Licking County, Ohio Obamacare 2024 Rates

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

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

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

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

Obamacare Providers, 73 Plans and 2024 Rates for Licking County, Ohio

Below, you’ll find a summary of the 73 plans for Licking County, Ohio and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.


Obamacare Rates and Providers for Other Years

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



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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
Bronze

(HMO) Anthem Bronze Pathway HMO 9450 ($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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.09
$326.98
$368.18
$514.53
$781.88
$508.48
$547.37
$588.57
$734.92
$728.87
$767.76
$808.96
$955.31
$949.26
$988.15
$1,029.35
$1,175.70
$220.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.18
$653.96
$736.36
$1,029.06
$1,563.76
$796.57
$874.35
$956.75
$1,249.45
$1,016.96
$1,094.74
$1,177.14
$1,469.84
$1,237.35
$1,315.13
$1,397.53
$1,690.23
$220.39
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway 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
$377.67
$428.66
$482.66
$674.52
$1,025.00
$666.59
$717.58
$771.58
$963.44
$955.51
$1,006.50
$1,060.50
$1,252.36
$1,244.43
$1,295.42
$1,349.42
$1,541.28
$288.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$755.34
$857.32
$965.32
$1,349.04
$2,050.00
$1,044.26
$1,146.24
$1,254.24
$1,637.96
$1,333.18
$1,435.16
$1,543.16
$1,926.88
$1,622.10
$1,724.08
$1,832.08
$2,215.80
$288.92
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Expanded Bronze

(HMO) Anthem Bronze Pathway HMO 7450/0% (+ 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
$314.79
$357.29
$402.30
$562.21
$854.34
$555.60
$598.10
$643.11
$803.02
$796.41
$838.91
$883.92
$1,043.83
$1,037.22
$1,079.72
$1,124.73
$1,284.64
$240.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$629.58
$714.58
$804.60
$1,124.42
$1,708.68
$870.39
$955.39
$1,045.41
$1,365.23
$1,111.20
$1,196.20
$1,286.22
$1,606.04
$1,352.01
$1,437.01
$1,527.03
$1,846.85
$240.81
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway HMO 5400/0% ( + 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
$399.15
$453.04
$510.11
$712.88
$1,083.29
$704.50
$758.39
$815.46
$1,018.23
$1,009.85
$1,063.74
$1,120.81
$1,323.58
$1,315.20
$1,369.09
$1,426.16
$1,628.93
$305.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$798.30
$906.08
$1,020.22
$1,425.76
$2,166.58
$1,103.65
$1,211.43
$1,325.57
$1,731.11
$1,409.00
$1,516.78
$1,630.92
$2,036.46
$1,714.35
$1,822.13
$1,936.27
$2,341.81
$305.35
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway 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
$373.32
$423.72
$477.10
$666.75
$1,013.19
$658.91
$709.31
$762.69
$952.34
$944.50
$994.90
$1,048.28
$1,237.93
$1,230.09
$1,280.49
$1,333.87
$1,523.52
$285.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.64
$847.44
$954.20
$1,333.50
$2,026.38
$1,032.23
$1,133.03
$1,239.79
$1,619.09
$1,317.82
$1,418.62
$1,525.38
$1,904.68
$1,603.41
$1,704.21
$1,810.97
$2,190.27
$285.59
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Catastrophic

