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Obamacare 2023 Rates for Fulton County

Obamacare > Rates > Ohio > Fulton 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 Fulton County, OH.

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, 103 Plans and 2023 Rates for Fulton County, Ohio

Below, you’ll find a summary of the 103 plans for Fulton County, Ohio 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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Anthem Blue Cross and Blue Shield

Local: 1-855-748-1808 | Toll Free: 1-855-748-1808

Toc - Plan #1 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$339.15
$384.94
$433.43
$605.72
$920.45
$598.60
$644.39
$692.88
$865.17
$858.05
$903.84
$952.33
$1,124.62
$1,117.50
$1,163.29
$1,211.78
$1,384.07
$259.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$678.30
$769.88
$866.86
$1,211.44
$1,840.90
$937.75
$1,029.33
$1,126.31
$1,470.89
$1,197.20
$1,288.78
$1,385.76
$1,730.34
$1,456.65
$1,548.23
$1,645.21
$1,989.79
$259.45
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 9100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$320.33
$363.57
$409.38
$572.11
$869.38
$565.38
$608.62
$654.43
$817.16
$810.43
$853.67
$899.48
$1,062.21
$1,055.48
$1,098.72
$1,144.53
$1,307.26
$245.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.66
$727.14
$818.76
$1,144.22
$1,738.76
$885.71
$972.19
$1,063.81
$1,389.27
$1,130.76
$1,217.24
$1,308.86
$1,634.32
$1,375.81
$1,462.29
$1,553.91
$1,879.37
$245.05
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 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
$427.30
$484.99
$546.09
$763.16
$1,159.69
$754.18
$811.87
$872.97
$1,090.04
$1,081.06
$1,138.75
$1,199.85
$1,416.92
$1,407.94
$1,465.63
$1,526.73
$1,743.80
$326.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$854.60
$969.98
$1,092.18
$1,526.32
$2,319.38
$1,181.48
$1,296.86
$1,419.06
$1,853.20
$1,508.36
$1,623.74
$1,745.94
$2,180.08
$1,835.24
$1,950.62
$2,072.82
$2,506.96
$326.88
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 7450/0% for HSA (+ Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 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
$344.07
$390.52
$439.72
$614.51
$933.81
$607.28
$653.73
$702.93
$877.72
$870.49
$916.94
$966.14
$1,140.93
$1,133.70
$1,180.15
$1,229.35
$1,404.14
$263.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.14
$781.04
$879.44
$1,229.02
$1,867.62
$951.35
$1,044.25
$1,142.65
$1,492.23
$1,214.56
$1,307.46
$1,405.86
$1,755.44
$1,477.77
$1,570.67
$1,669.07
$2,018.65
$263.21
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3200/10% for HSA (+ Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,200 $6,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.98
$488.03
$549.51
$767.94
$1,166.97
$758.91
$816.96
$878.44
$1,096.87
$1,087.84
$1,145.89
$1,207.37
$1,425.80
$1,416.77
$1,474.82
$1,536.30
$1,754.73
$328.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.96
$976.06
$1,099.02
$1,535.88
$2,333.94
$1,188.89
$1,304.99
$1,427.95
$1,864.81
$1,517.82
$1,633.92
$1,756.88
$2,193.74
$1,846.75
$1,962.85
$2,085.81
$2,522.67
$328.93
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000/20% for HSA (+ Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$348.58
$395.64
$445.49
$622.56
$946.05
$615.24
$662.30
$712.15
$889.22
$881.90
$928.96
$978.81
$1,155.88
$1,148.56
$1,195.62
$1,245.47
$1,422.54
$266.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$697.16
$791.28
$890.98
$1,245.12
$1,892.10
$963.82
$1,057.94
$1,157.64
$1,511.78
$1,230.48
$1,324.60
$1,424.30
$1,778.44
$1,497.14
$1,591.26
$1,690.96
$2,045.10
$266.66
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5400/0% for HSA ( + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$437.48
$496.54
$559.10
$781.34
$1,187.32
$772.15
$831.21
$893.77
$1,116.01
$1,106.82
$1,165.88
$1,228.44
$1,450.68
$1,441.49
$1,500.55
$1,563.11
$1,785.35
$334.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.96
$993.08
$1,118.20
$1,562.68
$2,374.64
$1,209.63
$1,327.75
$1,452.87
$1,897.35
$1,544.30
$1,662.42
$1,787.54
$2,232.02
$1,878.97
$1,997.09
$2,122.21
$2,566.69
$334.67
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 3000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$437.71
$496.80
$559.39
$781.75
$1,187.94
$772.56
$831.65
$894.24
$1,116.60
$1,107.41
$1,166.50
$1,229.09
$1,451.45
$1,442.26
$1,501.35
$1,563.94
$1,786.30
$334.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$875.42
$993.60
$1,118.78
$1,563.50
$2,375.88
$1,210.27
$1,328.45
$1,453.63
$1,898.35
$1,545.12
$1,663.30
$1,788.48
$2,233.20
$1,879.97
$1,998.15
$2,123.33
$2,568.05
$334.85
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,950 $15,900 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
$421.50
$478.40
$538.68
$752.80
$1,143.95
$743.95
$800.85
$861.13
$1,075.25
$1,066.40
$1,123.30
$1,183.58
$1,397.70
$1,388.85
$1,445.75
$1,506.03
$1,720.15
$322.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$843.00
$956.80
$1,077.36
$1,505.60
$2,287.90
$1,165.45
$1,279.25
$1,399.81
$1,828.05
$1,487.90
$1,601.70
$1,722.26
$2,150.50
$1,810.35
$1,924.15
$2,044.71
$2,472.95
$322.45
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway X HMO 9100 ( + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$253.50
$287.72
$323.97
$452.75
$688.00
$447.43
$481.65
$517.90
$646.68
$641.36
$675.58
$711.83
$840.61
$835.29
$869.51
$905.76
$1,034.54
$193.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$507.00
$575.44
$647.94
$905.50
$1,376.00
$700.93
$769.37
$841.87
$1,099.43
$894.86
$963.30
$1,035.80
$1,293.36
$1,088.79
$1,157.23
$1,229.73
$1,487.29
$193.93
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 6000/25% ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,800 $15,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$424.23
$481.50
$542.17
$757.67
$1,151.36
$748.77
$806.04
$866.71
$1,082.21
$1,073.31
$1,130.58
$1,191.25
$1,406.75
$1,397.85
$1,455.12
$1,515.79
$1,731.29
$324.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.46
$963.00
$1,084.34
$1,515.34
$2,302.72
$1,173.00
$1,287.54
$1,408.88
$1,839.88
$1,497.54
$1,612.08
$1,733.42
$2,164.42
$1,822.08
$1,936.62
$2,057.96
$2,488.96
$324.54
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$343.73
$390.13
$439.29
$613.90
$932.88
$606.68
$653.08
$702.24
$876.85
$869.63
$916.03
$965.19
$1,139.80
$1,132.58
$1,178.98
$1,228.14
$1,402.75
$262.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.46
$780.26
$878.58
$1,227.80
$1,865.76
$950.41
$1,043.21
$1,141.53
$1,490.75
$1,213.36
$1,306.16
$1,404.48
$1,753.70
$1,476.31
$1,569.11
$1,667.43
$2,016.65
$262.95
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 6000 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 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
$326.61
$370.70
$417.41
$583.33
$886.42
$576.47
$620.56
$667.27
$833.19
$826.33
$870.42
$917.13
$1,083.05
$1,076.19
$1,120.28
$1,166.99
$1,332.91
$249.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$653.22
$741.40
$834.82
$1,166.66
$1,772.84
$903.08
$991.26
$1,084.68
$1,416.52
$1,152.94
$1,241.12
$1,334.54
$1,666.38
$1,402.80
$1,490.98
$1,584.40
$1,916.24
$249.86
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway X HMO 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$321.05
$364.39
$410.30
$573.40
$871.33
$566.65
$609.99
$655.90
$819.00
$812.25
$855.59
$901.50
$1,064.60
$1,057.85
$1,101.19
$1,147.10
$1,310.20
$245.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$642.10
$728.78
$820.60
$1,146.80
$1,742.66
$887.70
$974.38
$1,066.20
$1,392.40
$1,133.30
$1,219.98
$1,311.80
$1,638.00
$1,378.90
$1,465.58
$1,557.40
$1,883.60
$245.60
Toc - Plan #15 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway X HMO 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$351.49
$398.94
$449.20
$627.76
$953.94
$620.38
$667.83
$718.09
$896.65
$889.27
$936.72
$986.98
$1,165.54
$1,158.16
$1,205.61
$1,255.87
$1,434.43
$268.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.98
$797.88
$898.40
$1,255.52
$1,907.88
$971.87
$1,066.77
$1,167.29
$1,524.41
$1,240.76
$1,335.66
$1,436.18
$1,793.30
$1,509.65
$1,604.55
$1,705.07
$2,062.19
$268.89
Toc - Plan #16 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway X HMO 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$419.15
$475.74
$535.67
$748.60
$1,137.57
$739.80
$796.39
$856.32
$1,069.25
$1,060.45
$1,117.04
$1,176.97
$1,389.90
$1,381.10
$1,437.69
$1,497.62
$1,710.55
$320.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$838.30
$951.48
$1,071.34
$1,497.20
$2,275.14
$1,158.95
$1,272.13
$1,391.99
$1,817.85
$1,479.60
$1,592.78
$1,712.64
$2,138.50
$1,800.25
$1,913.43
$2,033.29
$2,459.15
$320.65
Toc - Plan #17 Anthem Blue Cross and Blue Shield
Gold

