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Obamacare 2023 Rates for Montgomery County

Obamacare > Rates > North Carolina > Montgomery County

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

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

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

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

Obamacare Providers, 60 Plans and 2023 Rates for Montgomery County, North Carolina

Below, you’ll find a summary of the 60 plans for Montgomery County, North Carolina and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$551.59
$626.05
$704.93
$985.14
$1,497.02 		$973.56
$1,048.02
$1,126.90
$1,407.11 		$1,395.53
$1,469.99
$1,548.87
$1,829.08 		$1,817.50
$1,891.96
$1,970.84
$2,251.05 		$421.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,103.18
$1,252.10
$1,409.86
$1,970.28
$2,994.04 		$1,525.15
$1,674.07
$1,831.83
$2,392.25 		$1,947.12
$2,096.04
$2,253.80
$2,814.22 		$2,369.09
$2,518.01
$2,675.77
$3,236.19 		$421.97
Toc - Plan #2 Blue Cross and Blue Shield of NC
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$510.71
$579.66
$652.69
$912.13
$1,386.07 		$901.40
$970.35
$1,043.38
$1,302.82 		$1,292.09
$1,361.04
$1,434.07
$1,693.51 		$1,682.78
$1,751.73
$1,824.76
$2,084.20 		$390.69
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,021.42
$1,159.32
$1,305.38
$1,824.26
$2,772.14 		$1,412.11
$1,550.01
$1,696.07
$2,214.95 		$1,802.80
$1,940.70
$2,086.76
$2,605.64 		$2,193.49
$2,331.39
$2,477.45
$2,996.33 		$390.69
Toc - Plan #3 Blue Cross and Blue Shield of NC
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$1,900 $3,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$531.04
$602.73
$678.67
$948.44
$1,441.24 		$937.29
$1,008.98
$1,084.92
$1,354.69 		$1,343.54
$1,415.23
$1,491.17
$1,760.94 		$1,749.79
$1,821.48
$1,897.42
$2,167.19 		$406.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,062.08
$1,205.46
$1,357.34
$1,896.88
$2,882.48 		$1,468.33
$1,611.71
$1,763.59
$2,303.13 		$1,874.58
$2,017.96
$2,169.84
$2,709.38 		$2,280.83
$2,424.21
$2,576.09
$3,115.63 		$406.25
Toc - Plan #4 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$372.79
$423.12
$476.43
$665.80
$1,011.75 		$657.97
$708.30
$761.61
$950.98 		$943.15
$993.48
$1,046.79
$1,236.16 		$1,228.33
$1,278.66
$1,331.97
$1,521.34 		$285.18
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$745.58
$846.24
$952.86
$1,331.60
$2,023.50 		$1,030.76
$1,131.42
$1,238.04
$1,616.78 		$1,315.94
$1,416.60
$1,523.22
$1,901.96 		$1,601.12
$1,701.78
$1,808.40
$2,187.14 		$285.18
Toc - Plan #5 Blue Cross and Blue Shield of NC
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$524.68
$595.51
$670.54
$937.08
$1,423.98 		$926.06
$996.89
$1,071.92
$1,338.46 		$1,327.44
$1,398.27
$1,473.30
$1,739.84 		$1,728.82
$1,799.65
$1,874.68
$2,141.22 		$401.38
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,049.36
$1,191.02
$1,341.08
$1,874.16
$2,847.96 		$1,450.74
$1,592.40
$1,742.46
$2,275.54 		$1,852.12
$1,993.78
$2,143.84
$2,676.92 		$2,253.50
$2,395.16
$2,545.22
$3,078.30 		$401.38
Toc - Plan #6 Blue Cross and Blue Shield of NC
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$539.32
$612.13
$689.25
$963.23
$1,463.71 		$951.90
$1,024.71
$1,101.83
$1,375.81 		$1,364.48
$1,437.29
$1,514.41
$1,788.39 		$1,777.06
$1,849.87
$1,926.99
$2,200.97 		$412.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,078.64
$1,224.26
$1,378.50
$1,926.46
$2,927.42 		$1,491.22
$1,636.84
$1,791.08
$2,339.04 		$1,903.80
$2,049.42
$2,203.66
$2,751.62 		$2,316.38
$2,462.00
$2,616.24
$3,164.20 		$412.58
Toc - Plan #7 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$391.20
$444.01
$499.95
$698.68
$1,061.72 		$690.47
$743.28
$799.22
$997.95 		$989.74
$1,042.55
$1,098.49
$1,297.22 		$1,289.01
$1,341.82
$1,397.76
$1,596.49 		$299.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$782.40
$888.02
$999.90
$1,397.36
$2,123.44 		$1,081.67
$1,187.29
$1,299.17
$1,696.63 		$1,380.94
$1,486.56
$1,598.44
$1,995.90 		$1,680.21
$1,785.83
$1,897.71
$2,295.17 		$299.27
Toc - Plan #8 Blue Cross and Blue Shield of NC
Catastrophic

