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Providers for Zip Code 45324

Obamacare 2017 Marketplace Rates For Greene County, Ohio

Saturday, December 10th, 2016

Click for Fairborn, Ohio Forecast

Obamacare Providers, Plans and 2017 Rates for Greene County

The health insurance rates listed below are for calendar year 2017.

2017 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

This page gives you an overview of the rates for individual and family health insurance plans available from HealthCare.gov, the marketplace for Greene County, Ohio.

Currently, there are 50 plans offered in Greene County.

Below, you’ll find a summary of plans and rates for each of these providers. This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must complete an application at HealthCare.gov or contact the provider directly.

 

The table below shows premiums for the following scenarios:

  • Individual
  • Couple
  • Couple with 1 2 or 3 children
  • Individual with 1 2 or 3 children
  • A child alone

Each scenario is covered for age

  • Age 21, 30, 40, 50
  • Age 60 (Individual and Couple only)

 

Note: If you are over 65, you qualify for Medicare. Click here to see listings of 2017 Medicare Advantage plans for Greene County

 

For each plan, there are links that go to the insurance provider's website in a new window. You can find links to:

  • a summary of plan benefits and costs,
  • a plan brochure, and
  • a "Provider Directory" -- where you can find out which doctors and hospitals in the Fairborn, OH area accept this insurance coverage as within the plan's "network".

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

Premier Health Plan, Inc.

Local: 1-855-572-2159 | Toll Free: 1-855-572-2159

Plan: (HMO) Premier Health One Gold 1750

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $1,750 : Family: $3,500
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$349.96
$397.21
$447.25
$625.03
$949.80
$699.92
$794.42
$894.50
$1250.06
$1899.60
$922.15
$1016.65
$1116.73
$1472.29
$1144.38
$1238.88
$1338.96
$1694.52
$1366.61
$1461.11
$1561.19
$1916.75
$572.19
$619.44
$669.48
$847.26
$794.42
$841.67
$891.71
$1069.49
$1016.65
$1063.90
$1113.94
$1291.72
$222.23

Plan: (HMO) Premier Health One Silver 4750

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $4,750 : Family: $9,500
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$289.77
$328.89
$370.33
$517.54
$786.44
$579.54
$657.78
$740.66
$1035.08
$1572.88
$763.55
$841.79
$924.67
$1219.09
$947.56
$1025.80
$1108.68
$1403.10
$1131.57
$1209.81
$1292.69
$1587.11
$473.78
$512.90
$554.34
$701.55
$657.79
$696.91
$738.35
$885.56
$841.80
$880.92
$922.36
$1069.57
$184.01

Plan: (HMO) Premier Health One Silver 3250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $3,250 : Family: $6,500
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$310.51
$352.43
$396.83
$554.57
$842.73
$621.02
$704.86
$793.66
$1109.14
$1685.46
$818.19
$902.03
$990.83
$1306.31
$1015.36
$1099.20
$1188.00
$1503.48
$1212.53
$1296.37
$1385.17
$1700.65
$507.68
$549.60
$594.00
$751.74
$704.85
$746.77
$791.17
$948.91
$902.02
$943.94
$988.34
$1146.08
$197.17

Plan: (HMO) Premier Health One Bronze 6250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $6,250 : Family: $12,500
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$256.89
$291.57
$328.31
$458.81
$697.21
$513.78
$583.14
$656.62
$917.62
$1394.42
$676.91
$746.27
$819.75
$1080.75
$840.04
$909.40
$982.88
$1243.88
$1003.17
$1072.53
$1146.01
$1407.01
$420.02
$454.70
$491.44
$621.94
$583.15
$617.83
$654.57
$785.07
$746.28
$780.96
$817.70
$948.20
$163.13

Plan: (HMO) Premier Health One Bronze 6550

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$247.85
$281.31
$316.76
$442.67
$672.68
$495.70
$562.62
$633.52
$885.34
$1345.36
$653.09
$720.01
$790.91
$1042.73
$810.48
$877.40
$948.30
$1200.12
$967.87
$1034.79
$1105.69
$1357.51
$405.24
$438.70
$474.15
$600.06
$562.63
$596.09
$631.54
$757.45
$720.02
$753.48
$788.93
$914.84
$157.39