(HMO) Anthem Gold Pathway X HMO 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-748-1808

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
$608.44
$690.58
$777.59
$1,086.67
$1,651.31
$1,073.90
$1,156.04
$1,243.05
$1,552.13
$1,539.36
$1,621.50
$1,708.51
$2,017.59
$2,004.82
$2,086.96
$2,173.97
$2,483.05
$465.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,216.88
$1,381.16
$1,555.18
$2,173.34
$3,302.62
$1,682.34
$1,846.62
$2,020.64
$2,638.80
$2,147.80
$2,312.08
$2,486.10
$3,104.26
$2,613.26
$2,777.54
$2,951.56
$3,569.72
$465.46

ADVERTISEMENT

UnitedHealthcare

Local: 1-877-760-3310 | Toll Free: 1-877-760-3310 | TTY: 1-800-331-4680

Toc - Plan #18 UnitedHealthcare
Gold

(HMO) UHC Gold Value (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$2,150 $4,300 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
$429.70
$487.71
$549.16
$767.45
$1,166.21
$758.42
$816.43
$877.88
$1,096.17
$1,087.14
$1,145.15
$1,206.60
$1,424.89
$1,415.86
$1,473.87
$1,535.32
$1,753.61
$328.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.40
$975.42
$1,098.32
$1,534.90
$2,332.42
$1,188.12
$1,304.14
$1,427.04
$1,863.62
$1,516.84
$1,632.86
$1,755.76
$2,192.34
$1,845.56
$1,961.58
$2,084.48
$2,521.06
$328.72
Toc - Plan #19 UnitedHealthcare
Gold

(HMO) UHC Gold Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $1 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 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
$458.37
$520.25
$585.80
$818.66
$1,244.03
$809.03
$870.91
$936.46
$1,169.32
$1,159.69
$1,221.57
$1,287.12
$1,519.98
$1,510.35
$1,572.23
$1,637.78
$1,870.64
$350.66
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$916.74
$1,040.50
$1,171.60
$1,637.32
$2,488.06
$1,267.40
$1,391.16
$1,522.26
$1,987.98
$1,618.06
$1,741.82
$1,872.92
$2,338.64
$1,968.72
$2,092.48
$2,223.58
$2,689.30
$350.66
Toc - Plan #20 UnitedHealthcare
Gold

(HMO) UHC Gold Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$439.64
$499.00
$561.86
$785.20
$1,193.19
$775.97
$835.33
$898.19
$1,121.53
$1,112.30
$1,171.66
$1,234.52
$1,457.86
$1,448.63
$1,507.99
$1,570.85
$1,794.19
$336.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$879.28
$998.00
$1,123.72
$1,570.40
$2,386.38
$1,215.61
$1,334.33
$1,460.05
$1,906.73
$1,551.94
$1,670.66
$1,796.38
$2,243.06
$1,888.27
$2,006.99
$2,132.71
$2,579.39
$336.33
Toc - Plan #21 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,450 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$3,450 $6,900 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
$387.26
$439.55
$494.92
$691.65
$1,051.04
$683.52
$735.81
$791.18
$987.91
$979.78
$1,032.07
$1,087.44
$1,284.17
$1,276.04
$1,328.33
$1,383.70
$1,580.43
$296.26
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$774.52
$879.10
$989.84
$1,383.30
$2,102.08
$1,070.78
$1,175.36
$1,286.10
$1,679.56
$1,367.04
$1,471.62
$1,582.36
$1,975.82
$1,663.30
$1,767.88
$1,878.62
$2,272.08
$296.26
Toc - Plan #22 UnitedHealthcare
Silver

(HMO) UHC Silver Value $3,000 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$385.81
$437.90
$493.07
$689.06
$1,047.09
$680.96
$733.05
$788.22
$984.21
$976.11
$1,028.20
$1,083.37
$1,279.36
$1,271.26
$1,323.35
$1,378.52
$1,574.51
$295.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.62
$875.80
$986.14
$1,378.12
$2,094.18
$1,066.77
$1,170.95
$1,281.29
$1,673.27
$1,361.92
$1,466.10
$1,576.44
$1,968.42
$1,657.07
$1,761.25
$1,871.59
$2,263.57
$295.15
Toc - Plan #23 UnitedHealthcare
Silver

(HMO) UHC Silver Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$384.83
$436.78
$491.81
$687.30
$1,044.42
$679.22
$731.17
$786.20
$981.69
$973.61
$1,025.56
$1,080.59
$1,276.08
$1,268.00
$1,319.95
$1,374.98
$1,570.47
$294.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$769.66
$873.56
$983.62
$1,374.60
$2,088.84
$1,064.05
$1,167.95
$1,278.01
$1,668.99
$1,358.44
$1,462.34
$1,572.40
$1,963.38
$1,652.83
$1,756.73
$1,866.79
$2,257.77
$294.39
Toc - Plan #24 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage $0 Medical Ded ($0 Virtual Urgent Care + $0 PCP Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$393.27
$446.37
$502.60
$702.39
$1,067.34
$694.12
$747.22
$803.45
$1,003.24
$994.97
$1,048.07
$1,104.30
$1,304.09
$1,295.82
$1,348.92
$1,405.15
$1,604.94
$300.85
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.54
$892.74
$1,005.20
$1,404.78
$2,134.68
$1,087.39
$1,193.59
$1,306.05
$1,705.63
$1,388.24
$1,494.44
$1,606.90
$2,006.48
$1,689.09
$1,795.29
$1,907.75
$2,307.33
$300.85
Toc - Plan #25 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.25
$436.12
$491.07
$686.26
$1,042.84
$678.20
$730.07
$785.02
$980.21
$972.15
$1,024.02
$1,078.97
$1,274.16
$1,266.10
$1,317.97
$1,372.92
$1,568.11
$293.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.50
$872.24
$982.14
$1,372.52
$2,085.68
$1,062.45
$1,166.19
$1,276.09
$1,666.47
$1,356.40
$1,460.14
$1,570.04
$1,960.42
$1,650.35
$1,754.09
$1,863.99
$2,254.37
$293.95
Toc - Plan #26 UnitedHealthcare
Silver

(HMO) UHC Silver Advantage+ (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx, Dental + Vision)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.02
$457.43
$515.06
$719.80
$1,093.80
$711.33
$765.74
$823.37
$1,028.11
$1,019.64
$1,074.05
$1,131.68
$1,336.42
$1,327.95
$1,382.36
$1,439.99
$1,644.73
$308.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.04
$914.86
$1,030.12
$1,439.60
$2,187.60
$1,114.35
$1,223.17
$1,338.43
$1,747.91
$1,422.66
$1,531.48
$1,646.74
$2,056.22
$1,730.97
$1,839.79
$1,955.05
$2,364.53
$308.31
Toc - Plan #27 UnitedHealthcare
Silver