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$273.93
$310.91
$350.08
$489.24
$743.45 		$483.49
$520.47
$559.64
$698.80 		$693.05
$730.03
$769.20
$908.36 		$902.61
$939.59
$978.76
$1,117.92 		$209.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$547.86
$621.82
$700.16
$978.48
$1,486.90 		$757.42
$831.38
$909.72
$1,188.04 		$966.98
$1,040.94
$1,119.28
$1,397.60 		$1,176.54
$1,250.50
$1,328.84
$1,607.16 		$209.56
Toc - Plan #9 Blue Cross and Blue Shield of NC
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$533.19
$605.17
$681.42
$952.28
$1,447.08 		$941.08
$1,013.06
$1,089.31
$1,360.17 		$1,348.97
$1,420.95
$1,497.20
$1,768.06 		$1,756.86
$1,828.84
$1,905.09
$2,175.95 		$407.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,066.38
$1,210.34
$1,362.84
$1,904.56
$2,894.16 		$1,474.27
$1,618.23
$1,770.73
$2,312.45 		$1,882.16
$2,026.12
$2,178.62
$2,720.34 		$2,290.05
$2,434.01
$2,586.51
$3,128.23 		$407.89
Toc - Plan #10 Blue Cross and Blue Shield of NC
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$393.95
$447.13
$503.47
$703.59
$1,069.18 		$695.32
$748.50
$804.84
$1,004.96 		$996.69
$1,049.87
$1,106.21
$1,306.33 		$1,298.06
$1,351.24
$1,407.58
$1,607.70 		$301.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$787.90
$894.26
$1,006.94
$1,407.18
$2,138.36 		$1,089.27
$1,195.63
$1,308.31
$1,708.55 		$1,390.64
$1,497.00
$1,609.68
$2,009.92 		$1,692.01
$1,798.37
$1,911.05
$2,311.29 		$301.37
Toc - Plan #11 Blue Cross and Blue Shield of NC
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$373.51
$423.93
$477.35
$667.09
$1,013.71 		$659.25
$709.67
$763.09
$952.83 		$944.99
$995.41
$1,048.83
$1,238.57 		$1,230.73
$1,281.15
$1,334.57
$1,524.31 		$285.74
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$747.02
$847.86
$954.70
$1,334.18
$2,027.42 		$1,032.76
$1,133.60
$1,240.44
$1,619.92 		$1,318.50
$1,419.34
$1,526.18
$1,905.66 		$1,604.24
$1,705.08
$1,811.92
$2,191.40 		$285.74
Toc - Plan #12 Blue Cross and Blue Shield of NC
Gold

(PPO) Blue Advantage Gold Standard 2000 | Nationwide Doctors

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$522.75
$593.32
$668.07
$933.63
$1,418.74 		$922.65
$993.22
$1,067.97
$1,333.53 		$1,322.55
$1,393.12
$1,467.87
$1,733.43 		$1,722.45
$1,793.02
$1,867.77
$2,133.33 		$399.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,045.50
$1,186.64
$1,336.14
$1,867.26
$2,837.48 		$1,445.40
$1,586.54
$1,736.04
$2,267.16 		$1,845.30
$1,986.44
$2,135.94
$2,667.06 		$2,245.20
$2,386.34
$2,535.84
$3,066.96 		$399.90
Toc - Plan #13 Blue Cross and Blue Shield of NC
Silver

(PPO) Blue Advantage Silver Standard 5800 | Nationwide Doctors

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$528.83
$600.22
$675.84
$944.49
$1,435.24 		$933.38
$1,004.77
$1,080.39
$1,349.04 		$1,337.93
$1,409.32
$1,484.94
$1,753.59 		$1,742.48
$1,813.87
$1,889.49
$2,158.14 		$404.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,057.66
$1,200.44
$1,351.68
$1,888.98
$2,870.48 		$1,462.21
$1,604.99
$1,756.23
$2,293.53 		$1,866.76
$2,009.54
$2,160.78
$2,698.08 		$2,271.31
$2,414.09
$2,565.33
$3,102.63 		$404.55
Toc - Plan #14 Blue Cross and Blue Shield of NC
Expanded Bronze

(PPO) Blue Advantage Bronze Standard 7500 | Nationwide Doctors

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$373.23
$423.62
$476.99
$666.59
$1,012.95 		$658.75
$709.14
$762.51
$952.11 		$944.27
$994.66
$1,048.03
$1,237.63 		$1,229.79
$1,280.18
$1,333.55
$1,523.15 		$285.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$746.46
$847.24
$953.98
$1,333.18
$2,025.90 		$1,031.98
$1,132.76
$1,239.50
$1,618.70 		$1,317.50
$1,418.28
$1,525.02
$1,904.22 		$1,603.02
$1,703.80
$1,810.54
$2,189.74 		$285.52

ADVERTISEMENT

WellCare of North Carolina

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

Toc - Plan #15 WellCare of North Carolina
Expanded Bronze

(PPO) WellCare Secure Health Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$602.61
$683.95
$770.12
$1,076.24
$1,635.46 		$1,063.60
$1,144.94
$1,231.11
$1,537.23 		$1,524.59
$1,605.93
$1,692.10
$1,998.22 		$1,985.58
$2,066.92
$2,153.09
$2,459.21 		$460.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,205.22
$1,367.90
$1,540.24
$2,152.48
$3,270.92 		$1,666.21
$1,828.89
$2,001.23
$2,613.47 		$2,127.20
$2,289.88
$2,462.22
$3,074.46 		$2,588.19
$2,750.87
$2,923.21
$3,535.45 		$460.99
Toc - Plan #16 WellCare of North Carolina
Silver

