1,865.67
$1,942.10
$2,023.07
$2,310.70
$433.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,132.44
$1,285.30
$1,447.24
$2,022.50
$3,073.40
$1,565.59
$1,718.45
$1,880.39
$2,455.65
$1,998.74
$2,151.60
$2,313.54
$2,888.80
$2,431.89
$2,584.75
$2,746.69
$3,321.95
$433.15
Toc - Plan #100 Ambetter of North Carolina
Gold

(HMO) Complete Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$590.09
$669.75
$754.13
$1,053.89
$1,601.49
$1,041.50
$1,121.16
$1,205.54
$1,505.30
$1,492.91
$1,572.57
$1,656.95
$1,956.71
$1,944.32
$2,023.98
$2,108.36
$2,408.12
$451.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,180.18
$1,339.50
$1,508.26
$2,107.78
$3,202.98
$1,631.59
$1,790.91
$1,959.67
$2,559.19
$2,083.00
$2,242.32
$2,411.08
$3,010.60
$2,534.41
$2,693.73
$2,862.49
$3,462.01
$451.41
Toc - Plan #101 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$441.94
$501.60
$564.79
$789.30
$1,199.41
$780.02
$839.68
$902.87
$1,127.38
$1,118.10
$1,177.76
$1,240.95
$1,465.46
$1,456.18
$1,515.84
$1,579.03
$1,803.54
$338.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$883.88
$1,003.20
$1,129.58
$1,578.60
$2,398.82
$1,221.96
$1,341.28
$1,467.66
$1,916.68
$1,560.04
$1,679.36
$1,805.74
$2,254.76
$1,898.12
$2,017.44
$2,143.82
$2,592.84
$338.08
Toc - Plan #102 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,250 $18,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$504.60
$572.71
$644.87
$901.20
$1,369.46
$890.61
$958.72
$1,030.88
$1,287.21
$1,276.62
$1,344.73
$1,416.89
$1,673.22
$1,662.63
$1,730.74
$1,802.90
$2,059.23
$386.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,009.20
$1,145.42
$1,289.74
$1,802.40
$2,738.92
$1,395.21
$1,531.43
$1,675.75
$2,188.41
$1,781.22
$1,917.44
$2,061.76
$2,574.42
$2,167.23
$2,303.45
$2,447.77
$2,960.43
$386.01
Toc - Plan #103 Ambetter of North Carolina
Silver

(HMO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,300 $12,600 Annual Deductible
$8,000 $16,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$557.37
$632.61
$712.31
$995.45
$1,512.68
$983.75
$1,058.99
$1,138.69
$1,421.83
$1,410.13
$1,485.37
$1,565.07
$1,848.21
$1,836.51
$1,911.75
$1,991.45
$2,274.59
$426.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,114.74
$1,265.22
$1,424.62
$1,990.90
$3,025.36
$1,541.12
$1,691.60
$1,851.00
$2,417.28
$1,967.50
$2,117.98
$2,277.38
$2,843.66
$2,393.88
$2,544.36
$2,703.76
$3,270.04
$426.38
Toc - Plan #104 Ambetter of North Carolina
Silver

(HMO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$550.00
$624.24
$702.88
$982.28
$1,492.67
$970.74
$1,044.98
$1,123.62
$1,403.02
$1,391.48
$1,465.72
$1,544.36
$1,823.76
$1,812.22
$1,886.46
$1,965.10
$2,244.50
$420.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,100.00
$1,248.48
$1,405.76
$1,964.56
$2,985.34
$1,520.74
$1,669.22
$1,826.50
$2,385.30
$1,941.48
$2,089.96
$2,247.24
$2,806.04
$2,362.22
$2,510.70
$2,667.98
$3,226.78
$420.74
Toc - Plan #105 Ambetter of North Carolina
Expanded Bronze