(HMO) UHC Silver Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$389.15
$441.68
$497.33
$695.02
$1,056.15
$686.85
$739.38
$795.03
$992.72
$984.55
$1,037.08
$1,092.73
$1,290.42
$1,282.25
$1,334.78
$1,390.43
$1,588.12
$297.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.30
$883.36
$994.66
$1,390.04
$2,112.30
$1,076.00
$1,181.06
$1,292.36
$1,687.74
$1,373.70
$1,478.76
$1,590.06
$1,985.44
$1,671.40
$1,776.46
$1,887.76
$2,283.14
$297.70
Toc - Plan #28 UnitedHealthcare
Bronze

(HMO) UHC Bronze Essential ($3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$330.16
$374.74
$421.95
$589.67
$896.07
$582.74
$627.32
$674.53
$842.25
$835.32
$879.90
$927.11
$1,094.83
$1,087.90
$1,132.48
$1,179.69
$1,347.41
$252.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$660.32
$749.48
$843.90
$1,179.34
$1,792.14
$912.90
$1,002.06
$1,096.48
$1,431.92
$1,165.48
$1,254.64
$1,349.06
$1,684.50
$1,418.06
$1,507.22
$1,601.64
$1,937.08
$252.58
Toc - Plan #29 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value HSA $6,700 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$6,700 $13,400 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.92
$389.21
$438.25
$612.45
$930.67
$605.25
$651.54
$700.58
$874.78
$867.58
$913.87
$962.91
$1,137.11
$1,129.91
$1,176.20
$1,225.24
$1,399.44
$262.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.84
$778.42
$876.50
$1,224.90
$1,861.34
$948.17
$1,040.75
$1,138.83
$1,487.23
$1,210.50
$1,303.08
$1,401.16
$1,749.56
$1,472.83
$1,565.41
$1,663.49
$2,011.89
$262.33
Toc - Plan #30 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Value $8,100 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$8,100 $16,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.90
$401.68
$452.29
$632.07
$960.49
$624.64
$672.42
$723.03
$902.81
$895.38
$943.16
$993.77
$1,173.55
$1,166.12
$1,213.90
$1,264.51
$1,444.29
$270.74
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.80
$803.36
$904.58
$1,264.14
$1,920.98
$978.54
$1,074.10
$1,175.32
$1,534.88
$1,249.28
$1,344.84
$1,446.06
$1,805.62
$1,520.02
$1,615.58
$1,716.80
$2,076.36
$270.74
Toc - Plan #31 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Virtual First (Unlimited $0 App-based Care, $3 T1 Preferred Rx) (Disponible en español)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

Annual Out of Pocket Expenses:

Individual Family
$7,250 $14,500 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
$342.74
$389.01
$438.03
$612.14
$930.21
$604.94
$651.21
$700.23
$874.34
$867.14
$913.41
$962.43
$1,136.54
$1,129.34
$1,175.61
$1,224.63
$1,398.74
$262.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.48
$778.02
$876.06
$1,224.28
$1,860.42
$947.68
$1,040.22
$1,138.26
$1,486.48
$1,209.88
$1,302.42
$1,400.46
$1,748.68
$1,472.08
$1,564.62
$1,662.66
$2,010.88
$262.20
Toc - Plan #32 UnitedHealthcare
Expanded Bronze

(HMO) UHC Bronze Standard $7,500 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$350.55
$397.87
$448.00
$626.08
$951.39
$618.72
$666.04
$716.17
$894.25
$886.89
$934.21
$984.34
$1,162.42
$1,155.06
$1,202.38
$1,252.51
$1,430.59
$268.17
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$701.10
$795.74
$896.00
$1,252.16
$1,902.78
$969.27
$1,063.91
$1,164.17
$1,520.33
$1,237.44
$1,332.08
$1,432.34
$1,788.50
$1,505.61
$1,600.25
$1,700.51
$2,056.67
$268.17
Toc - Plan #33 UnitedHealthcare
Bronze

(HMO) UHC Bronze Standard $9,100 Deductible

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-760-3310

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
$330.20
$374.78
$421.99
$589.73
$896.16
$582.80
$627.38
$674.59
$842.33
$835.40
$879.98
$927.19
$1,094.93
$1,088.00
$1,132.58
$1,179.79
$1,347.53
$252.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$660.40
$749.56
$843.98
$1,179.46
$1,792.32
$913.00
$1,002.16
$1,096.58
$1,432.06
$1,165.60
$1,254.76
$1,349.18
$1,684.66
$1,418.20
$1,507.36
$1,601.78
$1,937.26
$252.60

ADVERTISEMENT

Ambetter from Buckeye Health Plan

Local: 1-877-687-1189 | Toll Free: 1-877-687-1189 | TTY: 1-877-941-9236

Toc - Plan #34 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$401.90
$456.15
$513.62
$717.78
$1,090.74
$709.35
$763.60
$821.07
$1,025.23
$1,016.80
$1,071.05
$1,128.52
$1,332.68
$1,324.25
$1,378.50
$1,435.97
$1,640.13
$307.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$803.80
$912.30
$1,027.24
$1,435.56
$2,181.48
$1,111.25
$1,219.75
$1,334.69
$1,743.01
$1,418.70
$1,527.20
$1,642.14
$2,050.46
$1,726.15
$1,834.65
$1,949.59
$2,357.91
$307.45
Toc - Plan #35 Ambetter from Buckeye Health Plan
Silver

(HMO) Everyday Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$398.25
$452.00
$508.94
$711.25
$1,080.81
$702.90
$756.65
$813.59
$1,015.90
$1,007.55
$1,061.30
$1,118.24
$1,320.55
$1,312.20
$1,365.95
$1,422.89
$1,625.20
$304.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.50
$904.00
$1,017.88
$1,422.50
$2,161.62
$1,101.15
$1,208.65
$1,322.53
$1,727.15
$1,405.80
$1,513.30
$1,627.18
$2,031.80
$1,710.45
$1,817.95
$1,931.83
$2,336.45
$304.65
Toc - Plan #36 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$430.04
$488.08
$549.57
$768.02
$1,167.09
$759.01
$817.05
$878.54
$1,096.99
$1,087.98
$1,146.02
$1,207.51
$1,425.96
$1,416.95
$1,474.99
$1,536.48
$1,754.93
$328.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$860.08
$976.16
$1,099.14
$1,536.04
$2,334.18
$1,189.05
$1,305.13
$1,428.11
$1,865.01
$1,518.02
$1,634.10
$1,757.08
$2,193.98
$1,846.99
$1,963.07
$2,086.05
$2,522.95
$328.97
Toc - Plan #37 Ambetter from Buckeye Health Plan
Bronze