(PPO) WellCare Secure Health Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$773.07
$877.42
$987.97
$1,380.68
$2,098.08 		$1,364.46
$1,468.81
$1,579.36
$1,972.07 		$1,955.85
$2,060.20
$2,170.75
$2,563.46 		$2,547.24
$2,651.59
$2,762.14
$3,154.85 		$591.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,546.14
$1,754.84
$1,975.94
$2,761.36
$4,196.16 		$2,137.53
$2,346.23
$2,567.33
$3,352.75 		$2,728.92
$2,937.62
$3,158.72
$3,944.14 		$3,320.31
$3,529.01
$3,750.11
$4,535.53 		$591.39
Toc - Plan #17 WellCare of North Carolina
Gold

(PPO) WellCare Secure Health Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$799.89
$907.87
$1,022.25
$1,428.59
$2,170.89 		$1,411.80
$1,519.78
$1,634.16
$2,040.50 		$2,023.71
$2,131.69
$2,246.07
$2,652.41 		$2,635.62
$2,743.60
$2,857.98
$3,264.32 		$611.91
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,599.78
$1,815.74
$2,044.50
$2,857.18
$4,341.78 		$2,211.69
$2,427.65
$2,656.41
$3,469.09 		$2,823.60
$3,039.56
$3,268.32
$4,081.00 		$3,435.51
$3,651.47
$3,880.23
$4,692.91 		$611.91
Toc - Plan #18 WellCare of North Carolina
Expanded Bronze

(PPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$603.62
$685.09
$771.41
$1,078.04
$1,638.18 		$1,065.38
$1,146.85
$1,233.17
$1,539.80 		$1,527.14
$1,608.61
$1,694.93
$2,001.56 		$1,988.90
$2,070.37
$2,156.69
$2,463.32 		$461.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,207.24
$1,370.18
$1,542.82
$2,156.08
$3,276.36 		$1,669.00
$1,831.94
$2,004.58
$2,617.84 		$2,130.76
$2,293.70
$2,466.34
$3,079.60 		$2,592.52
$2,755.46
$2,928.10
$3,541.36 		$461.76
Toc - Plan #19 WellCare of North Carolina
Silver

(PPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$763.72
$866.81
$976.02
$1,363.98
$2,072.70 		$1,347.95
$1,451.04
$1,560.25
$1,948.21 		$1,932.18
$2,035.27
$2,144.48
$2,532.44 		$2,516.41
$2,619.50
$2,728.71
$3,116.67 		$584.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,527.44
$1,733.62
$1,952.04
$2,727.96
$4,145.40 		$2,111.67
$2,317.85
$2,536.27
$3,312.19 		$2,695.90
$2,902.08
$3,120.50
$3,896.42 		$3,280.13
$3,486.31
$3,704.73
$4,480.65 		$584.23
Toc - Plan #20 WellCare of North Carolina
Gold

(PPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-833-705-2175

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$777.79
$882.78
$994.00
$1,389.11
$2,110.88 		$1,372.79
$1,477.78
$1,589.00
$1,984.11 		$1,967.79
$2,072.78
$2,184.00
$2,579.11 		$2,562.79
$2,667.78
$2,779.00
$3,174.11 		$595.00
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,555.58
$1,765.56
$1,988.00
$2,778.22
$4,221.76 		$2,150.58
$2,360.56
$2,583.00
$3,373.22 		$2,745.58
$2,955.56
$3,178.00
$3,968.22 		$3,340.58
$3,550.56
$3,773.00
$4,563.22 		$595.00

ADVERTISEMENT

Cigna Healthcare

Local: 1-877-900-1237 | Toll Free: 1-877-900-1237 | TTY: 1-800-676-3777
Toc - Plan #21 Cigna Healthcare
Gold

(HMO) Cigna Connect 2100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$699.18
$793.56
$893.55
$1,248.73
$1,897.56 		$1,234.05
$1,328.43
$1,428.42
$1,783.60 		$1,768.92
$1,863.30
$1,963.29
$2,318.47 		$2,303.79
$2,398.17
$2,498.16
$2,853.34 		$534.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,398.36
$1,587.12
$1,787.10
$2,497.46
$3,795.12 		$1,933.23
$2,121.99
$2,321.97
$3,032.33 		$2,468.10
$2,656.86
$2,856.84
$3,567.20 		$3,002.97
$3,191.73
$3,391.71
$4,102.07 		$534.87
Toc - Plan #22 Cigna Healthcare
Bronze

(HMO) Cigna Connect 8700

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.35
$466.88
$525.70
$734.67
$1,116.40 		$726.03
$781.56
$840.38
$1,049.35 		$1,040.71
$1,096.24
$1,155.06
$1,364.03 		$1,355.39
$1,410.92
$1,469.74
$1,678.71 		$314.68
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.70
$933.76
$1,051.40
$1,469.34
$2,232.80 		$1,137.38
$1,248.44
$1,366.08
$1,784.02 		$1,452.06
$1,563.12
$1,680.76
$2,098.70 		$1,766.74
$1,877.80
$1,995.44
$2,413.38 		$314.68
Toc - Plan #23 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 7800