Plan: (HMO) Premier Health One Bronze 7150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$232.74
$264.17
$297.45
$415.68
$631.67
$465.48
$528.34
$594.90
$831.36
$1263.34
$613.27
$676.13
$742.69
$979.15
$761.06
$823.92
$890.48
$1126.94
$908.85
$971.71
$1038.27
$1274.73
$380.53
$411.96
$445.24
$563.47
$528.32
$559.75
$593.03
$711.26
$676.11
$707.54
$740.82
$859.05
$147.79

Plan: (HMO) Premier Health One Silver 3000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$311.04
$353.03
$397.51
$555.51
$844.16
$622.08
$706.06
$795.02
$1111.02
$1688.32
$819.59
$903.57
$992.53
$1308.53
$1017.10
$1101.08
$1190.04
$1506.04
$1214.61
$1298.59
$1387.55
$1703.55
$508.55
$550.54
$595.02
$753.02
$706.06
$748.05
$792.53
$950.53
$903.57
$945.56
$990.04
$1148.04
$197.51

Plan: (HMO) Premier Health One Silver 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$288.28
$327.19
$368.42
$514.86
$782.38
$576.56
$654.38
$736.84
$1029.72
$1564.76
$759.62
$837.44
$919.90
$1212.78
$942.68
$1020.50
$1102.96
$1395.84
$1125.74
$1203.56
$1286.02
$1578.90
$471.34
$510.25
$551.48
$697.92
$654.40
$693.31
$734.54
$880.98
$837.46
$876.37
$917.60
$1064.04
$183.06

Plan: (HMO) Premier Health One Silver 4500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$291.24
$330.56
$372.21
$520.16
$790.43
$582.48
$661.12
$744.42
$1040.32
$1580.86
$767.42
$846.06
$929.36
$1225.26
$952.36
$1031.00
$1114.30
$1410.20
$1137.30
$1215.94
$1299.24
$1595.14
$476.18
$515.50
$557.15
$705.10
$661.12
$700.44
$742.09
$890.04
$846.06
$885.38
$927.03
$1074.98
$184.94

Plan: (HMO) Premier Health One Bronze 6500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-572-2159 - Provider Directory for This Plan: (Premier Health Plan, Inc.)

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$258.47
$293.37
$330.33
$461.63
$701.49
$516.94
$586.74
$660.66
$923.26
$1402.98
$681.07
$750.87
$824.79
$1087.39
$845.20
$915.00
$988.92
$1251.52
$1009.33
$1079.13
$1153.05
$1415.65
$422.60
$457.50
$494.46
$625.76
$586.73
$621.63
$658.59
$789.89
$750.86
$785.76
$822.72
$954.02
$164.13

Community Insurance Company(Anthem BCBS)

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

Plan: (PPO) Anthem Catastrophic Pathway X PPO 7150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$214.02
$242.91
$273.52
$382.24
$580.85
$428.04
$485.82
$547.04
$764.48
$1161.70
$563.94
$621.72
$682.94
$900.38
$699.84
$757.62
$818.84
$1036.28
$835.74
$893.52
$954.74
$1172.18
$349.92
$378.81
$409.42
$518.14
$485.82
$514.71
$545.32
$654.04
$621.72
$650.61
$681.22
$789.94
$135.90

Plan: (PPO) Anthem Bronze Pathway X PPO 0 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$266.75
$302.76
$340.91
$476.42
$723.96
$533.50
$605.52
$681.82
$952.84
$1447.92
$702.89
$774.91
$851.21
$1122.23
$872.28
$944.30
$1020.60
$1291.62
$1041.67
$1113.69
$1189.99
$1461.01
$436.14
$472.15
$510.30
$645.81
$605.53
$641.54
$679.69
$815.20
$774.92
$810.93
$849.08
$984.59
$169.39

Plan: (PPO) Anthem Bronze Pathway X PPO 5150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $5,150 : Family: $10,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$266.38
$302.34
$340.43
$475.75
$722.96
$532.76
$604.68
$680.86
$951.50
$1445.92
$701.91
$773.83
$850.01
$1120.65
$871.06
$942.98
$1019.16
$1289.80
$1040.21
$1112.13
$1188.31
$1458.95
$435.53
$471.49
$509.58
$644.90
$604.68
$640.64
$678.73
$814.05
$773.83
$809.79
$847.88
$983.20
$169.15