(HMO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$323.13
$366.74
$412.95
$577.10
$876.95
$570.32
$613.93
$660.14
$824.29
$817.51
$861.12
$907.33
$1,071.48
$1,064.70
$1,108.31
$1,154.52
$1,318.67
$247.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$646.26
$733.48
$825.90
$1,154.20
$1,753.90
$893.45
$980.67
$1,073.09
$1,401.39
$1,140.64
$1,227.86
$1,320.28
$1,648.58
$1,387.83
$1,475.05
$1,567.47
$1,895.77
$247.19
Toc - Plan #38 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$353.76
$401.50
$452.09
$631.79
$960.07
$624.38
$672.12
$722.71
$902.41
$895.00
$942.74
$993.33
$1,173.03
$1,165.62
$1,213.36
$1,263.95
$1,443.65
$270.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.52
$803.00
$904.18
$1,263.58
$1,920.14
$978.14
$1,073.62
$1,174.80
$1,534.20
$1,248.76
$1,344.24
$1,445.42
$1,804.82
$1,519.38
$1,614.86
$1,716.04
$2,075.44
$270.62
Toc - Plan #39 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$344.39
$390.87
$440.12
$615.07
$934.65
$607.84
$654.32
$703.57
$878.52
$871.29
$917.77
$967.02
$1,141.97
$1,134.74
$1,181.22
$1,230.47
$1,405.42
$263.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$688.78
$781.74
$880.24
$1,230.14
$1,869.30
$952.23
$1,045.19
$1,143.69
$1,493.59
$1,215.68
$1,308.64
$1,407.14
$1,757.04
$1,479.13
$1,572.09
$1,670.59
$2,020.49
$263.45
Toc - Plan #40 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$385.55
$437.58
$492.71
$688.57
$1,046.34
$680.48
$732.51
$787.64
$983.50
$975.41
$1,027.44
$1,082.57
$1,278.43
$1,270.34
$1,322.37
$1,377.50
$1,573.36
$294.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$771.10
$875.16
$985.42
$1,377.14
$2,092.68
$1,066.03
$1,170.09
$1,280.35
$1,672.07
$1,360.96
$1,465.02
$1,575.28
$1,967.00
$1,655.89
$1,759.95
$1,870.21
$2,261.93
$294.93
Toc - Plan #41 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$394.07
$447.25
$503.60
$703.78
$1,069.47
$695.52
$748.70
$805.05
$1,005.23
$996.97
$1,050.15
$1,106.50
$1,306.68
$1,298.42
$1,351.60
$1,407.95
$1,608.13
$301.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$788.14
$894.50
$1,007.20
$1,407.56
$2,138.94
$1,089.59
$1,195.95
$1,308.65
$1,709.01
$1,391.04
$1,497.40
$1,610.10
$2,010.46
$1,692.49
$1,798.85
$1,911.55
$2,311.91
$301.45
Toc - Plan #42 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$396.92
$450.49
$507.25
$708.88
$1,077.21
$700.56
$754.13
$810.89
$1,012.52
$1,004.20
$1,057.77
$1,114.53
$1,316.16
$1,307.84
$1,361.41
$1,418.17
$1,619.80
$303.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$793.84
$900.98
$1,014.50
$1,417.76
$2,154.42
$1,097.48
$1,204.62
$1,318.14
$1,721.40
$1,401.12
$1,508.26
$1,621.78
$2,025.04
$1,704.76
$1,811.90
$1,925.42
$2,328.68
$303.64
Toc - Plan #43 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$412.83
$468.56
$527.59
$737.30
$1,120.40
$728.64
$784.37
$843.40
$1,053.11
$1,044.45
$1,100.18
$1,159.21
$1,368.92
$1,360.26
$1,415.99
$1,475.02
$1,684.73
$315.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$825.66
$937.12
$1,055.18
$1,474.60
$2,240.80
$1,141.47
$1,252.93
$1,370.99
$1,790.41
$1,457.28
$1,568.74
$1,686.80
$2,106.22
$1,773.09
$1,884.55
$2,002.61
$2,422.03
$315.81
Toc - Plan #44 Ambetter from Buckeye Health Plan
Silver

(HMO) Enhanced Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 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
$395.99
$449.44
$506.07
$707.23
$1,074.70
$698.92
$752.37
$809.00
$1,010.16
$1,001.85
$1,055.30
$1,111.93
$1,313.09
$1,304.78
$1,358.23
$1,414.86
$1,616.02
$302.93
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.98
$898.88
$1,012.14
$1,414.46
$2,149.40
$1,094.91
$1,201.81
$1,315.07
$1,717.39
$1,397.84
$1,504.74
$1,618.00
$2,020.32
$1,700.77
$1,807.67
$1,920.93
$2,323.25
$302.93
Toc - Plan #45 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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
$407.49
$462.49
$520.76
$727.76
$1,105.90
$719.21
$774.21
$832.48
$1,039.48
$1,030.93
$1,085.93
$1,144.20
$1,351.20
$1,342.65
$1,397.65
$1,455.92
$1,662.92
$311.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.98
$924.98
$1,041.52
$1,455.52
$2,211.80
$1,126.70
$1,236.70
$1,353.24
$1,767.24
$1,438.42
$1,548.42
$1,664.96
$2,078.96
$1,750.14
$1,860.14
$1,976.68
$2,390.68
$311.72
Toc - Plan #46 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$337.76
$383.35
$431.65
$603.22
$916.65
$596.14
$641.73
$690.03
$861.60
$854.52
$900.11
$948.41
$1,119.98
$1,112.90
$1,158.49
$1,206.79
$1,378.36
$258.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$675.52
$766.70
$863.30
$1,206.44
$1,833.30
$933.90
$1,025.08
$1,121.68
$1,464.82
$1,192.28
$1,283.46
$1,380.06
$1,723.20
$1,450.66
$1,541.84
$1,638.44
$1,981.58
$258.38
Toc - Plan #47 Ambetter from Buckeye Health Plan
Silver

(HMO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$393.50
$446.61
$502.88
$702.78
$1,067.94
$694.52
$747.63
$803.90
$1,003.80
$995.54
$1,048.65
$1,104.92
$1,304.82
$1,296.56
$1,349.67
$1,405.94
$1,605.84
$301.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.00
$893.22
$1,005.76
$1,405.56
$2,135.88
$1,088.02
$1,194.24
$1,306.78
$1,706.58
$1,389.04
$1,495.26
$1,607.80
$2,007.60
$1,690.06
$1,796.28
$1,908.82
$2,308.62
$301.02
Toc - Plan #48 Ambetter from Buckeye Health Plan
Gold

(HMO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$409.98
$465.32
$523.94
$732.21
$1,112.66
$723.61
$778.95
$837.57
$1,045.84
$1,037.24
$1,092.58
$1,151.20
$1,359.47
$1,350.87
$1,406.21
$1,464.83
$1,673.10
$313.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$819.96
$930.64
$1,047.88
$1,464.42
$2,225.32
$1,133.59
$1,244.27
$1,361.51
$1,778.05
$1,447.22
$1,557.90
$1,675.14
$2,091.68
$1,760.85
$1,871.53
$1,988.77
$2,405.31
$313.63
Toc - Plan #49 Ambetter from Buckeye Health Plan
Silver