(HMO) Anthem Catastrophic Pathway HMO 9450 ( + Incentives)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$223.34
$253.49
$285.43
$398.89
$606.14
$394.20
$424.35
$456.29
$569.75
$565.06
$595.21
$627.15
$740.61
$735.92
$766.07
$798.01
$911.47
$170.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$446.68
$506.98
$570.86
$797.78
$1,212.28
$617.54
$677.84
$741.72
$968.64
$788.40
$848.70
$912.58
$1,139.50
$959.26
$1,019.56
$1,083.44
$1,310.36
$170.86
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway 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
$374.95
$425.57
$479.19
$669.66
$1,017.61
$661.79
$712.41
$766.03
$956.50
$948.63
$999.25
$1,052.87
$1,243.34
$1,235.47
$1,286.09
$1,339.71
$1,530.18
$286.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$749.90
$851.14
$958.38
$1,339.32
$2,035.22
$1,036.74
$1,137.98
$1,245.22
$1,626.16
$1,323.58
$1,424.82
$1,532.06
$1,913.00
$1,610.42
$1,711.66
$1,818.90
$2,199.84
$286.84
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.71
$345.85
$389.42
$544.21
$826.98
$537.81
$578.95
$622.52
$777.31
$770.91
$812.05
$855.62
$1,010.41
$1,004.01
$1,045.15
$1,088.72
$1,243.51
$233.10
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$609.42
$691.70
$778.84
$1,088.42
$1,653.96
$842.52
$924.80
$1,011.94
$1,321.52
$1,075.62
$1,157.90
$1,245.04
$1,554.62
$1,308.72
$1,391.00
$1,478.14
$1,787.72
$233.10
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway 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
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$298.64
$338.96
$381.66
$533.37
$810.51
$527.10
$567.42
$610.12
$761.83
$755.56
$795.88
$838.58
$990.29
$984.02
$1,024.34
$1,067.04
$1,218.75
$228.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$597.28
$677.92
$763.32
$1,066.74
$1,621.02
$825.74
$906.38
$991.78
$1,295.20
$1,054.20
$1,134.84
$1,220.24
$1,523.66
$1,282.66
$1,363.30
$1,448.70
$1,752.12
$228.46
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.37
$345.46
$388.98
$543.60
$826.06
$537.21
$578.30
$621.82
$776.44
$770.05
$811.14
$854.66
$1,009.28
$1,002.89
$1,043.98
$1,087.50
$1,242.12
$232.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$608.74
$690.92
$777.96
$1,087.20
$1,652.12
$841.58
$923.76
$1,010.80
$1,320.04
$1,074.42
$1,156.60
$1,243.64
$1,552.88
$1,307.26
$1,389.44
$1,476.48
$1,785.72
$232.84
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$367.05
$416.60
$469.09
$655.55
$996.17
$647.84
$697.39
$749.88
$936.34
$928.63
$978.18
$1,030.67
$1,217.13
$1,209.42
$1,258.97
$1,311.46
$1,497.92
$280.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$734.10
$833.20
$938.18
$1,311.10
$1,992.34
$1,014.89
$1,113.99
$1,218.97
$1,591.89
$1,295.68
$1,394.78
$1,499.76
$1,872.68
$1,576.47
$1,675.57
$1,780.55
$2,153.47
$280.79
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$545.26
$618.87
$696.84
$973.83
$1,479.84
$962.38
$1,035.99
$1,113.96
$1,390.95
$1,379.50
$1,453.11
$1,531.08
$1,808.07
$1,796.62
$1,870.23
$1,948.20
$2,225.19
$417.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,090.52
$1,237.74
$1,393.68
$1,947.66
$2,959.68
$1,507.64
$1,654.86
$1,810.80
$2,364.78
$1,924.76
$2,071.98
$2,227.92
$2,781.90
$2,341.88
$2,489.10
$2,645.04
$3,199.02
$417.12
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Bronze

(HMO) Anthem Bronze Pathway HMO 9450 Adult Dental & Vision ($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
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$291.65
$331.02
$372.73
$520.89
$791.54
$514.76
$554.13
$595.84
$744.00
$737.87
$777.24
$818.95
$967.11
$960.98
$1,000.35
$1,042.06
$1,190.22
$223.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$583.30
$662.04
$745.46
$1,041.78
$1,583.08
$806.41
$885.15
$968.57
$1,264.89
$1,029.52
$1,108.26
$1,191.68
$1,488.00
$1,252.63
$1,331.37
$1,414.79
$1,711.11
$223.11
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Silver

(HMO) Anthem Silver Pathway HMO 5000 Adult Dental & Vision ($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
$376.89
$427.77
$481.67
$673.13
$1,022.88
$665.21
$716.09
$769.99
$961.45
$953.53
$1,004.41
$1,058.31
$1,249.77
$1,241.85
$1,292.73
$1,346.63
$1,538.09
$288.32
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.78
$855.54
$963.34
$1,346.26
$2,045.76
$1,042.10
$1,143.86
$1,251.66
$1,634.58
$1,330.42
$1,432.18
$1,539.98
$1,922.90
$1,618.74
$1,720.50
$1,828.30
$2,211.22
$288.32

ADVERTISEMENT

Oscar Health Insurance

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

Toc - Plan #15 Oscar Health Insurance
Expanded Bronze

(HMO) Bronze Classic PCP Saver (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$278.95
$316.60
$356.49
$498.19
$757.05
$492.34
$529.99
$569.88
$711.58
$705.73
$743.38
$783.27
$924.97
$919.12
$956.77
$996.66
$1,138.36
$213.39
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$557.90
$633.20
$712.98
$996.38
$1,514.10
$771.29
$846.59
$926.37
$1,209.77
$984.68
$1,059.98
$1,139.76
$1,423.16
$1,198.07
$1,273.37
$1,353.15
$1,636.55
$213.39
Toc - Plan #16 Oscar Health Insurance
Expanded Bronze

(HMO) Bronze Elite + PCP Saver Plus (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.17
$359.97
$405.33
$566.44
$860.76
$559.80
$602.60
$647.96
$809.07
$802.43
$845.23
$890.59
$1,051.70
$1,045.06
$1,087.86
$1,133.22
$1,294.33
$242.63
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.34
$719.94
$810.66
$1,132.88
$1,721.52
$876.97
$962.57
$1,053.29
$1,375.51
$1,119.60
$1,205.20
$1,295.92
$1,618.14
$1,362.23
$1,447.83
$1,538.55
$1,860.77
$242.63
Toc - Plan #17 Oscar Health Insurance
Silver