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

Annual Out of Pocket Expenses:

Individual Family
$7,800 $15,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433.01
$491.47
$553.39
$773.36
$1,175.20 		$764.26
$822.72
$884.64
$1,104.61 		$1,095.51
$1,153.97
$1,215.89
$1,435.86 		$1,426.76
$1,485.22
$1,547.14
$1,767.11 		$331.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$866.02
$982.94
$1,106.78
$1,546.72
$2,350.40 		$1,197.27
$1,314.19
$1,438.03
$1,877.97 		$1,528.52
$1,645.44
$1,769.28
$2,209.22 		$1,859.77
$1,976.69
$2,100.53
$2,540.47 		$331.25
Toc - Plan #24 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 5900

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$427.41
$485.11
$546.23
$763.35
$1,159.99 		$754.38
$812.08
$873.20
$1,090.32 		$1,081.35
$1,139.05
$1,200.17
$1,417.29 		$1,408.32
$1,466.02
$1,527.14
$1,744.26 		$326.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.82
$970.22
$1,092.46
$1,526.70
$2,319.98 		$1,181.79
$1,297.19
$1,419.43
$1,853.67 		$1,508.76
$1,624.16
$1,746.40
$2,180.64 		$1,835.73
$1,951.13
$2,073.37
$2,507.61 		$326.97
Toc - Plan #25 Cigna Healthcare
Silver

(HMO) Cigna Connect 5500

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

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$504.59
$572.71
$644.87
$901.21
$1,369.47 		$890.60
$958.72
$1,030.88
$1,287.22 		$1,276.61
$1,344.73
$1,416.89
$1,673.23 		$1,662.62
$1,730.74
$1,802.90
$2,059.24 		$386.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,009.18
$1,145.42
$1,289.74
$1,802.42
$2,738.94 		$1,395.19
$1,531.43
$1,675.75
$2,188.43 		$1,781.20
$1,917.44
$2,061.76
$2,574.44 		$2,167.21
$2,303.45
$2,447.77
$2,960.45 		$386.01
Toc - Plan #26 Cigna Healthcare
Silver

(HMO) Cigna Connect 4500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$503.90
$571.93
$643.99
$899.97
$1,367.59 		$889.38
$957.41
$1,029.47
$1,285.45 		$1,274.86
$1,342.89
$1,414.95
$1,670.93 		$1,660.34
$1,728.37
$1,800.43
$2,056.41 		$385.48
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,007.80
$1,143.86
$1,287.98
$1,799.94
$2,735.18 		$1,393.28
$1,529.34
$1,673.46
$2,185.42 		$1,778.76
$1,914.82
$2,058.94
$2,570.90 		$2,164.24
$2,300.30
$2,444.42
$2,956.38 		$385.48
Toc - Plan #27 Cigna Healthcare
Silver

(HMO) Cigna Connect 3500

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$506.04
$574.35
$646.72
$903.78
$1,373.39 		$893.16
$961.47
$1,033.84
$1,290.90 		$1,280.28
$1,348.59
$1,420.96
$1,678.02 		$1,667.40
$1,735.71
$1,808.08
$2,065.14 		$387.12
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,012.08
$1,148.70
$1,293.44
$1,807.56
$2,746.78 		$1,399.20
$1,535.82
$1,680.56
$2,194.68 		$1,786.32
$1,922.94
$2,067.68
$2,581.80 		$2,173.44
$2,310.06
$2,454.80
$2,968.92 		$387.12
Toc - Plan #28 Cigna Healthcare
Silver

(HMO) Cigna Connect 3800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$3,800 $7,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$508.64
$577.30
$650.04
$908.43
$1,380.44 		$897.75
$966.41
$1,039.15
$1,297.54 		$1,286.86
$1,355.52
$1,428.26
$1,686.65 		$1,675.97
$1,744.63
$1,817.37
$2,075.76 		$389.11
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,017.28
$1,154.60
$1,300.08
$1,816.86
$2,760.88 		$1,406.39
$1,543.71
$1,689.19
$2,205.97 		$1,795.50
$1,932.82
$2,078.30
$2,595.08 		$2,184.61
$2,321.93
$2,467.41
$2,984.19 		$389.11
Toc - Plan #29 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect HSA 7050

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

Annual Out of Pocket Expenses:

Individual Family
$7,050 $14,100 Annual Deductible
$7,050 $14,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$429.43
$487.40
$548.81
$766.96
$1,165.48 		$757.94
$815.91
$877.32
$1,095.47 		$1,086.45
$1,144.42
$1,205.83
$1,423.98 		$1,414.96
$1,472.93
$1,534.34
$1,752.49 		$328.51
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$858.86
$974.80
$1,097.62
$1,533.92
$2,330.96 		$1,187.37
$1,303.31
$1,426.13
$1,862.43 		$1,515.88
$1,631.82
$1,754.64
$2,190.94 		$1,844.39
$1,960.33
$2,083.15
$2,519.45 		$328.51
Toc - Plan #30 Cigna Healthcare
Silver