(HMO) Everyday Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$411.45
$466.98
$525.82
$734.83
$1,116.64
$726.20
$781.73
$840.57
$1,049.58
$1,040.95
$1,096.48
$1,155.32
$1,364.33
$1,355.70
$1,411.23
$1,470.07
$1,679.08
$314.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$822.90
$933.96
$1,051.64
$1,469.66
$2,233.28
$1,137.65
$1,248.71
$1,366.39
$1,784.41
$1,452.40
$1,563.46
$1,681.14
$2,099.16
$1,767.15
$1,878.21
$1,995.89
$2,413.91
$314.75
Toc - Plan #50 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$415.22
$471.27
$530.64
$741.57
$1,126.89
$732.86
$788.91
$848.28
$1,059.21
$1,050.50
$1,106.55
$1,165.92
$1,376.85
$1,368.14
$1,424.19
$1,483.56
$1,694.49
$317.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.44
$942.54
$1,061.28
$1,483.14
$2,253.78
$1,148.08
$1,260.18
$1,378.92
$1,800.78
$1,465.72
$1,577.82
$1,696.56
$2,118.42
$1,783.36
$1,895.46
$2,014.20
$2,436.06
$317.64
Toc - Plan #51 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$444.29
$504.26
$567.79
$793.48
$1,205.78
$784.16
$844.13
$907.66
$1,133.35
$1,124.03
$1,184.00
$1,247.53
$1,473.22
$1,463.90
$1,523.87
$1,587.40
$1,813.09
$339.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$888.58
$1,008.52
$1,135.58
$1,586.96
$2,411.56
$1,228.45
$1,348.39
$1,475.45
$1,926.83
$1,568.32
$1,688.26
$1,815.32
$2,266.70
$1,908.19
$2,028.13
$2,155.19
$2,606.57
$339.87
Toc - Plan #52 Ambetter from Buckeye Health Plan
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$333.84
$378.90
$426.64
$596.23
$906.02
$589.22
$634.28
$682.02
$851.61
$844.60
$889.66
$937.40
$1,106.99
$1,099.98
$1,145.04
$1,192.78
$1,362.37
$255.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667.68
$757.80
$853.28
$1,192.46
$1,812.04
$923.06
$1,013.18
$1,108.66
$1,447.84
$1,178.44
$1,268.56
$1,364.04
$1,703.22
$1,433.82
$1,523.94
$1,619.42
$1,958.60
$255.38
Toc - Plan #53 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$365.48
$414.81
$467.07
$652.73
$991.89
$645.07
$694.40
$746.66
$932.32
$924.66
$973.99
$1,026.25
$1,211.91
$1,204.25
$1,253.58
$1,305.84
$1,491.50
$279.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$730.96
$829.62
$934.14
$1,305.46
$1,983.78
$1,010.55
$1,109.21
$1,213.73
$1,585.05
$1,290.14
$1,388.80
$1,493.32
$1,864.64
$1,569.73
$1,668.39
$1,772.91
$2,144.23
$279.59
Toc - Plan #54 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$355.81
$403.83
$454.71
$635.45
$965.64
$628.00
$676.02
$726.90
$907.64
$900.19
$948.21
$999.09
$1,179.83
$1,172.38
$1,220.40
$1,271.28
$1,452.02
$272.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$711.62
$807.66
$909.42
$1,270.90
$1,931.28
$983.81
$1,079.85
$1,181.61
$1,543.09
$1,256.00
$1,352.04
$1,453.80
$1,815.28
$1,528.19
$1,624.23
$1,725.99
$2,087.47
$272.19
Toc - Plan #55 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$398.33
$452.09
$509.05
$711.39
$1,081.03
$703.04
$756.80
$813.76
$1,016.10
$1,007.75
$1,061.51
$1,118.47
$1,320.81
$1,312.46
$1,366.22
$1,423.18
$1,625.52
$304.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.66
$904.18
$1,018.10
$1,422.78
$2,162.06
$1,101.37
$1,208.89
$1,322.81
$1,727.49
$1,406.08
$1,513.60
$1,627.52
$2,032.20
$1,710.79
$1,818.31
$1,932.23
$2,336.91
$304.71
Toc - Plan #56 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$407.13
$462.08
$520.30
$727.11
$1,104.92
$718.58
$773.53
$831.75
$1,038.56
$1,030.03
$1,084.98
$1,143.20
$1,350.01
$1,341.48
$1,396.43
$1,454.65
$1,661.46
$311.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$814.26
$924.16
$1,040.60
$1,454.22
$2,209.84
$1,125.71
$1,235.61
$1,352.05
$1,765.67
$1,437.16
$1,547.06
$1,663.50
$2,077.12
$1,748.61
$1,858.51
$1,974.95
$2,388.57
$311.45
Toc - Plan #57 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$410.08
$465.43
$524.06
$732.38
$1,112.92
$723.78
$779.13
$837.76
$1,046.08
$1,037.48
$1,092.83
$1,151.46
$1,359.78
$1,351.18
$1,406.53
$1,465.16
$1,673.48
$313.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$820.16
$930.86
$1,048.12
$1,464.76
$2,225.84
$1,133.86
$1,244.56
$1,361.82
$1,778.46
$1,447.56
$1,558.26
$1,675.52
$2,092.16
$1,761.26
$1,871.96
$1,989.22
$2,405.86
$313.70
Toc - Plan #58 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$426.52
$484.09
$545.08
$761.74
$1,157.54
$752.80
$810.37
$871.36
$1,088.02
$1,079.08
$1,136.65
$1,197.64
$1,414.30
$1,405.36
$1,462.93
$1,523.92
$1,740.58
$326.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$853.04
$968.18
$1,090.16
$1,523.48
$2,315.08
$1,179.32
$1,294.46
$1,416.44
$1,849.76
$1,505.60
$1,620.74
$1,742.72
$2,176.04
$1,831.88
$1,947.02
$2,069.00
$2,502.32
$326.28
Toc - Plan #59 Ambetter from Buckeye Health Plan
Silver

(HMO) Enhanced Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 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
$409.12
$464.34
$522.84
$730.67
$1,110.33
$722.09
$777.31
$835.81
$1,043.64
$1,035.06
$1,090.28
$1,148.78
$1,356.61
$1,348.03
$1,403.25
$1,461.75
$1,669.58
$312.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.24
$928.68
$1,045.68
$1,461.34
$2,220.66
$1,131.21
$1,241.65
$1,358.65
$1,774.31
$1,444.18
$1,554.62
$1,671.62
$2,087.28
$1,757.15
$1,867.59
$1,984.59
$2,400.25
$312.97
Toc - Plan #60 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 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
$421.00
$477.82
$538.02
$751.88
$1,142.56
$743.05
$799.87
$860.07
$1,073.93
$1,065.10
$1,121.92
$1,182.12
$1,395.98
$1,387.15
$1,443.97
$1,504.17
$1,718.03
$322.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$842.00
$955.64
$1,076.04
$1,503.76
$2,285.12
$1,164.05
$1,277.69
$1,398.09
$1,825.81
$1,486.10
$1,599.74
$1,720.14
$2,147.86
$1,808.15
$1,921.79
$2,042.19
$2,469.91
$322.05
Toc - Plan #61 Ambetter from Buckeye Health Plan
Expanded Bronze

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$337.28
$382.80
$431.03
$602.36
$915.35
$595.29
$640.81
$689.04
$860.37
$853.30
$898.82
$947.05
$1,118.38
$1,111.31
$1,156.83
$1,205.06
$1,376.39
$258.01
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$674.56
$765.60
$862.06
$1,204.72
$1,830.70
$932.57
$1,023.61
$1,120.07
$1,462.73
$1,190.58
$1,281.62
$1,378.08
$1,720.74
$1,448.59
$1,539.63
$1,636.09
$1,978.75
$258.01
Toc - Plan #62 Ambetter from Buckeye Health Plan
Silver

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$389.44
$442.01
$497.70
$695.53
$1,056.92
$687.36
$739.93
$795.62
$993.45
$985.28
$1,037.85
$1,093.54
$1,291.37
$1,283.20
$1,335.77
$1,391.46
$1,589.29
$297.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$778.88
$884.02
$995.40
$1,391.06
$2,113.84
$1,076.80
$1,181.94
$1,293.32
$1,688.98
$1,374.72
$1,479.86
$1,591.24
$1,986.90
$1,672.64
$1,777.78
$1,889.16
$2,284.82
$297.92
Toc - Plan #63 Ambetter from Buckeye Health Plan
Gold

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

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-877-687-1189

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
$413.36
$469.15
$528.26
$738.24
$1,121.82
$729.57
$785.36
$844.47
$1,054.45
$1,045.78
$1,101.57
$1,160.68
$1,370.66
$1,361.99
$1,417.78
$1,476.89
$1,686.87
$316.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.72
$938.30
$1,056.52
$1,476.48
$2,243.64
$1,142.93
$1,254.51
$1,372.73
$1,792.69
$1,459.14
$1,570.72
$1,688.94
$2,108.90
$1,775.35
$1,886.93
$2,005.15
$2,425.11
$316.21

ADVERTISEMENT

Molina Healthcare

Local: 1-888-296-7677 | Toll Free: 1-888-296-7677

Toc - Plan #64 Molina Healthcare
Gold

(HMO) Confident Care Gold 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

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
$379.26
$430.46
$484.69
$677.35
$1,029.30
$669.39
$720.59
$774.82
$967.48
$959.52
$1,010.72
$1,064.95
$1,257.61
$1,249.65
$1,300.85
$1,355.08
$1,547.74
$290.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.52
$860.92
$969.38
$1,354.70
$2,058.60
$1,048.65
$1,151.05
$1,259.51
$1,644.83
$1,338.78
$1,441.18
$1,549.64
$1,934.96
$1,628.91
$1,731.31
$1,839.77
$2,225.09
$290.13
Toc - Plan #65 Molina Healthcare
Silver

(HMO) Constant Care Silver 1

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$340.05
$385.95
$434.58
$607.32
$922.89
$600.19
$646.09
$694.72
$867.46
$860.33
$906.23
$954.86
$1,127.60
$1,120.47
$1,166.37
$1,215.00
$1,387.74
$260.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$680.10
$771.90
$869.16
$1,214.64
$1,845.78
$940.24
$1,032.04
$1,129.30
$1,474.78
$1,200.38
$1,292.18
$1,389.44
$1,734.92
$1,460.52
$1,552.32
$1,649.58
$1,995.06
$260.14
Toc - Plan #66 Molina Healthcare
Gold