Plan: (PPO) Anthem Bronze Pathway X PPO 6800

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $6,800 : Family: $13,600
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$269.15
$305.49
$343.97
$480.70
$730.47
$538.30
$610.98
$687.94
$961.40
$1460.94
$709.21
$781.89
$858.85
$1132.31
$880.12
$952.80
$1029.76
$1303.22
$1051.03
$1123.71
$1200.67
$1474.13
$440.06
$476.40
$514.88
$651.61
$610.97
$647.31
$685.79
$822.52
$781.88
$818.22
$856.70
$993.43
$170.91

Plan: (PPO) Anthem Silver Pathway X PPO 3000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$316.97
$359.76
$405.09
$566.11
$860.26
$633.94
$719.52
$810.18
$1132.22
$1720.52
$835.22
$920.80
$1011.46
$1333.50
$1036.50
$1122.08
$1212.74
$1534.78
$1237.78
$1323.36
$1414.02
$1736.06
$518.25
$561.04
$606.37
$767.39
$719.53
$762.32
$807.65
$968.67
$920.81
$963.60
$1008.93
$1169.95
$201.28

Plan: (PPO) Anthem Silver Pathway X PPO 10 for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $2,700 : Family: $5,400
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$320.47
$363.73
$409.56
$572.36
$869.76
$640.94
$727.46
$819.12
$1144.72
$1739.52
$844.44
$930.96
$1022.62
$1348.22
$1047.94
$1134.46
$1226.12
$1551.72
$1251.44
$1337.96
$1429.62
$1755.22
$523.97
$567.23
$613.06
$775.86
$727.47
$770.73
$816.56
$979.36
$930.97
$974.23
$1020.06
$1182.86
$203.50

Plan: (PPO) Anthem Silver Pathway X PPO 4050

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $4,050 : Family: $8,100
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$319.54
$362.68
$408.37
$570.70
$867.23
$639.08
$725.36
$816.74
$1141.40
$1734.46
$841.99
$928.27
$1019.65
$1344.31
$1044.90
$1131.18
$1222.56
$1547.22
$1247.81
$1334.09
$1425.47
$1750.13
$522.45
$565.59
$611.28
$773.61
$725.36
$768.50
$814.19
$976.52
$928.27
$971.41
$1017.10
$1179.43
$202.91

Plan: (PPO) Anthem Silver Pathway X PPO 2000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$328.54
$372.89
$419.87
$586.77
$891.66
$657.08
$745.78
$839.74
$1173.54
$1783.32
$865.70
$954.40
$1048.36
$1382.16
$1074.32
$1163.02
$1256.98
$1590.78
$1282.94
$1371.64
$1465.60
$1799.40
$537.16
$581.51
$628.49
$795.39
$745.78
$790.13
$837.11
$1004.01
$954.40
$998.75
$1045.73
$1212.63
$208.62

Plan: (PPO) Anthem Silver Pathway X PPO 2500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$326.57
$370.66
$417.36
$583.25
$886.31
$653.14
$741.32
$834.72
$1166.50
$1772.62
$860.51
$948.69
$1042.09
$1373.87
$1067.88
$1156.06
$1249.46
$1581.24
$1275.25
$1363.43
$1456.83
$1788.61
$533.94
$578.03
$624.73
$790.62
$741.31
$785.40
$832.10
$997.99
$948.68
$992.77
$1039.47
$1205.36
$207.37

Plan: (PPO) Anthem Silver Pathway X PPO 3500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $5,700 : Family: $11,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$318.62
$361.63
$407.20
$569.06
$864.73
$637.24
$723.26
$814.40
$1138.12
$1729.46
$839.56
$925.58
$1016.72
$1340.44
$1041.88
$1127.90
$1219.04
$1542.76
$1244.20
$1330.22
$1421.36
$1745.08
$520.94
$563.95
$609.52
$771.38
$723.26
$766.27
$811.84
$973.70
$925.58
$968.59
$1014.16
$1176.02
$202.32

Plan: (PPO) Anthem Bronze Pathway X PPO 5850

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $5,850 : Family: $11,700
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$260.22
$295.35
$332.56
$464.75
$706.24
$520.44
$590.70
$665.12
$929.50
$1412.48
$685.68
$755.94
$830.36
$1094.74
$850.92
$921.18
$995.60
$1259.98
$1016.16
$1086.42
$1160.84
$1425.22
$425.46
$460.59
$497.80
$629.99
$590.70
$625.83
$663.04
$795.23
$755.94
$791.07
$828.28
$960.47
$165.24