(HMO) Cigna Connect 4200 Enhanced Asthma COPD Care

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

Annual Out of Pocket Expenses:

Individual Family
$4,200 $8,400 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$507.14
$575.60
$648.12
$905.75
$1,376.37 		$895.10
$963.56
$1,036.08
$1,293.71 		$1,283.06
$1,351.52
$1,424.04
$1,681.67 		$1,671.02
$1,739.48
$1,812.00
$2,069.63 		$387.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,014.28
$1,151.20
$1,296.24
$1,811.50
$2,752.74 		$1,402.24
$1,539.16
$1,684.20
$2,199.46 		$1,790.20
$1,927.12
$2,072.16
$2,587.42 		$2,178.16
$2,315.08
$2,460.12
$2,975.38 		$387.96
Toc - Plan #31 Cigna Healthcare
Bronze

(HMO) Cigna Simple Choice 9100

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.30
$462.29
$520.53
$727.44
$1,105.42 		$718.89
$773.88
$832.12
$1,039.03 		$1,030.48
$1,085.47
$1,143.71
$1,350.62 		$1,342.07
$1,397.06
$1,455.30
$1,662.21 		$311.59
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.60
$924.58
$1,041.06
$1,454.88
$2,210.84 		$1,126.19
$1,236.17
$1,352.65
$1,766.47 		$1,437.78
$1,547.76
$1,664.24
$2,078.06 		$1,749.37
$1,859.35
$1,975.83
$2,389.65 		$311.59
Toc - Plan #32 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Simple Choice 7500

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$424.58
$481.90
$542.61
$758.30
$1,152.30 		$749.38
$806.70
$867.41
$1,083.10 		$1,074.18
$1,131.50
$1,192.21
$1,407.90 		$1,398.98
$1,456.30
$1,517.01
$1,732.70 		$324.80
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$849.16
$963.80
$1,085.22
$1,516.60
$2,304.60 		$1,173.96
$1,288.60
$1,410.02
$1,841.40 		$1,498.76
$1,613.40
$1,734.82
$2,166.20 		$1,823.56
$1,938.20
$2,059.62
$2,491.00 		$324.80
Toc - Plan #33 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 0A

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$453.87
$515.14
$580.04
$810.61
$1,231.80 		$801.08
$862.35
$927.25
$1,157.82 		$1,148.29
$1,209.56
$1,274.46
$1,505.03 		$1,495.50
$1,556.77
$1,621.67
$1,852.24 		$347.21
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$907.74
$1,030.28
$1,160.08
$1,621.22
$2,463.60 		$1,254.95
$1,377.49
$1,507.29
$1,968.43 		$1,602.16
$1,724.70
$1,854.50
$2,315.64 		$1,949.37
$2,071.91
$2,201.71
$2,662.85 		$347.21
Toc - Plan #34 Cigna Healthcare
Silver

(HMO) Cigna Simple Choice 5800

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$504.13
$572.19
$644.28
$900.38
$1,368.21 		$889.79
$957.85
$1,029.94
$1,286.04 		$1,275.45
$1,343.51
$1,415.60
$1,671.70 		$1,661.11
$1,729.17
$1,801.26
$2,057.36 		$385.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,008.26
$1,144.38
$1,288.56
$1,800.76
$2,736.42 		$1,393.92
$1,530.04
$1,674.22
$2,186.42 		$1,779.58
$1,915.70
$2,059.88
$2,572.08 		$2,165.24
$2,301.36
$2,445.54
$2,957.74 		$385.66
Toc - Plan #35 Cigna Healthcare
Gold

(HMO) Cigna Simple Choice 2000

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$702.82
$797.70
$898.20
$1,255.23
$1,907.44 		$1,240.47
$1,335.35
$1,435.85
$1,792.88 		$1,778.12
$1,873.00
$1,973.50
$2,330.53 		$2,315.77
$2,410.65
$2,511.15
$2,868.18 		$537.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,405.64
$1,595.40
$1,796.40
$2,510.46
$3,814.88 		$1,943.29
$2,133.05
$2,334.05
$3,048.11 		$2,480.94
$2,670.70
$2,871.70
$3,585.76 		$3,018.59
$3,208.35
$3,409.35
$4,123.41 		$537.65
Toc - Plan #36 Cigna Healthcare
Expanded Bronze

(HMO) Cigna Connect 6800 Enhanced Diabetes Care

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

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$427.76
$485.50
$546.67
$763.97
$1,160.93 		$754.99
$812.73
$873.90
$1,091.20 		$1,082.22
$1,139.96
$1,201.13
$1,418.43 		$1,409.45
$1,467.19
$1,528.36
$1,745.66 		$327.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$855.52
$971.00
$1,093.34
$1,527.94
$2,321.86 		$1,182.75
$1,298.23
$1,420.57
$1,855.17 		$1,509.98
$1,625.46
$1,747.80
$2,182.40 		$1,837.21
$1,952.69
$2,075.03
$2,509.63 		$327.23