(HMO) Confident Care Gold 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

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
$391.10
$443.90
$499.82
$698.50
$1,061.44
$690.29
$743.09
$799.01
$997.69
$989.48
$1,042.28
$1,098.20
$1,296.88
$1,288.67
$1,341.47
$1,397.39
$1,596.07
$299.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.20
$887.80
$999.64
$1,397.00
$2,122.88
$1,081.39
$1,186.99
$1,298.83
$1,696.19
$1,380.58
$1,486.18
$1,598.02
$1,995.38
$1,679.77
$1,785.37
$1,897.21
$2,294.57
$299.19
Toc - Plan #67 Molina Healthcare
Silver

(HMO) Constant Care Silver 8

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

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
$346.81
$393.63
$443.22
$619.40
$941.23
$612.12
$658.94
$708.53
$884.71
$877.43
$924.25
$973.84
$1,150.02
$1,142.74
$1,189.56
$1,239.15
$1,415.33
$265.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.62
$787.26
$886.44
$1,238.80
$1,882.46
$958.93
$1,052.57
$1,151.75
$1,504.11
$1,224.24
$1,317.88
$1,417.06
$1,769.42
$1,489.55
$1,583.19
$1,682.37
$2,034.73
$265.31
Toc - Plan #68 Molina Healthcare
Gold

(HMO) Confident Care Gold 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

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
$381.88
$433.43
$488.04
$682.03
$1,036.41
$674.02
$725.57
$780.18
$974.17
$966.16
$1,017.71
$1,072.32
$1,266.31
$1,258.30
$1,309.85
$1,364.46
$1,558.45
$292.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.76
$866.86
$976.08
$1,364.06
$2,072.82
$1,055.90
$1,159.00
$1,268.22
$1,656.20
$1,348.04
$1,451.14
$1,560.36
$1,948.34
$1,640.18
$1,743.28
$1,852.50
$2,240.48
$292.14
Toc - Plan #69 Molina Healthcare
Silver

(HMO) Constant Care Silver 1 + Vision

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-296-7677

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 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
$342.67
$388.93
$437.94
$612.01
$930.01
$604.81
$651.07
$700.08
$874.15
$866.95
$913.21
$962.22
$1,136.29
$1,129.09
$1,175.35
$1,224.36
$1,398.43
$262.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.34
$777.86
$875.88
$1,224.02
$1,860.02
$947.48
$1,040.00
$1,138.02
$1,486.16
$1,209.62
$1,302.14
$1,400.16
$1,748.30
$1,471.76
$1,564.28
$1,662.30
$2,010.44
$262.14

ADVERTISEMENT

Paramount

Local: 1-419-887-2525 | Toll Free: 1-800-462-3589 | TTY: 1-888-740-5670

Toc - Plan #70 Paramount
Silver

(HMO) Paramount Silver 5

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$450.86
$511.72
$576.20
$805.23
$1,223.63
$795.77
$856.63
$921.11
$1,150.14
$1,140.68
$1,201.54
$1,266.02
$1,495.05
$1,485.59
$1,546.45
$1,610.93
$1,839.96
$344.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$901.72
$1,023.44
$1,152.40
$1,610.46
$2,447.26
$1,246.63
$1,368.35
$1,497.31
$1,955.37
$1,591.54
$1,713.26
$1,842.22
$2,300.28
$1,936.45
$2,058.17
$2,187.13
$2,645.19
$344.91
Toc - Plan #71 Paramount
Silver

(HMO) Paramount Silver 6

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$7,750 $15,500 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
$443.17
$503.00
$566.37
$791.51
$1,202.77
$782.20
$842.03
$905.40
$1,130.54
$1,121.23
$1,181.06
$1,244.43
$1,469.57
$1,460.26
$1,520.09
$1,583.46
$1,808.60
$339.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.34
$1,006.00
$1,132.74
$1,583.02
$2,405.54
$1,225.37
$1,345.03
$1,471.77
$1,922.05
$1,564.40
$1,684.06
$1,810.80
$2,261.08
$1,903.43
$2,023.09
$2,149.83
$2,600.11
$339.03
Toc - Plan #72 Paramount
Gold

(HMO) Paramount Gold 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$6,500 $13,000 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
$496.48
$563.50
$634.50
$886.71
$1,347.44
$876.29
$943.31
$1,014.31
$1,266.52
$1,256.10
$1,323.12
$1,394.12
$1,646.33
$1,635.91
$1,702.93
$1,773.93
$2,026.14
$379.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$992.96
$1,127.00
$1,269.00
$1,773.42
$2,694.88
$1,372.77
$1,506.81
$1,648.81
$2,153.23
$1,752.58
$1,886.62
$2,028.62
$2,533.04
$2,132.39
$2,266.43
$2,408.43
$2,912.85
$379.81
Toc - Plan #73 Paramount
Expanded Bronze

(HMO) Paramount Bronze 3

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

Annual Out of Pocket Expenses:

Individual Family
$5,500 $11,000 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
$339.83
$385.71
$434.31
$606.94
$922.30
$599.80
$645.68
$694.28
$866.91
$859.77
$905.65
$954.25
$1,126.88
$1,119.74
$1,165.62
$1,214.22
$1,386.85
$259.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$679.66
$771.42
$868.62
$1,213.88
$1,844.60
$939.63
$1,031.39
$1,128.59
$1,473.85
$1,199.60
$1,291.36
$1,388.56
$1,733.82
$1,459.57
$1,551.33
$1,648.53
$1,993.79
$259.97
Toc - Plan #74 Paramount
Expanded Bronze

(HMO) Paramount Bronze 4 HRA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

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
$304.28
$345.36
$388.87
$543.44
$825.81
$537.05
$578.13
$621.64
$776.21
$769.82
$810.90
$854.41
$1,008.98
$1,002.59
$1,043.67
$1,087.18
$1,241.75
$232.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$608.56
$690.72
$777.74
$1,086.88
$1,651.62
$841.33
$923.49
$1,010.51
$1,319.65
$1,074.10
$1,156.26
$1,243.28
$1,552.42
$1,306.87
$1,389.03
$1,476.05
$1,785.19
$232.77
Toc - Plan #75 Paramount
Gold

(HMO) Paramount Gold Standard 2

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

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
$486.31
$551.97
$621.51
$868.56
$1,319.86
$858.34
$924.00
$993.54
$1,240.59
$1,230.37
$1,296.03
$1,365.57
$1,612.62
$1,602.40
$1,668.06
$1,737.60
$1,984.65
$372.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.62
$1,103.94
$1,243.02
$1,737.12
$2,639.72
$1,344.65
$1,475.97
$1,615.05
$2,109.15
$1,716.68
$1,848.00
$1,987.08
$2,481.18
$2,088.71
$2,220.03
$2,359.11
$2,853.21
$372.03
Toc - Plan #76 Paramount
Silver

(HMO) Paramount Silver Standard 2 Off Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

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
$424.33
$481.61
$542.29
$757.85
$1,151.63
$748.94
$806.22
$866.90
$1,082.46
$1,073.55
$1,130.83
$1,191.51
$1,407.07
$1,398.16
$1,455.44
$1,516.12
$1,731.68
$324.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$848.66
$963.22
$1,084.58
$1,515.70
$2,303.26
$1,173.27
$1,287.83
$1,409.19
$1,840.31
$1,497.88
$1,612.44
$1,733.80
$2,164.92
$1,822.49
$1,937.05
$2,058.41
$2,489.53
$324.61
Toc - Plan #77 Paramount
Expanded Bronze

(HMO) Paramount Expanded Bronze Standard 2 On Exchange

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-462-3589

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
$322.92
$366.52
$412.70
$576.74
$876.41
$569.96
$613.56
$659.74
$823.78
$817.00
$860.60
$906.78
$1,070.82
$1,064.04
$1,107.64
$1,153.82
$1,317.86
$247.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$645.84
$733.04
$825.40
$1,153.48
$1,752.82
$892.88
$980.08
$1,072.44
$1,400.52
$1,139.92
$1,227.12
$1,319.48
$1,647.56
$1,386.96
$1,474.16
$1,566.52
$1,894.60
$247.04