(HMO) Silver Classic (Select)

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

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,700 $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
$353.88
$401.64
$452.25
$632.02
$960.41
$624.59
$672.35
$722.96
$902.73
$895.30
$943.06
$993.67
$1,173.44
$1,166.01
$1,213.77
$1,264.38
$1,444.15
$270.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.76
$803.28
$904.50
$1,264.04
$1,920.82
$978.47
$1,073.99
$1,175.21
$1,534.75
$1,249.18
$1,344.70
$1,445.92
$1,805.46
$1,519.89
$1,615.41
$1,716.63
$2,076.17
$270.71
Toc - Plan #18 Oscar Health Insurance
Silver

(HMO) Silver Simple (Select)

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

Annual Out of Pocket Expenses:

Individual Family
$4,500 $9,000 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
$350.73
$398.07
$448.22
$626.39
$951.85
$619.03
$666.37
$716.52
$894.69
$887.33
$934.67
$984.82
$1,162.99
$1,155.63
$1,202.97
$1,253.12
$1,431.29
$268.30
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$701.46
$796.14
$896.44
$1,252.78
$1,903.70
$969.76
$1,064.44
$1,164.74
$1,521.08
$1,238.06
$1,332.74
$1,433.04
$1,789.38
$1,506.36
$1,601.04
$1,701.34
$2,057.68
$268.30
Toc - Plan #19 Oscar Health Insurance
Catastrophic

(HMO) Secure (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$223.51
$253.68
$285.64
$399.18
$606.59
$394.49
$424.66
$456.62
$570.16
$565.47
$595.64
$627.60
$741.14
$736.45
$766.62
$798.58
$912.12
$170.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$447.02
$507.36
$571.28
$798.36
$1,213.18
$618.00
$678.34
$742.26
$969.34
$788.98
$849.32
$913.24
$1,140.32
$959.96
$1,020.30
$1,084.22
$1,311.30
$170.98
Toc - Plan #20 Oscar Health Insurance
Expanded Bronze

(HMO) Bronze Elite + Specialist Saver Plus (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$328.32
$372.63
$419.58
$586.36
$891.03
$579.48
$623.79
$670.74
$837.52
$830.64
$874.95
$921.90
$1,088.68
$1,081.80
$1,126.11
$1,173.06
$1,339.84
$251.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.64
$745.26
$839.16
$1,172.72
$1,782.06
$907.80
$996.42
$1,090.32
$1,423.88
$1,158.96
$1,247.58
$1,341.48
$1,675.04
$1,410.12
$1,498.74
$1,592.64
$1,926.20
$251.16
Toc - Plan #21 Oscar Health Insurance
Gold

(HMO) Gold Classic (Select)

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

Annual Out of Pocket Expenses:

Individual Family
$3,500 $7,000 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$391.45
$444.28
$500.26
$699.11
$1,062.36
$690.90
$743.73
$799.71
$998.56
$990.35
$1,043.18
$1,099.16
$1,298.01
$1,289.80
$1,342.63
$1,398.61
$1,597.46
$299.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$782.90
$888.56
$1,000.52
$1,398.22
$2,124.72
$1,082.35
$1,188.01
$1,299.97
$1,697.67
$1,381.80
$1,487.46
$1,599.42
$1,997.12
$1,681.25
$1,786.91
$1,898.87
$2,296.57
$299.45
Toc - Plan #22 Oscar Health Insurance
Expanded Bronze

(HMO) Bronze Classic 4700 (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$292.29
$331.74
$373.54
$522.01
$793.25
$515.89
$555.34
$597.14
$745.61
$739.49
$778.94
$820.74
$969.21
$963.09
$1,002.54
$1,044.34
$1,192.81
$223.60
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$584.58
$663.48
$747.08
$1,044.02
$1,586.50
$808.18
$887.08
$970.68
$1,267.62
$1,031.78
$1,110.68
$1,194.28
$1,491.22
$1,255.38
$1,334.28
$1,417.88
$1,714.82
$223.60
Toc - Plan #23 Oscar Health Insurance
Silver

(HMO) Silver Simple PCP Saver (Select)

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

Annual Out of Pocket Expenses:

Individual Family
$5,750 $11,500 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
$339.48
$385.30
$433.84
$606.29
$921.32
$599.17
$644.99
$693.53
$865.98
$858.86
$904.68
$953.22
$1,125.67
$1,118.55
$1,164.37
$1,212.91
$1,385.36
$259.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$678.96
$770.60
$867.68
$1,212.58
$1,842.64
$938.65
$1,030.29
$1,127.37
$1,472.27
$1,198.34
$1,289.98
$1,387.06
$1,731.96
$1,458.03
$1,549.67
$1,646.75
$1,991.65
$259.69
Toc - Plan #24 Oscar Health Insurance
Silver