ADVERTISEMENT

Ambetter of North Carolina

Local: 1-833-863-1310 | Toll Free: 1-833-863-1310 | TTY: 1-833-863-1310
Toc - Plan #37 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$328.64
$372.99
$419.98
$586.93
$891.89 		$580.04
$624.39
$671.38
$838.33 		$831.44
$875.79
$922.78
$1,089.73 		$1,082.84
$1,127.19
$1,174.18
$1,341.13 		$251.40
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$657.28
$745.98
$839.96
$1,173.86
$1,783.78 		$908.68
$997.38
$1,091.36
$1,425.26 		$1,160.08
$1,248.78
$1,342.76
$1,676.66 		$1,411.48
$1,500.18
$1,594.16
$1,928.06 		$251.40
Toc - Plan #38 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$361.39
$410.17
$461.85
$645.43
$980.79 		$637.85
$686.63
$738.31
$921.89 		$914.31
$963.09
$1,014.77
$1,198.35 		$1,190.77
$1,239.55
$1,291.23
$1,474.81 		$276.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$722.78
$820.34
$923.70
$1,290.86
$1,961.58 		$999.24
$1,096.80
$1,200.16
$1,567.32 		$1,275.70
$1,373.26
$1,476.62
$1,843.78 		$1,552.16
$1,649.72
$1,753.08
$2,120.24 		$276.46
Toc - Plan #39 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 		$445.67
$505.82
$569.55
$795.94
$1,209.51 		$786.60
$846.75
$910.48
$1,136.87 		$1,127.53
$1,187.68
$1,251.41
$1,477.80 		$1,468.46
$1,528.61
$1,592.34
$1,818.73 		$340.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$891.34
$1,011.64
$1,139.10
$1,591.88
$2,419.02 		$1,232.27
$1,352.57
$1,480.03
$1,932.81 		$1,573.20
$1,693.50
$1,820.96
$2,273.74 		$1,914.13
$2,034.43
$2,161.89
$2,614.67 		$340.93
Toc - Plan #40 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 		$464.92
$527.67
$594.15
$830.33
$1,261.76 		$820.57
$883.32
$949.80
$1,185.98 		$1,176.22
$1,238.97
$1,305.45
$1,541.63 		$1,531.87
$1,594.62
$1,661.10
$1,897.28 		$355.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$929.84
$1,055.34
$1,188.30
$1,660.66
$2,523.52 		$1,285.49
$1,410.99
$1,543.95
$2,016.31 		$1,641.14
$1,766.64
$1,899.60
$2,371.96 		$1,996.79
$2,122.29
$2,255.25
$2,727.61 		$355.65
Toc - Plan #41 Ambetter of North Carolina
Silver

(HMO) Everyday Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.52
$501.12
$564.25
$788.54
$1,198.26 		$779.28
$838.88
$902.01
$1,126.30 		$1,117.04
$1,176.64
$1,239.77
$1,464.06 		$1,454.80
$1,514.40
$1,577.53
$1,801.82 		$337.76
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$883.04
$1,002.24
$1,128.50
$1,577.08
$2,396.52 		$1,220.80
$1,340.00
$1,466.26
$1,914.84 		$1,558.56
$1,677.76
$1,804.02
$2,252.60 		$1,896.32
$2,015.52
$2,141.78
$2,590.36 		$337.76
Toc - Plan #42 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze

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

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$350.65
$397.98
$448.12
$626.25
$951.64 		$618.89
$666.22
$716.36
$894.49 		$887.13
$934.46
$984.60
$1,162.73 		$1,155.37
$1,202.70
$1,252.84
$1,430.97 		$268.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$701.30
$795.96
$896.24
$1,252.50
$1,903.28 		$969.54
$1,064.20
$1,164.48
$1,520.74 		$1,237.78
$1,332.44
$1,432.72
$1,788.98 		$1,506.02
$1,600.68
$1,700.96
$2,057.22 		$268.24
Toc - Plan #43 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.59
$447.85
$504.28
$704.73
$1,070.90 		$696.45
$749.71
$806.14
$1,006.59 		$998.31
$1,051.57
$1,108.00
$1,308.45 		$1,300.17
$1,353.43
$1,409.86
$1,610.31 		$301.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$789.18
$895.70
$1,008.56
$1,409.46
$2,141.80 		$1,091.04
$1,197.56
$1,310.42
$1,711.32 		$1,392.90
$1,499.42
$1,612.28
$2,013.18 		$1,694.76
$1,801.28
$1,914.14
$2,315.04 		$301.86
Toc - Plan #44 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 		$440.36
$499.80
$562.77
$786.47
$1,195.12 		$777.23
$836.67
$899.64
$1,123.34 		$1,114.10
$1,173.54
$1,236.51
$1,460.21 		$1,450.97
$1,510.41
$1,573.38
$1,797.08 		$336.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$880.72
$999.60
$1,125.54
$1,572.94
$2,390.24 		$1,217.59
$1,336.47
$1,462.41
$1,909.81 		$1,554.46
$1,673.34
$1,799.28
$2,246.68 		$1,891.33
$2,010.21
$2,136.15
$2,583.55 		$336.87
Toc - Plan #45 Ambetter of North Carolina
Silver