ADVERTISEMENT

CareSource

Local: 1-833-230-2099 | Toll Free: 1-833-230-2099 | TTY: 1-800-750-0750

Toc - Plan #78 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
$343.78
$390.19
$439.35
$613.99
$933.01
$606.77
$653.18
$702.34
$876.98
$869.76
$916.17
$965.33
$1,139.97
$1,132.75
$1,179.16
$1,228.32
$1,402.96
$262.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.56
$780.38
$878.70
$1,227.98
$1,866.02
$950.55
$1,043.37
$1,141.69
$1,490.97
$1,213.54
$1,306.36
$1,404.68
$1,753.96
$1,476.53
$1,569.35
$1,667.67
$2,016.95
$262.99
Toc - Plan #79 CareSource
Gold

(HMO) CareSource Marketplace Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$486.31
$551.95
$621.49
$868.54
$1,319.82
$858.33
$923.97
$993.51
$1,240.56
$1,230.35
$1,295.99
$1,365.53
$1,612.58
$1,602.37
$1,668.01
$1,737.55
$1,984.60
$372.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$972.62
$1,103.90
$1,242.98
$1,737.08
$2,639.64
$1,344.64
$1,475.92
$1,615.00
$2,109.10
$1,716.66
$1,847.94
$1,987.02
$2,481.12
$2,088.68
$2,219.96
$2,359.04
$2,853.14
$372.02
Toc - Plan #80 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.12
$398.51
$448.72
$627.09
$952.92
$619.72
$667.11
$717.32
$895.69
$888.32
$935.71
$985.92
$1,164.29
$1,156.92
$1,204.31
$1,254.52
$1,432.89
$268.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.24
$797.02
$897.44
$1,254.18
$1,905.84
$970.84
$1,065.62
$1,166.04
$1,522.78
$1,239.44
$1,334.22
$1,434.64
$1,791.38
$1,508.04
$1,602.82
$1,703.24
$2,059.98
$268.60
Toc - Plan #81 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

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

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$254.98
$289.40
$325.86
$455.39
$692.00
$450.04
$484.46
$520.92
$650.45
$645.10
$679.52
$715.98
$845.51
$840.16
$874.58
$911.04
$1,040.57
$195.06
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$509.96
$578.80
$651.72
$910.78
$1,384.00
$705.02
$773.86
$846.78
$1,105.84
$900.08
$968.92
$1,041.84
$1,300.90
$1,095.14
$1,163.98
$1,236.90
$1,495.96
$195.06
Toc - Plan #82 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$249.41
$283.08
$318.75
$445.45
$676.90
$440.21
$473.88
$509.55
$636.25
$631.01
$664.68
$700.35
$827.05
$821.81
$855.48
$891.15
$1,017.85
$190.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$498.82
$566.16
$637.50
$890.90
$1,353.80
$689.62
$756.96
$828.30
$1,081.70
$880.42
$947.76
$1,019.10
$1,272.50
$1,071.22
$1,138.56
$1,209.90
$1,463.30
$190.80
Toc - Plan #83 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.07
$446.13
$502.34
$702.02
$1,066.79
$693.77
$746.83
$803.04
$1,002.72
$994.47
$1,047.53
$1,103.74
$1,303.42
$1,295.17
$1,348.23
$1,404.44
$1,604.12
$300.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.14
$892.26
$1,004.68
$1,404.04
$2,133.58
$1,086.84
$1,192.96
$1,305.38
$1,704.74
$1,387.54
$1,493.66
$1,606.08
$2,005.44
$1,688.24
$1,794.36
$1,906.78
$2,306.14
$300.70
Toc - Plan #84 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
$349.31
$396.46
$446.41
$623.86
$948.02
$616.53
$663.68
$713.63
$891.08
$883.75
$930.90
$980.85
$1,158.30
$1,150.97
$1,198.12
$1,248.07
$1,425.52
$267.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$698.62
$792.92
$892.82
$1,247.72
$1,896.04
$965.84
$1,060.14
$1,160.04
$1,514.94
$1,233.06
$1,327.36
$1,427.26
$1,782.16
$1,500.28
$1,594.58
$1,694.48
$2,049.38
$267.22
Toc - Plan #85 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$493.00
$559.55
$630.05
$880.50
$1,338.00
$870.14
$936.69
$1,007.19
$1,257.64
$1,247.28
$1,313.83
$1,384.33
$1,634.78
$1,624.42
$1,690.97
$1,761.47
$2,011.92
$377.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$986.00
$1,119.10
$1,260.10
$1,761.00
$2,676.00
$1,363.14
$1,496.24
$1,637.24
$2,138.14
$1,740.28
$1,873.38
$2,014.38
$2,515.28
$2,117.42
$2,250.52
$2,391.52
$2,892.42
$377.14
Toc - Plan #86 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$356.64
$404.78
$455.78
$636.95
$967.90
$629.46
$677.60
$728.60
$909.77
$902.28
$950.42
$1,001.42
$1,182.59
$1,175.10
$1,223.24
$1,274.24
$1,455.41
$272.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$713.28
$809.56
$911.56
$1,273.90
$1,935.80
$986.10
$1,082.38
$1,184.38
$1,546.72
$1,258.92
$1,355.20
$1,457.20
$1,819.54
$1,531.74
$1,628.02
$1,730.02
$2,092.36
$272.82
Toc - Plan #87 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
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$259.93
$295.02
$332.19
$464.23
$705.44
$458.77
$493.86
$531.03
$663.07
$657.61
$692.70
$729.87
$861.91
$856.45
$891.54
$928.71
$1,060.75
$198.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$519.86
$590.04
$664.38
$928.46
$1,410.88
$718.70
$788.88
$863.22
$1,127.30
$917.54
$987.72
$1,062.06
$1,326.14
$1,116.38
$1,186.56
$1,260.90
$1,524.98
$198.84
Toc - Plan #88 CareSource
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$254.08
$288.38
$324.71
$453.78
$689.56
$448.45
$482.75
$519.08
$648.15
$642.82
$677.12
$713.45
$842.52
$837.19
$871.49
$907.82
$1,036.89
$194.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$508.16
$576.76
$649.42
$907.56
$1,379.12
$702.53
$771.13
$843.79
$1,101.93
$896.90
$965.50
$1,038.16
$1,296.30
$1,091.27
$1,159.87
$1,232.53
$1,490.67
$194.37
Toc - Plan #89 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,150 $12,300 Annual Deductible
$6,150 $12,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$398.41
$452.19
$509.17
$711.56
$1,081.28
$703.19
$756.97
$813.95
$1,016.34
$1,007.97
$1,061.75
$1,118.73
$1,321.12
$1,312.75
$1,366.53
$1,423.51
$1,625.90
$304.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$796.82
$904.38
$1,018.34
$1,423.12
$2,162.56
$1,101.60
$1,209.16
$1,323.12
$1,727.90
$1,406.38
$1,513.94
$1,627.90
$2,032.68
$1,711.16
$1,818.72
$1,932.68
$2,337.46
$304.78

ADVERTISEMENT

MedMutual

Local: 1-888-308-0357 | Toll Free: 1-888-308-0357

Toc - Plan #90 MedMutual
Gold

(HMO) Market HMO 2500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,750 $11,500 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
$567.34
$643.93
$725.06
$1,013.27
$1,539.76
$1,001.36
$1,077.95
$1,159.08
$1,447.29
$1,435.38
$1,511.97
$1,593.10
$1,881.31
$1,869.40
$1,945.99
$2,027.12
$2,315.33
$434.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,134.68
$1,287.86
$1,450.12
$2,026.54
$3,079.52
$1,568.70
$1,721.88
$1,884.14
$2,460.56
$2,002.72
$2,155.90
$2,318.16
$2,894.58
$2,436.74
$2,589.92
$2,752.18
$3,328.60
$434.02
Toc - Plan #91 MedMutual
Silver

(HMO) Market HMO 3500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$425.60
$483.05
$543.91
$760.11
$1,155.07
$751.18
$808.63
$869.49
$1,085.69
$1,076.76
$1,134.21
$1,195.07
$1,411.27
$1,402.34
$1,459.79
$1,520.65
$1,736.85
$325.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$851.20
$966.10
$1,087.82
$1,520.22
$2,310.14
$1,176.78
$1,291.68
$1,413.40
$1,845.80
$1,502.36
$1,617.26
$1,738.98
$2,171.38
$1,827.94
$1,942.84
$2,064.56
$2,496.96
$325.58
Toc - Plan #92 MedMutual
Silver