(HMO) Silver Elite Saver Plus (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.91
$406.22
$457.40
$639.22
$971.35
$631.71
$680.02
$731.20
$913.02
$905.51
$953.82
$1,005.00
$1,186.82
$1,179.31
$1,227.62
$1,278.80
$1,460.62
$273.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.82
$812.44
$914.80
$1,278.44
$1,942.70
$989.62
$1,086.24
$1,188.60
$1,552.24
$1,263.42
$1,360.04
$1,462.40
$1,826.04
$1,537.22
$1,633.84
$1,736.20
$2,099.84
$273.80
Toc - Plan #25 Oscar Health Insurance
Gold

(HMO) Gold Elite Saver Plus (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$423.08
$480.19
$540.69
$755.61
$1,148.22
$746.73
$803.84
$864.34
$1,079.26
$1,070.38
$1,127.49
$1,187.99
$1,402.91
$1,394.03
$1,451.14
$1,511.64
$1,726.56
$323.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$846.16
$960.38
$1,081.38
$1,511.22
$2,296.44
$1,169.81
$1,284.03
$1,405.03
$1,834.87
$1,493.46
$1,607.68
$1,728.68
$2,158.52
$1,817.11
$1,931.33
$2,052.33
$2,482.17
$323.65
Toc - Plan #26 Oscar Health Insurance
Expanded Bronze

(HMO) Bronze Classic Standard (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.96
$323.42
$364.17
$508.92
$773.36
$502.95
$541.41
$582.16
$726.91
$720.94
$759.40
$800.15
$944.90
$938.93
$977.39
$1,018.14
$1,162.89
$217.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$569.92
$646.84
$728.34
$1,017.84
$1,546.72
$787.91
$864.83
$946.33
$1,235.83
$1,005.90
$1,082.82
$1,164.32
$1,453.82
$1,223.89
$1,300.81
$1,382.31
$1,671.81
$217.99
Toc - Plan #27 Oscar Health Insurance
Silver

(HMO) Silver Classic Standard (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.72
$390.11
$439.26
$613.87
$932.83
$606.66
$653.05
$702.20
$876.81
$869.60
$915.99
$965.14
$1,139.75
$1,132.54
$1,178.93
$1,228.08
$1,402.69
$262.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$687.44
$780.22
$878.52
$1,227.74
$1,865.66
$950.38
$1,043.16
$1,141.46
$1,490.68
$1,213.32
$1,306.10
$1,404.40
$1,753.62
$1,476.26
$1,569.04
$1,667.34
$2,016.56
$262.94
Toc - Plan #28 Oscar Health Insurance
Gold

(HMO) Gold Classic Standard (Select)

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.25
$427.03
$480.83
$671.96
$1,021.10
$664.07
$714.85
$768.65
$959.78
$951.89
$1,002.67
$1,056.47
$1,247.60
$1,239.71
$1,290.49
$1,344.29
$1,535.42
$287.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$752.50
$854.06
$961.66
$1,343.92
$2,042.20
$1,040.32
$1,141.88
$1,249.48
$1,631.74
$1,328.14
$1,429.70
$1,537.30
$1,919.56
$1,615.96
$1,717.52
$1,825.12
$2,207.38
$287.82

ADVERTISEMENT

Molina Healthcare

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

Toc - Plan #29 Molina Healthcare
Gold

(HMO) Gold 1

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$448.42
$508.96
$573.08
$800.88
$1,217.01
$791.46
$852.00
$916.12
$1,143.92
$1,134.50
$1,195.04
$1,259.16
$1,486.96
$1,477.54
$1,538.08
$1,602.20
$1,830.00
$343.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$896.84
$1,017.92
$1,146.16
$1,601.76
$2,434.02
$1,239.88
$1,360.96
$1,489.20
$1,944.80
$1,582.92
$1,704.00
$1,832.24
$2,287.84
$1,925.96
$2,047.04
$2,175.28
$2,630.88
$343.04
Toc - Plan #30 Molina Healthcare
Silver

(HMO) Silver 1

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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
$413.96
$469.85
$529.05
$739.34
$1,123.50
$730.64
$786.53
$845.73
$1,056.02
$1,047.32
$1,103.21
$1,162.41
$1,372.70
$1,364.00
$1,419.89
$1,479.09
$1,689.38
$316.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$827.92
$939.70
$1,058.10
$1,478.68
$2,247.00
$1,144.60
$1,256.38
$1,374.78
$1,795.36
$1,461.28
$1,573.06
$1,691.46
$2,112.04
$1,777.96
$1,889.74
$2,008.14
$2,428.72
$316.68
Toc - Plan #31 Molina Healthcare
Gold