Plan: (HMO) Anthem Bronze Pathway X HMO 5000

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $5,000 : Family: $10,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$240.52
$272.99
$307.38
$429.57
$652.77
$481.04
$545.98
$614.76
$859.14
$1305.54
$633.77
$698.71
$767.49
$1011.87
$786.50
$851.44
$920.22
$1164.60
$939.23
$1004.17
$1072.95
$1317.33
$393.25
$425.72
$460.11
$582.30
$545.98
$578.45
$612.84
$735.03
$698.71
$731.18
$765.57
$887.76
$152.73

Plan: (HMO) Anthem Bronze Pathway X HMO 5200

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $5,200 : Family: $10,400
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$243.64
$276.53
$311.37
$435.14
$661.24
$487.28
$553.06
$622.74
$870.28
$1322.48
$641.99
$707.77
$777.45
$1024.99
$796.70
$862.48
$932.16
$1179.70
$951.41
$1017.19
$1086.87
$1334.41
$398.35
$431.24
$466.08
$589.85
$553.06
$585.95
$620.79
$744.56
$707.77
$740.66
$775.50
$899.27
$154.71

Plan: (HMO) Anthem Bronze Pathway X HMO 7150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$237.19
$269.21
$303.13
$423.62
$643.73
$474.38
$538.42
$606.26
$847.24
$1287.46
$625.00
$689.04
$756.88
$997.86
$775.62
$839.66
$907.50
$1148.48
$926.24
$990.28
$1058.12
$1299.10
$387.81
$419.83
$453.75
$574.24
$538.43
$570.45
$604.37
$724.86
$689.05
$721.07
$754.99
$875.48
$150.62

Plan: (HMO) Anthem Silver Pathway X HMO 4250

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $4,250 : Family: $8,500
Out of Pocket Maximum per year: Individual: $5,250 : Family: $10,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$285.06
$323.54
$364.31
$509.12
$773.65
$570.12
$647.08
$728.62
$1018.24
$1547.30
$751.13
$828.09
$909.63
$1199.25
$932.14
$1009.10
$1090.64
$1380.26
$1113.15
$1190.11
$1271.65
$1561.27
$466.07
$504.55
$545.32
$690.13
$647.08
$685.56
$726.33
$871.14
$828.09
$866.57
$907.34
$1052.15
$181.01

Plan: (HMO) Anthem Silver Pathway X HMO 2850

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $2,850 : Family: $5,700
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$285.18
$323.68
$364.46
$509.33
$773.98
$570.36
$647.36
$728.92
$1018.66
$1547.96
$751.45
$828.45
$910.01
$1199.75
$932.54
$1009.54
$1091.10
$1380.84
$1113.63
$1190.63
$1272.19
$1561.93
$466.27
$504.77
$545.55
$690.42
$647.36
$685.86
$726.64
$871.51
$828.45
$866.95
$907.73
$1052.60
$181.09

Plan: (HMO) Anthem Gold Pathway X HMO 1450

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $1,450 : Family: $4,350
Out of Pocket Maximum per year: Individual: $4,200 : Family: $8,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$364.46
$413.66
$465.78
$650.93
$989.14
$728.92
$827.32
$931.56
$1301.86
$1978.28
$960.35
$1058.75
$1162.99
$1533.29
$1191.78
$1290.18
$1394.42
$1764.72
$1423.21
$1521.61
$1625.85
$1996.15
$595.89
$645.09
$697.21
$882.36
$827.32
$876.52
$928.64
$1113.79
$1058.75
$1107.95
$1160.07
$1345.22
$231.43

Plan: (HMO) Anthem Silver Core Pathway X HMO 5300

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $5,300 : Family: $10,600
Out of Pocket Maximum per year: Individual: $6,750 : Family: $13,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$267.04
$303.09
$341.28
$476.93
$724.75
$534.08
$606.18
$682.56
$953.86
$1449.50
$703.65
$775.75
$852.13
$1123.43
$873.22
$945.32
$1021.70
$1293.00
$1042.79
$1114.89
$1191.27
$1462.57
$436.61
$472.66
$510.85
$646.50
$606.18
$642.23
$680.42
$816.07
$775.75
$811.80
$849.99
$985.64
$169.57