(HMO) Market HMO 4000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$5,850 $11,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$425.96
$483.46
$544.37
$760.76
$1,156.04
$751.82
$809.32
$870.23
$1,086.62
$1,077.68
$1,135.18
$1,196.09
$1,412.48
$1,403.54
$1,461.04
$1,521.95
$1,738.34
$325.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$851.92
$966.92
$1,088.74
$1,521.52
$2,312.08
$1,177.78
$1,292.78
$1,414.60
$1,847.38
$1,503.64
$1,618.64
$1,740.46
$2,173.24
$1,829.50
$1,944.50
$2,066.32
$2,499.10
$325.86
Toc - Plan #93 MedMutual
Silver

(HMO) Market HMO 6500 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$424.52
$481.83
$542.53
$758.19
$1,152.14
$749.28
$806.59
$867.29
$1,082.95
$1,074.04
$1,131.35
$1,192.05
$1,407.71
$1,398.80
$1,456.11
$1,516.81
$1,732.47
$324.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$849.04
$963.66
$1,085.06
$1,516.38
$2,304.28
$1,173.80
$1,288.42
$1,409.82
$1,841.14
$1,498.56
$1,613.18
$1,734.58
$2,165.90
$1,823.32
$1,937.94
$2,059.34
$2,490.66
$324.76
Toc - Plan #94 MedMutual
Silver

(HMO) Market HMO Select Silver - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,250 $16,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$457.97
$519.80
$585.29
$817.94
$1,242.94
$808.32
$870.15
$935.64
$1,168.29
$1,158.67
$1,220.50
$1,285.99
$1,518.64
$1,509.02
$1,570.85
$1,636.34
$1,868.99
$350.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$915.94
$1,039.60
$1,170.58
$1,635.88
$2,485.88
$1,266.29
$1,389.95
$1,520.93
$1,986.23
$1,616.64
$1,740.30
$1,871.28
$2,336.58
$1,966.99
$2,090.65
$2,221.63
$2,686.93
$350.35
Toc - Plan #95 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.14
$367.90
$414.26
$578.92
$879.73
$572.11
$615.87
$662.23
$826.89
$820.08
$863.84
$910.20
$1,074.86
$1,068.05
$1,111.81
$1,158.17
$1,322.83
$247.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$648.28
$735.80
$828.52
$1,157.84
$1,759.46
$896.25
$983.77
$1,076.49
$1,405.81
$1,144.22
$1,231.74
$1,324.46
$1,653.78
$1,392.19
$1,479.71
$1,572.43
$1,901.75
$247.97
Toc - Plan #96 MedMutual
Expanded Bronze

(HMO) Market HMO 8000 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

Annual Out of Pocket Expenses:

Individual Family
$8,000 $16,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.83
$352.79
$397.24
$555.15
$843.60
$548.62
$590.58
$635.03
$792.94
$786.41
$828.37
$872.82
$1,030.73
$1,024.20
$1,066.16
$1,110.61
$1,268.52
$237.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$621.66
$705.58
$794.48
$1,110.30
$1,687.20
$859.45
$943.37
$1,032.27
$1,348.09
$1,097.24
$1,181.16
$1,270.06
$1,585.88
$1,335.03
$1,418.95
$1,507.85
$1,823.67
$237.79
Toc - Plan #97 MedMutual
Bronze

(HMO) Market HMO 9100 - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$306.52
$347.89
$391.73
$547.44
$831.88
$541.00
$582.37
$626.21
$781.92
$775.48
$816.85
$860.69
$1,016.40
$1,009.96
$1,051.33
$1,095.17
$1,250.88
$234.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$613.04
$695.78
$783.46
$1,094.88
$1,663.76
$847.52
$930.26
$1,017.94
$1,329.36
$1,082.00
$1,164.74
$1,252.42
$1,563.84
$1,316.48
$1,399.22
$1,486.90
$1,798.32
$234.48
Toc - Plan #98 MedMutual
Expanded Bronze

(HMO) Market HMO Select Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$365.88
$415.27
$467.59
$653.45
$992.99
$645.77
$695.16
$747.48
$933.34
$925.66
$975.05
$1,027.37
$1,213.23
$1,205.55
$1,254.94
$1,307.26
$1,493.12
$279.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$731.76
$830.54
$935.18
$1,306.90
$1,985.98
$1,011.65
$1,110.43
$1,215.07
$1,586.79
$1,291.54
$1,390.32
$1,494.96
$1,866.68
$1,571.43
$1,670.21
$1,774.85
$2,146.57
$279.89
Toc - Plan #99 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$202.18
$229.48
$258.39
$361.10
$548.73
$356.85
$384.15
$413.06
$515.77
$511.52
$538.82
$567.73
$670.44
$666.19
$693.49
$722.40
$825.11
$154.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$404.36
$458.96
$516.78
$722.20
$1,097.46
$559.03
$613.63
$671.45
$876.87
$713.70
$768.30
$826.12
$1,031.54
$868.37
$922.97
$980.79
$1,186.21
$154.67
Toc - Plan #100 MedMutual
Gold

(HMO) Market HMO Standard Gold - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$545.40
$619.02
$697.02
$974.08
$1,480.20
$962.63
$1,036.25
$1,114.25
$1,391.31
$1,379.86
$1,453.48
$1,531.48
$1,808.54
$1,797.09
$1,870.71
$1,948.71
$2,225.77
$417.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,090.80
$1,238.04
$1,394.04
$1,948.16
$2,960.40
$1,508.03
$1,655.27
$1,811.27
$2,365.39
$1,925.26
$2,072.50
$2,228.50
$2,782.62
$2,342.49
$2,489.73
$2,645.73
$3,199.85
$417.23
Toc - Plan #101 MedMutual
Silver

(HMO) Market HMO Standard Silver - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$422.72
$479.78
$540.23
$754.97
$1,147.26
$746.10
$803.16
$863.61
$1,078.35
$1,069.48
$1,126.54
$1,186.99
$1,401.73
$1,392.86
$1,449.92
$1,510.37
$1,725.11
$323.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$845.44
$959.56
$1,080.46
$1,509.94
$2,294.52
$1,168.82
$1,282.94
$1,403.84
$1,833.32
$1,492.20
$1,606.32
$1,727.22
$2,156.70
$1,815.58
$1,929.70
$2,050.60
$2,480.08
$323.38
Toc - Plan #102 MedMutual
Expanded Bronze

(HMO) Market HMO Standard Expanded Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$332.06
$376.89
$424.37
$593.06
$901.21
$586.08
$630.91
$678.39
$847.08
$840.10
$884.93
$932.41
$1,101.10
$1,094.12
$1,138.95
$1,186.43
$1,355.12
$254.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$664.12
$753.78
$848.74
$1,186.12
$1,802.42
$918.14
$1,007.80
$1,102.76
$1,440.14
$1,172.16
$1,261.82
$1,356.78
$1,694.16
$1,426.18
$1,515.84
$1,610.80
$1,948.18
$254.02
Toc - Plan #103 MedMutual
Bronze

(HMO) Market HMO Standard Bronze - Northern Ohio

Benefits & Coverage Provider Directory
Customer Service Phone: 1-888-308-0357

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
$310.11
$351.98
$396.32
$553.86
$841.65
$547.35
$589.22
$633.56
$791.10
$784.59
$826.46
$870.80
$1,028.34
$1,021.83
$1,063.70
$1,108.04
$1,265.58
$237.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.22
$703.96
$792.64
$1,107.72
$1,683.30
$857.46
$941.20
$1,029.88
$1,344.96
$1,094.70
$1,178.44
$1,267.12
$1,582.20
$1,331.94
$1,415.68
$1,504.36
$1,819.44
$237.24

‡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 Fulton County here.

Fulton County is in “Rating Area 1” of Ohio.

Currently, there are 103 plans offered in Rating Area 1.

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2023 Obamacare Plans for Fulton County, OH

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