(HMO) Gold 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$466.29
$529.24
$595.91
$832.79
$1,265.50
$823.00
$885.95
$952.62
$1,189.50
$1,179.71
$1,242.66
$1,309.33
$1,546.21
$1,536.42
$1,599.37
$1,666.04
$1,902.92
$356.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$932.58
$1,058.48
$1,191.82
$1,665.58
$2,531.00
$1,289.29
$1,415.19
$1,548.53
$2,022.29
$1,646.00
$1,771.90
$1,905.24
$2,379.00
$2,002.71
$2,128.61
$2,261.95
$2,735.71
$356.71
Toc - Plan #32 Molina Healthcare
Silver

(HMO) Silver 8

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$401.08
$455.22
$512.58
$716.33
$1,088.53
$707.91
$762.05
$819.41
$1,023.16
$1,014.74
$1,068.88
$1,126.24
$1,329.99
$1,321.57
$1,375.71
$1,433.07
$1,636.82
$306.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$802.16
$910.44
$1,025.16
$1,432.66
$2,177.06
$1,108.99
$1,217.27
$1,331.99
$1,739.49
$1,415.82
$1,524.10
$1,638.82
$2,046.32
$1,722.65
$1,830.93
$1,945.65
$2,353.15
$306.83
Toc - Plan #33 Molina Healthcare
Silver

(HMO) Silver 12 with first 4 free PCP or MH visits

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$403.30
$457.74
$515.41
$720.29
$1,094.55
$711.82
$766.26
$823.93
$1,028.81
$1,020.34
$1,074.78
$1,132.45
$1,337.33
$1,328.86
$1,383.30
$1,440.97
$1,645.85
$308.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$806.60
$915.48
$1,030.82
$1,440.58
$2,189.10
$1,115.12
$1,224.00
$1,339.34
$1,749.10
$1,423.64
$1,532.52
$1,647.86
$2,057.62
$1,732.16
$1,841.04
$1,956.38
$2,366.14
$308.52
Toc - Plan #34 Molina Healthcare
Gold

(HMO) Gold 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$1,550 $3,100 Annual Deductible
$8,100 $16,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$451.62
$512.58
$577.16
$806.59
$1,225.68
$797.11
$858.07
$922.65
$1,152.08
$1,142.60
$1,203.56
$1,268.14
$1,497.57
$1,488.09
$1,549.05
$1,613.63
$1,843.06
$345.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$903.24
$1,025.16
$1,154.32
$1,613.18
$2,451.36
$1,248.73
$1,370.65
$1,499.81
$1,958.67
$1,594.22
$1,716.14
$1,845.30
$2,304.16
$1,939.71
$2,061.63
$2,190.79
$2,649.65
$345.49
Toc - Plan #35 Molina Healthcare
Silver

(HMO) Silver 1 with Adult Vision Services

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,850 $15,700 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
$417.15
$473.47
$533.12
$745.03
$1,132.15
$736.27
$792.59
$852.24
$1,064.15
$1,055.39
$1,111.71
$1,171.36
$1,383.27
$1,374.51
$1,430.83
$1,490.48
$1,702.39
$319.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$834.30
$946.94
$1,066.24
$1,490.06
$2,264.30
$1,153.42
$1,266.06
$1,385.36
$1,809.18
$1,472.54
$1,585.18
$1,704.48
$2,128.30
$1,791.66
$1,904.30
$2,023.60
$2,447.42
$319.12

ADVERTISEMENT

CareSource

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

Toc - Plan #36 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
$436.79
$495.76
$558.22
$780.11
$1,185.45
$770.93
$829.90
$892.36
$1,114.25
$1,105.07
$1,164.04
$1,226.50
$1,448.39
$1,439.21
$1,498.18
$1,560.64
$1,782.53
$334.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$873.58
$991.52
$1,116.44
$1,560.22
$2,370.90
$1,207.72
$1,325.66
$1,450.58
$1,894.36
$1,541.86
$1,659.80
$1,784.72
$2,228.50
$1,876.00
$1,993.94
$2,118.86
$2,562.64
$334.14
Toc - Plan #37 CareSource
Gold

(HMO) CareSource Marketplace Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$697.12
$791.23
$890.92
$1,245.05
$1,891.98
$1,230.41
$1,324.52
$1,424.21
$1,778.34
$1,763.70
$1,857.81
$1,957.50
$2,311.63
$2,296.99
$2,391.10
$2,490.79
$2,844.92
$533.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,394.24
$1,582.46
$1,781.84
$2,490.10
$3,783.96
$1,927.53
$2,115.75
$2,315.13
$3,023.39
$2,460.82
$2,649.04
$2,848.42
$3,556.68
$2,994.11
$3,182.33
$3,381.71
$4,089.97
$533.29
Toc - Plan #38 CareSource
Silver