Plan: (HMO) Anthem Bronze Pathway X HMO 0% for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$245.35
$278.47
$313.56
$438.20
$665.88
$490.70
$556.94
$627.12
$876.40
$1331.76
$646.50
$712.74
$782.92
$1032.20
$802.30
$868.54
$938.72
$1188.00
$958.10
$1024.34
$1094.52
$1343.80
$401.15
$434.27
$469.36
$594.00
$556.95
$590.07
$625.16
$749.80
$712.75
$745.87
$780.96
$905.60
$155.80

Plan: (HMO) Anthem Silver Pathway X HMO 10% for HSA

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $3,200 : Family: $6,400
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$288.56
$327.52
$368.78
$515.37
$783.15
$577.12
$655.04
$737.56
$1030.74
$1566.30
$760.36
$838.28
$920.80
$1213.98
$943.60
$1021.52
$1104.04
$1397.22
$1126.84
$1204.76
$1287.28
$1580.46
$471.80
$510.76
$552.02
$698.61
$655.04
$694.00
$735.26
$881.85
$838.28
$877.24
$918.50
$1065.09
$183.24

Plan: (HMO) Anthem Silver Pathway X HMO 3500

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-748-1808 - Provider Directory for This Plan: (Community Insurance Company(Anthem BCBS))

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $5,700 : Family: $11,400

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$291.51
$330.86
$372.55
$520.64
$791.16
$583.02
$661.72
$745.10
$1041.28
$1582.32
$768.13
$846.83
$930.21
$1226.39
$953.24
$1031.94
$1115.32
$1411.50
$1138.35
$1217.05
$1300.43
$1596.61
$476.62
$515.97
$557.66
$705.75
$661.73
$701.08
$742.77
$890.86
$846.84
$886.19
$927.88
$1075.97
$185.11

Molina Healthcare of Ohio, Inc.

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

Plan: (HMO) Molina Marketplace Gold Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-296-7677 - Provider Directory for This Plan: (Molina Healthcare of Ohio, Inc.)

Deductible: Individual: $1,025 : Family: $2,050
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$270.05
$306.50
$345.12
$482.31
$732.91
$540.10
$613.00
$690.24
$964.62
$1465.82
$711.58
$784.48
$861.72
$1136.10
$883.06
$955.96
$1033.20
$1307.58
$1054.54
$1127.44
$1204.68
$1479.06
$441.53
$477.98
$516.60
$653.79
$613.01
$649.46
$688.08
$825.27
$784.49
$820.94
$859.56
$996.75
$171.48

Plan: (HMO) Molina Marketplace Silver Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-296-7677 - Provider Directory for This Plan: (Molina Healthcare of Ohio, Inc.)

Deductible: Individual: $2,400 : Family: $4,800
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$212.16
$240.80
$271.14
$378.92
$575.80
$424.32
$481.60
$542.28
$757.84
$1151.60
$559.04
$616.32
$677.00
$892.56
$693.76
$751.04
$811.72
$1027.28
$828.48
$885.76
$946.44
$1162.00
$346.88
$375.52
$405.86
$513.64
$481.60
$510.24
$540.58
$648.36
$616.32
$644.96
$675.30
$783.08
$134.72

Plan: (HMO) Molina Marketplace Bronze Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-296-7677 - Provider Directory for This Plan: (Molina Healthcare of Ohio, Inc.)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$182.53
$207.17
$233.28
$326.00
$495.39
$365.06
$414.34
$466.56
$652.00
$990.78
$480.97
$530.25
$582.47
$767.91
$596.88
$646.16
$698.38
$883.82
$712.79
$762.07
$814.29
$999.73
$298.44
$323.08
$349.19
$441.91
$414.35
$438.99
$465.10
$557.82
$530.26
$554.90
$581.01
$673.73
$115.91

Plan: (HMO) Molina Marketplace Options Silver Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-296-7677 - Provider Directory for This Plan: (Molina Healthcare of Ohio, Inc.)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$214.11
$243.02
$273.64
$382.40
$581.10
$428.22
$486.04
$547.28
$764.80
$1162.20
$564.18
$622.00
$683.24
$900.76
$700.14
$757.96
$819.20
$1036.72
$836.10
$893.92
$955.16
$1172.68
$350.07
$378.98
$409.60
$518.36
$486.03
$514.94
$545.56
$654.32
$621.99
$650.90
$681.52
$790.28
$135.96

Plan: (HMO) Molina Marketplace Options Bronze Plan

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-296-7677 - Provider Directory for This Plan: (Molina Healthcare of Ohio, Inc.)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$187.80
$213.15
$240.01
$335.41
$509.68
$375.60
$426.30
$480.02
$670.82
$1019.36
$494.85
$545.55
$599.27
$790.07
$614.10
$664.80
$718.52
$909.32
$733.35
$784.05
$837.77
$1028.57
$307.05
$332.40
$359.26
$454.66
$426.30
$451.65
$478.51
$573.91
$545.55
$570.90
$597.76
$693.16
$119.25

Humana Health Plan of Ohio, Inc.