(HMO) Focused Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$440.54
$500.00
$563.00
$786.79
$1,195.60 		$777.55
$837.01
$900.01
$1,123.80 		$1,114.56
$1,174.02
$1,237.02
$1,460.81 		$1,451.57
$1,511.03
$1,574.03
$1,797.82 		$337.01
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$881.08
$1,000.00
$1,126.00
$1,573.58
$2,391.20 		$1,218.09
$1,337.01
$1,463.01
$1,910.59 		$1,555.10
$1,674.02
$1,800.02
$2,247.60 		$1,892.11
$2,011.03
$2,137.03
$2,584.61 		$337.01
Toc - Plan #46 Ambetter of North Carolina
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$343.83
$390.24
$439.41
$614.07
$933.14 		$606.85
$653.26
$702.43
$877.09 		$869.87
$916.28
$965.45
$1,140.11 		$1,132.89
$1,179.30
$1,228.47
$1,403.13 		$263.02
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$687.66
$780.48
$878.82
$1,228.14
$1,866.28 		$950.68
$1,043.50
$1,141.84
$1,491.16 		$1,213.70
$1,306.52
$1,404.86
$1,754.18 		$1,476.72
$1,569.54
$1,667.88
$2,017.20 		$263.02
Toc - Plan #47 Ambetter of North Carolina
Silver

(HMO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$436.04
$494.89
$557.25
$778.75
$1,183.38 		$769.60
$828.45
$890.81
$1,112.31 		$1,103.16
$1,162.01
$1,224.37
$1,445.87 		$1,436.72
$1,495.57
$1,557.93
$1,779.43 		$333.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$872.08
$989.78
$1,114.50
$1,557.50
$2,366.76 		$1,205.64
$1,323.34
$1,448.06
$1,891.06 		$1,539.20
$1,656.90
$1,781.62
$2,224.62 		$1,872.76
$1,990.46
$2,115.18
$2,558.18 		$333.56
Toc - Plan #48 Ambetter of North Carolina
Gold

(HMO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$441.25
$500.81
$563.91
$788.06
$1,197.54 		$778.80
$838.36
$901.46
$1,125.61 		$1,116.35
$1,175.91
$1,239.01
$1,463.16 		$1,453.90
$1,513.46
$1,576.56
$1,800.71 		$337.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$882.50
$1,001.62
$1,127.82
$1,576.12
$2,395.08 		$1,220.05
$1,339.17
$1,465.37
$1,913.67 		$1,557.60
$1,676.72
$1,802.92
$2,251.22 		$1,895.15
$2,014.27
$2,140.47
$2,588.77 		$337.55
Toc - Plan #49 Ambetter of North Carolina
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$342.48
$388.70
$437.67
$611.65
$929.46 		$604.47
$650.69
$699.66
$873.64 		$866.46
$912.68
$961.65
$1,135.63 		$1,128.45
$1,174.67
$1,223.64
$1,397.62 		$261.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.96
$777.40
$875.34
$1,223.30
$1,858.92 		$946.95
$1,039.39
$1,137.33
$1,485.29 		$1,208.94
$1,301.38
$1,399.32
$1,747.28 		$1,470.93
$1,563.37
$1,661.31
$2,009.27 		$261.99
Toc - Plan #50 Ambetter of North Carolina
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$376.61
$427.45
$481.30
$672.61
$1,022.10 		$664.71
$715.55
$769.40
$960.71 		$952.81
$1,003.65
$1,057.50
$1,248.81 		$1,240.91
$1,291.75
$1,345.60
$1,536.91 		$288.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$753.22
$854.90
$962.60
$1,345.22
$2,044.20 		$1,041.32
$1,143.00
$1,250.70
$1,633.32 		$1,329.42
$1,431.10
$1,538.80
$1,921.42 		$1,617.52
$1,719.20
$1,826.90
$2,209.52 		$288.10
Toc - Plan #51 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 		$464.44
$527.12
$593.54
$829.47
$1,260.45 		$819.73
$882.41
$948.83
$1,184.76 		$1,175.02
$1,237.70
$1,304.12
$1,540.05 		$1,530.31
$1,592.99
$1,659.41
$1,895.34 		$355.29
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$928.88
$1,054.24
$1,187.08
$1,658.94
$2,520.90 		$1,284.17
$1,409.53
$1,542.37
$2,014.23 		$1,639.46
$1,764.82
$1,897.66
$2,369.52 		$1,994.75
$2,120.11
$2,252.95
$2,724.81 		$355.29
Toc - Plan #52 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 		$484.50
$549.90
$619.18
$865.30
$1,314.91 		$855.13
$920.53
$989.81
$1,235.93 		$1,225.76
$1,291.16
$1,360.44
$1,606.56 		$1,596.39
$1,661.79
$1,731.07
$1,977.19 		$370.63
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$969.00
$1,099.80
$1,238.36
$1,730.60
$2,629.82 		$1,339.63
$1,470.43
$1,608.99
$2,101.23 		$1,710.26
$1,841.06
$1,979.62
$2,471.86 		$2,080.89
$2,211.69
$2,350.25
$2,842.49 		$370.63
Toc - Plan #53 Ambetter of North Carolina
Silver