(HMO) Standard Expanded Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.19
$492.79
$554.88
$775.44
$1,178.36
$766.34
$824.94
$887.03
$1,107.59
$1,098.49
$1,157.09
$1,219.18
$1,439.74
$1,430.64
$1,489.24
$1,551.33
$1,771.89
$332.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.38
$985.58
$1,109.76
$1,550.88
$2,356.72
$1,200.53
$1,317.73
$1,441.91
$1,883.03
$1,532.68
$1,649.88
$1,774.06
$2,215.18
$1,864.83
$1,982.03
$2,106.21
$2,547.33
$332.15
Toc - Plan #106 Ambetter of North Carolina
Silver

(HMO) Standard Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$546.28
$620.02
$698.14
$975.64
$1,482.58
$964.18
$1,037.92
$1,116.04
$1,393.54
$1,382.08
$1,455.82
$1,533.94
$1,811.44
$1,799.98
$1,873.72
$1,951.84
$2,229.34
$417.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,092.56
$1,240.04
$1,396.28
$1,951.28
$2,965.16
$1,510.46
$1,657.94
$1,814.18
$2,369.18
$1,928.36
$2,075.84
$2,232.08
$2,787.08
$2,346.26
$2,493.74
$2,649.98
$3,204.98
$417.90
Toc - Plan #107 Ambetter of North Carolina
Gold

(HMO) Standard Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$566.39
$642.84
$723.83
$1,011.55
$1,537.14
$999.67
$1,076.12
$1,157.11
$1,444.83
$1,432.95
$1,509.40
$1,590.39
$1,878.11
$1,866.23
$1,942.68
$2,023.67
$2,311.39
$433.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,132.78
$1,285.68
$1,447.66
$2,023.10
$3,074.28
$1,566.06
$1,718.96
$1,880.94
$2,456.38
$1,999.34
$2,152.24
$2,314.22
$2,889.66
$2,432.62
$2,585.52
$2,747.50
$3,322.94
$433.28
Toc - Plan #108 Ambetter of North Carolina
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$448.61
$509.16
$573.31
$801.20
$1,217.50
$791.79
$852.34
$916.49
$1,144.38
$1,134.97
$1,195.52
$1,259.67
$1,487.56
$1,478.15
$1,538.70
$1,602.85
$1,830.74
$343.18
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$897.22
$1,018.32
$1,146.62
$1,602.40
$2,435.00
$1,240.40
$1,361.50
$1,489.80
$1,945.58
$1,583.58
$1,704.68
$1,832.98
$2,288.76
$1,926.76
$2,047.86
$2,176.16
$2,631.94
$343.18
Toc - Plan #109 Ambetter of North Carolina
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$554.71
$629.58
$708.90
$990.69
$1,505.44
$979.05
$1,053.92
$1,133.24
$1,415.03
$1,403.39
$1,478.26
$1,557.58
$1,839.37
$1,827.73
$1,902.60
$1,981.92
$2,263.71
$424.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,109.42
$1,259.16
$1,417.80
$1,981.38
$3,010.88
$1,533.76
$1,683.50
$1,842.14
$2,405.72
$1,958.10
$2,107.84
$2,266.48
$2,830.06
$2,382.44
$2,532.18
$2,690.82
$3,254.40
$424.34
Toc - Plan #110 Ambetter of North Carolina
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$582.14
$660.71
$743.96
$1,039.68
$1,579.89
$1,027.47
$1,106.04
$1,189.29
$1,485.01
$1,472.80
$1,551.37
$1,634.62
$1,930.34
$1,918.13
$1,996.70
$2,079.95
$2,375.67
$445.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,164.28
$1,321.42
$1,487.92
$2,079.36
$3,159.78
$1,609.61
$1,766.75
$1,933.25
$2,524.69
$2,054.94
$2,212.08
$2,378.58
$2,970.02
$2,500.27
$2,657.41
$2,823.91
$3,415.35
$445.33

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

McDowell County is in “” of North Carolina.

Currently, there are 110 plans offered in .

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