Local: 1-877-720-4854 | Toll Free: 1-877-720-4854

TTY: 1-800-325-2028

Plan: (HMO) Humana Basic 7150/Dayton HMOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Health Plan of Ohio, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$206.89
$234.82
$264.41
$369.51
$561.50
$413.78
$469.64
$528.82
$739.02
$1123.00
$545.16
$601.02
$660.20
$870.40
$676.54
$732.40
$791.58
$1001.78
$807.92
$863.78
$922.96
$1133.16
$338.27
$366.20
$395.79
$500.89
$469.65
$497.58
$527.17
$632.27
$601.03
$628.96
$658.55
$763.65
$131.38

Plan: (HMO) Humana Bronze 6550/Dayton HMOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Health Plan of Ohio, Inc.)

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$268.88
$305.18
$343.63
$480.22
$729.74
$537.76
$610.36
$687.26
$960.44
$1459.48
$708.50
$781.10
$858.00
$1131.18
$879.24
$951.84
$1028.74
$1301.92
$1049.98
$1122.58
$1199.48
$1472.66
$439.62
$475.92
$514.37
$650.96
$610.36
$646.66
$685.11
$821.70
$781.10
$817.40
$855.85
$992.44
$170.74

Plan: (HMO) Humana Silver 4150/Dayton HMOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Health Plan of Ohio, Inc.)

Deductible: Individual: $4,150 : Family: $8,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$344.00
$390.44
$439.63
$614.38
$933.62
$688.00
$780.88
$879.26
$1228.76
$1867.24
$906.44
$999.32
$1097.70
$1447.20
$1124.88
$1217.76
$1316.14
$1665.64
$1343.32
$1436.20
$1534.58
$1884.08
$562.44
$608.88
$658.07
$832.82
$780.88
$827.32
$876.51
$1051.26
$999.32
$1045.76
$1094.95
$1269.70
$218.44

Plan: (HMO) Humana Gold 1400/Dayton HMOx

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-877-720-4854 - Provider Directory for This Plan: (Humana Health Plan of Ohio, Inc.)

Deductible: Individual: $1,400 : Family: $2,800
Out of Pocket Maximum per year: Individual: $6,000 : Family: $12,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$436.91
$495.89
$558.37
$780.32
$1185.77
$873.82
$991.78
$1116.74
$1560.64
$2371.54
$1151.26
$1269.22
$1394.18
$1838.08
$1428.70
$1546.66
$1671.62
$2115.52
$1706.14
$1824.10
$1949.06
$2392.96
$714.35
$773.33
$835.81
$1057.76
$991.79
$1050.77
$1113.25
$1335.20
$1269.23
$1328.21
$1390.69
$1612.64
$277.44
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CareSource

Local: 1-800-479-9502 | Toll Free: 1-800-479-9502

TTY: 1-800-750-0750

Plan: (HMO) CareSource Gold

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$264.95
$300.72
$338.61
$473.20
$719.08
$529.90
$601.44
$677.22
$946.40
$1438.16
$698.14
$769.68
$845.46
$1114.64
$866.38
$937.92
$1013.70
$1282.88
$1034.62
$1106.16
$1181.94
$1451.12
$433.19
$468.96
$506.85
$641.44
$601.43
$637.20
$675.09
$809.68
$769.67
$805.44
$843.33
$977.92
$168.24

Plan: (HMO) CareSource Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $3,300 : Family: $6,600
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$219.22
$248.82
$280.16
$391.53
$594.97
$438.44
$497.64
$560.32
$783.06
$1189.94
$577.65
$636.85
$699.53
$922.27
$716.86
$776.06
$838.74
$1061.48
$856.07
$915.27
$977.95
$1200.69
$358.43
$388.03
$419.37
$530.74
$497.64
$527.24
$558.58
$669.95
$636.85
$666.45
$697.79
$809.16
$139.21