(HMO) CareSource Marketplace Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$429.66
$487.66
$549.11
$767.37
$1,166.10
$758.35
$816.35
$877.80
$1,096.06
$1,087.04
$1,145.04
$1,206.49
$1,424.75
$1,415.73
$1,473.73
$1,535.18
$1,753.44
$328.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$859.32
$975.32
$1,098.22
$1,534.74
$2,332.20
$1,188.01
$1,304.01
$1,426.91
$1,863.43
$1,516.70
$1,632.70
$1,755.60
$2,192.12
$1,845.39
$1,961.39
$2,084.29
$2,520.81
$328.69
Toc - Plan #39 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$345.68
$392.34
$441.77
$617.38
$938.16
$610.12
$656.78
$706.21
$881.82
$874.56
$921.22
$970.65
$1,146.26
$1,139.00
$1,185.66
$1,235.09
$1,410.70
$264.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$691.36
$784.68
$883.54
$1,234.76
$1,876.32
$955.80
$1,049.12
$1,147.98
$1,499.20
$1,220.24
$1,313.56
$1,412.42
$1,763.64
$1,484.68
$1,578.00
$1,676.86
$2,028.08
$264.44
Toc - Plan #40 CareSource
Silver

(HMO) CareSource Marketplace Diabetes Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.44
$514.65
$579.49
$809.84
$1,230.63
$800.32
$861.53
$926.37
$1,156.72
$1,147.20
$1,208.41
$1,273.25
$1,503.60
$1,494.08
$1,555.29
$1,620.13
$1,850.48
$346.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$906.88
$1,029.30
$1,158.98
$1,619.68
$2,461.26
$1,253.76
$1,376.18
$1,505.86
$1,966.56
$1,600.64
$1,723.06
$1,852.74
$2,313.44
$1,947.52
$2,069.94
$2,199.62
$2,660.32
$346.88
Toc - Plan #41 CareSource
Gold

(HMO) CareSource Marketplace Diabetes Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$714.10
$810.50
$912.61
$1,275.38
$1,938.06
$1,260.38
$1,356.78
$1,458.89
$1,821.66
$1,806.66
$1,903.06
$2,005.17
$2,367.94
$2,352.94
$2,449.34
$2,551.45
$2,914.22
$546.28
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,428.20
$1,621.00
$1,825.22
$2,550.76
$3,876.12
$1,974.48
$2,167.28
$2,371.50
$3,097.04
$2,520.76
$2,713.56
$2,917.78
$3,643.32
$3,067.04
$3,259.84
$3,464.06
$4,189.60
$546.28
Toc - Plan #42 CareSource
Gold

(HMO) CareSource Marketplace Core Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$651.26
$739.18
$832.31
$1,163.15
$1,767.52
$1,149.47
$1,237.39
$1,330.52
$1,661.36
$1,647.68
$1,735.60
$1,828.73
$2,159.57
$2,145.89
$2,233.81
$2,326.94
$2,657.78
$498.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,302.52
$1,478.36
$1,664.62
$2,326.30
$3,535.04
$1,800.73
$1,976.57
$2,162.83
$2,824.51
$2,298.94
$2,474.78
$2,661.04
$3,322.72
$2,797.15
$2,972.99
$3,159.25
$3,820.93
$498.21
Toc - Plan #43 CareSource
Silver