(HMO) Everyday Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.12
$522.22
$588.02
$821.75
$1,248.73 		$812.10
$874.20
$940.00
$1,173.73 		$1,164.08
$1,226.18
$1,291.98
$1,525.71 		$1,516.06
$1,578.16
$1,643.96
$1,877.69 		$351.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$920.24
$1,044.44
$1,176.04
$1,643.50
$2,497.46 		$1,272.22
$1,396.42
$1,528.02
$1,995.48 		$1,624.20
$1,748.40
$1,880.00
$2,347.46 		$1,976.18
$2,100.38
$2,231.98
$2,699.44 		$351.98
Toc - Plan #54 Ambetter of North Carolina
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$365.42
$414.74
$467.00
$652.62
$991.73 		$644.96
$694.28
$746.54
$932.16 		$924.50
$973.82
$1,026.08
$1,211.70 		$1,204.04
$1,253.36
$1,305.62
$1,491.24 		$279.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$730.84
$829.48
$934.00
$1,305.24
$1,983.46 		$1,010.38
$1,109.02
$1,213.54
$1,584.78 		$1,289.92
$1,388.56
$1,493.08
$1,864.32 		$1,569.46
$1,668.10
$1,772.62
$2,143.86 		$279.54
Toc - Plan #55 Ambetter of North Carolina
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.21
$466.72
$525.52
$734.41
$1,116.01 		$725.78
$781.29
$840.09
$1,048.98 		$1,040.35
$1,095.86
$1,154.66
$1,363.55 		$1,354.92
$1,410.43
$1,469.23
$1,678.12 		$314.57
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.42
$933.44
$1,051.04
$1,468.82
$2,232.02 		$1,136.99
$1,248.01
$1,365.61
$1,783.39 		$1,451.56
$1,562.58
$1,680.18
$2,097.96 		$1,766.13
$1,877.15
$1,994.75
$2,412.53 		$314.57
Toc - Plan #56 Ambetter of North Carolina
Silver

(HMO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$459.10
$521.06
$586.71
$819.93
$1,245.96 		$810.30
$872.26
$937.91
$1,171.13 		$1,161.50
$1,223.46
$1,289.11
$1,522.33 		$1,512.70
$1,574.66
$1,640.31
$1,873.53 		$351.20
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$918.20
$1,042.12
$1,173.42
$1,639.86
$2,491.92 		$1,269.40
$1,393.32
$1,524.62
$1,991.06 		$1,620.60
$1,744.52
$1,875.82
$2,342.26 		$1,971.80
$2,095.72
$2,227.02
$2,693.46 		$351.20
Toc - Plan #57 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 		$458.91
$520.85
$586.47
$819.60
$1,245.46 		$809.97
$871.91
$937.53
$1,170.66 		$1,161.03
$1,222.97
$1,288.59
$1,521.72 		$1,512.09
$1,574.03
$1,639.65
$1,872.78 		$351.06
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$917.82
$1,041.70
$1,172.94
$1,639.20
$2,490.92 		$1,268.88
$1,392.76
$1,524.00
$1,990.26 		$1,619.94
$1,743.82
$1,875.06
$2,341.32 		$1,971.00
$2,094.88
$2,226.12
$2,692.38 		$351.06
Toc - Plan #58 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 		$342.41
$388.62
$437.58
$611.52
$929.27 		$604.34
$650.55
$699.51
$873.45 		$866.27
$912.48
$961.44
$1,135.38 		$1,128.20
$1,174.41
$1,223.37
$1,397.31 		$261.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$684.82
$777.24
$875.16
$1,223.04
$1,858.54 		$946.75
$1,039.17
$1,137.09
$1,484.97 		$1,208.68
$1,301.10
$1,399.02
$1,746.90 		$1,470.61
$1,563.03
$1,660.95
$2,008.83 		$261.93
Toc - Plan #59 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 		$430.91
$489.08
$550.70
$769.60
$1,169.48 		$760.55
$818.72
$880.34
$1,099.24 		$1,090.19
$1,148.36
$1,209.98
$1,428.88 		$1,419.83
$1,478.00
$1,539.62
$1,758.52 		$329.64
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$861.82
$978.16
$1,101.40
$1,539.20
$2,338.96 		$1,191.46
$1,307.80
$1,431.04
$1,868.84 		$1,521.10
$1,637.44
$1,760.68
$2,198.48 		$1,850.74
$1,967.08
$2,090.32
$2,528.12 		$329.64
Toc - Plan #60 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 		$451.73
$512.70
$577.29
$806.77
$1,225.96 		$797.29
$858.26
$922.85
$1,152.33 		$1,142.85
$1,203.82
$1,268.41
$1,497.89 		$1,488.41
$1,549.38
$1,613.97
$1,843.45 		$345.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$903.46
$1,025.40
$1,154.58
$1,613.54
$2,451.92 		$1,249.02
$1,370.96
$1,500.14
$1,959.10 		$1,594.58
$1,716.52
$1,845.70
$2,304.66 		$1,940.14
$2,062.08
$2,191.26
$2,650.22 		$345.56

‡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 Montgomery County here.

Montgomery County is in “Rating Area 8” of North Carolina.

Currently, there are 60 plans offered in Rating Area 8.

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2023 Obamacare Plans for Montgomery County, NC

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