Plan: (HMO) CareSource Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$189.45
$215.02
$242.11
$338.35
$514.16
$378.90
$430.04
$484.22
$676.70
$1028.32
$499.20
$550.34
$604.52
$797.00
$619.50
$670.64
$724.82
$917.30
$739.80
$790.94
$845.12
$1037.60
$309.75
$335.32
$362.41
$458.65
$430.05
$455.62
$482.71
$578.95
$550.35
$575.92
$603.01
$699.25
$120.30

Plan: (HMO) CareSource Gold Dental and Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $1,000 : Family: $2,000
Out of Pocket Maximum per year: Individual: $2,500 : Family: $5,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$280.41
$318.26
$358.36
$500.81
$761.02
$560.82
$636.52
$716.72
$1001.62
$1522.04
$738.88
$814.58
$894.78
$1179.68
$916.94
$992.64
$1072.84
$1357.74
$1095.00
$1170.70
$1250.90
$1535.80
$458.47
$496.32
$536.42
$678.87
$636.53
$674.38
$714.48
$856.93
$814.59
$852.44
$892.54
$1034.99
$178.06

Plan: (HMO) CareSource Silver Dental and Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $3,300 : Family: $6,600
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$235.00
$266.72
$300.33
$419.71
$637.78
$470.00
$533.44
$600.66
$839.42
$1275.56
$619.22
$682.66
$749.88
$988.64
$768.44
$831.88
$899.10
$1137.86
$917.66
$981.10
$1048.32
$1287.08
$384.22
$415.94
$449.55
$568.93
$533.44
$565.16
$598.77
$718.15
$682.66
$714.38
$747.99
$867.37
$149.22

Plan: (HMO) CareSource Bronze Dental and Vision

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$205.31
$233.03
$262.39
$366.68
$557.21
$410.62
$466.06
$524.78
$733.36
$1114.42
$540.99
$596.43
$655.15
$863.73
$671.36
$726.80
$785.52
$994.10
$801.73
$857.17
$915.89
$1124.47
$335.68
$363.40
$392.76
$497.05
$466.05
$493.77
$523.13
$627.42
$596.42
$624.14
$653.50
$757.79
$130.37

Plan: (HMO) CareSource Federal Simple Choice Gold

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $1,250 : Family: $2,500
Out of Pocket Maximum per year: Individual: $4,750 : Family: $9,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$242.26
$274.97
$309.61
$432.68
$657.50
$484.52
$549.94
$619.22
$865.36
$1315.00
$638.36
$703.78
$773.06
$1019.20
$792.20
$857.62
$926.90
$1173.04
$946.04
$1011.46
$1080.74
$1326.88
$396.10
$428.81
$463.45
$586.52
$549.94
$582.65
$617.29
$740.36
$703.78
$736.49
$771.13
$894.20
$153.84

Plan: (HMO) CareSource Federal Simple Choice Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$199.87
$226.85
$255.43
$356.96
$542.43
$399.74
$453.70
$510.86
$713.92
$1084.86
$526.65
$580.61
$637.77
$840.83
$653.56
$707.52
$764.68
$967.74
$780.47
$834.43
$891.59
$1094.65
$326.78
$353.76
$382.34
$483.87
$453.69
$480.67
$509.25
$610.78
$580.60
$607.58
$636.16
$737.69
$126.91

Plan: (HMO) CareSource Federal Simple Choice Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $6,650 : Family: $13,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$175.82
$199.56
$224.70
$314.01
$477.18
$351.64
$399.12
$449.40
$628.02
$954.36
$463.29
$510.77
$561.05
$739.67
$574.94
$622.42
$672.70
$851.32
$686.59
$734.07
$784.35
$962.97
$287.47
$311.21
$336.35
$425.66
$399.12
$422.86
$448.00
$537.31
$510.77
$534.51
$559.65
$648.96
$111.65

Plan: (HMO) CareSource Low Premium Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-800-479-9502 - Provider Directory for This Plan: (CareSource)

Deductible: Individual: $6,150 : Family: $12,300
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$187.80
$213.15
$240.01
$335.41
$509.69
$375.60
$426.30
$480.02
$670.82
$1019.38
$494.85
$545.55
$599.27
$790.07
$614.10
$664.80
$718.52
$909.32
$733.35
$784.05
$837.77
$1028.57
$307.05
$332.40
$359.26
$454.66
$426.30
$451.65
$478.51
$573.91
$545.55
$570.90
$597.76
$693.16
$119.25