(HMO) CareSource Marketplace Core Silver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$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
$443.40
$503.26
$566.67
$791.91
$1,203.39
$782.60
$842.46
$905.87
$1,131.11
$1,121.80
$1,181.66
$1,245.07
$1,470.31
$1,461.00
$1,520.86
$1,584.27
$1,809.51
$339.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.80
$1,006.52
$1,133.34
$1,583.82
$2,406.78
$1,226.00
$1,345.72
$1,472.54
$1,923.02
$1,565.20
$1,684.92
$1,811.74
$2,262.22
$1,904.40
$2,024.12
$2,150.94
$2,601.42
$339.20
Toc - Plan #44 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
$442.64
$502.39
$565.69
$790.55
$1,201.31
$781.26
$841.01
$904.31
$1,129.17
$1,119.88
$1,179.63
$1,242.93
$1,467.79
$1,458.50
$1,518.25
$1,581.55
$1,806.41
$338.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$885.28
$1,004.78
$1,131.38
$1,581.10
$2,402.62
$1,223.90
$1,343.40
$1,470.00
$1,919.72
$1,562.52
$1,682.02
$1,808.62
$2,258.34
$1,901.14
$2,020.64
$2,147.24
$2,596.96
$338.62
Toc - Plan #45 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$705.12
$800.30
$901.13
$1,259.33
$1,913.68
$1,244.53
$1,339.71
$1,440.54
$1,798.74
$1,783.94
$1,879.12
$1,979.95
$2,338.15
$2,323.35
$2,418.53
$2,519.36
$2,877.56
$539.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,410.24
$1,600.60
$1,802.26
$2,518.66
$3,827.36
$1,949.65
$2,140.01
$2,341.67
$3,058.07
$2,489.06
$2,679.42
$2,881.08
$3,597.48
$3,028.47
$3,218.83
$3,420.49
$4,136.89
$539.41
Toc - Plan #46 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$435.51
$494.30
$556.57
$777.81
$1,181.96
$768.67
$827.46
$889.73
$1,110.97
$1,101.83
$1,160.62
$1,222.89
$1,444.13
$1,434.99
$1,493.78
$1,556.05
$1,777.29
$333.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.02
$988.60
$1,113.14
$1,555.62
$2,363.92
$1,204.18
$1,321.76
$1,446.30
$1,888.78
$1,537.34
$1,654.92
$1,779.46
$2,221.94
$1,870.50
$1,988.08
$2,112.62
$2,555.10
$333.16
Toc - Plan #47 CareSource
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$351.27
$398.69
$448.92
$627.36
$953.33
$619.99
$667.41
$717.64
$896.08
$888.71
$936.13
$986.36
$1,164.80
$1,157.43
$1,204.85
$1,255.08
$1,433.52
$268.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$702.54
$797.38
$897.84
$1,254.72
$1,906.66
$971.26
$1,066.10
$1,166.56
$1,523.44
$1,239.98
$1,334.82
$1,435.28
$1,792.16
$1,508.70
$1,603.54
$1,704.00
$2,060.88
$268.72
Toc - Plan #48 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$459.28
$521.28
$586.96
$820.28
$1,246.49
$810.63
$872.63
$938.31
$1,171.63
$1,161.98
$1,223.98
$1,289.66
$1,522.98
$1,513.33
$1,575.33
$1,641.01
$1,874.33
$351.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$918.56
$1,042.56
$1,173.92
$1,640.56
$2,492.98
$1,269.91
$1,393.91
$1,525.27
$1,991.91
$1,621.26
$1,745.26
$1,876.62
$2,343.26
$1,972.61
$2,096.61
$2,227.97
$2,694.61
$351.35
Toc - Plan #49 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$722.10
$819.57
$922.83
$1,289.66
$1,959.76
$1,274.50
$1,371.97
$1,475.23
$1,842.06
$1,826.90
$1,924.37
$2,027.63
$2,394.46
$2,379.30
$2,476.77
$2,580.03
$2,946.86
$552.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,444.20
$1,639.14
$1,845.66
$2,579.32
$3,919.52
$1,996.60
$2,191.54
$2,398.06
$3,131.72
$2,549.00
$2,743.94
$2,950.46
$3,684.12
$3,101.40
$3,296.34
$3,502.86
$4,236.52
$552.40
Toc - Plan #50 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$659.26
$748.26
$842.53
$1,177.43
$1,789.22
$1,163.59
$1,252.59
$1,346.86
$1,681.76
$1,667.92
$1,756.92
$1,851.19
$2,186.09
$2,172.25
$2,261.25
$2,355.52
$2,690.42
$504.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,318.52
$1,496.52
$1,685.06
$2,354.86
$3,578.44
$1,822.85
$2,000.85
$2,189.39
$2,859.19
$2,327.18
$2,505.18
$2,693.72
$3,363.52
$2,831.51
$3,009.51
$3,198.05
$3,867.85
$504.33
Toc - Plan #51 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$449.25
$509.89
$574.13
$802.35
$1,219.25
$792.92
$853.56
$917.80
$1,146.02
$1,136.59
$1,197.23
$1,261.47
$1,489.69
$1,480.26
$1,540.90
$1,605.14
$1,833.36
$343.67
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$898.50
$1,019.78
$1,148.26
$1,604.70
$2,438.50
$1,242.17
$1,363.45
$1,491.93
$1,948.37
$1,585.84
$1,707.12
$1,835.60
$2,292.04
$1,929.51
$2,050.79
$2,179.27
$2,635.71
$343.67

ADVERTISEMENT

Aetna CVS Health

Local: 1-888-438-8581 | Toll Free: 1-877-336-3915

Toc - Plan #52 Aetna CVS Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$337.18
$382.70
$430.91
$602.20
$915.09
$595.12
$640.64
$688.85
$860.14
$853.06
$898.58
$946.79
$1,118.08
$1,111.00
$1,156.52
$1,204.73
$1,376.02
$257.94
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$674.36
$765.40
$861.82
$1,204.40
$1,830.18
$932.30
$1,023.34
$1,119.76
$1,462.34
$1,190.24
$1,281.28
$1,377.70
$1,720.28
$1,448.18
$1,539.22
$1,635.64
$1,978.22
$257.94
Toc - Plan #53 Aetna CVS Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$359.00
$407.47
$458.81
$641.18
$974.33
$633.64
$682.11
$733.45
$915.82
$908.28
$956.75
$1,008.09
$1,190.46
$1,182.92
$1,231.39
$1,282.73
$1,465.10
$274.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$718.00
$814.94
$917.62
$1,282.36
$1,948.66
$992.64
$1,089.58
$1,192.26
$1,557.00
$1,267.28
$1,364.22
$1,466.90
$1,831.64
$1,541.92
$1,638.86
$1,741.54
$2,106.28
$274.64
Toc - Plan #54 Aetna CVS Health
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.33
$389.68
$438.77
$613.18
$931.79
$605.98
$652.33
$701.42
$875.83
$868.63
$914.98
$964.07
$1,138.48
$1,131.28
$1,177.63
$1,226.72
$1,401.13
$262.65
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.66
$779.36
$877.54
$1,226.36
$1,863.58
$949.31
$1,042.01
$1,140.19
$1,489.01
$1,211.96
$1,304.66
$1,402.84
$1,751.66
$1,474.61
$1,567.31
$1,665.49
$2,014.31
$262.65
Toc - Plan #55 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$498.72
$566.04
$637.36
$890.70
$1,353.51
$880.24
$947.56
$1,018.88
$1,272.22
$1,261.76
$1,329.08
$1,400.40
$1,653.74
$1,643.28
$1,710.60
$1,781.92
$2,035.26
$381.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$997.44
$1,132.08
$1,274.72
$1,781.40
$2,707.02
$1,378.96
$1,513.60
$1,656.24
$2,162.92
$1,760.48
$1,895.12
$2,037.76
$2,544.44
$2,142.00
$2,276.64
$2,419.28
$2,925.96
$381.52
Toc - Plan #56 Aetna CVS Health
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$501.14
$568.79
$640.46
$895.03
$1,360.09
$884.51
$952.16
$1,023.83
$1,278.40
$1,267.88
$1,335.53
$1,407.20
$1,661.77
$1,651.25
$1,718.90
$1,790.57
$2,045.14
$383.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,002.28
$1,137.58
$1,280.92
$1,790.06
$2,720.18
$1,385.65
$1,520.95
$1,664.29
$2,173.43
$1,769.02
$1,904.32
$2,047.66
$2,556.80
$2,152.39
$2,287.69
$2,431.03
$2,940.17
$383.37
Toc - Plan #57 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.43
$464.71
$523.25
$731.24
$1,111.19
$722.65
$777.93
$836.47
$1,044.46
$1,035.87
$1,091.15
$1,149.69
$1,357.68
$1,349.09
$1,404.37
$1,462.91
$1,670.90
$313.22
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.86
$929.42
$1,046.50
$1,462.48
$2,222.38
$1,132.08
$1,242.64
$1,359.72
$1,775.70
$1,445.30
$1,555.86
$1,672.94
$2,088.92
$1,758.52
$1,869.08
$1,986.16
$2,402.14
$313.22
Toc - Plan #58 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.03
$474.46
$534.24
$746.59
$1,134.52
$737.82
$794.25
$854.03
$1,066.38
$1,057.61
$1,114.04
$1,173.82
$1,386.17
$1,377.40
$1,433.83
$1,493.61
$1,705.96
$319.79
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.06
$948.92
$1,068.48
$1,493.18
$2,269.04
$1,155.85
$1,268.71
$1,388.27
$1,812.97
$1,475.64
$1,588.50
$1,708.06
$2,132.76
$1,795.43
$1,908.29
$2,027.85
$2,452.55
$319.79
Toc - Plan #59 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$418.20
$474.65
$534.45
$746.89
$1,134.97
$738.12
$794.57
$854.37
$1,066.81
$1,058.04
$1,114.49
$1,174.29
$1,386.73
$1,377.96
$1,434.41
$1,494.21
$1,706.65
$319.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$836.40
$949.30
$1,068.90
$1,493.78
$2,269.94
$1,156.32
$1,269.22
$1,388.82
$1,813.70
$1,476.24
$1,589.14
$1,708.74
$2,133.62
$1,796.16
$1,909.06
$2,028.66
$2,453.54
$319.92
Toc - Plan #60 Aetna CVS Health
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.60
$464.90
$523.47
$731.54
$1,111.65
$722.95
$778.25
$836.82
$1,044.89
$1,036.30
$1,091.60
$1,150.17
$1,358.24
$1,349.65
$1,404.95
$1,463.52
$1,671.59
$313.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$819.20
$929.80
$1,046.94
$1,463.08
$2,223.30
$1,132.55
$1,243.15
$1,360.29
$1,776.43
$1,445.90
$1,556.50
$1,673.64
$2,089.78
$1,759.25
$1,869.85
$1,986.99
$2,403.13
$313.35

ADVERTISEMENT

MedMutual

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

Toc - Plan #61 MedMutual
Gold

(HMO) Market HMO 2500

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
$545.64
$619.31
$697.33
$974.52
$1,480.88
$963.06
$1,036.73
$1,114.75
$1,391.94
$1,380.48
$1,454.15
$1,532.17
$1,809.36
$1,797.90
$1,871.57
$1,949.59
$2,226.78
$417.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,091.28
$1,238.62
$1,394.66
$1,949.04
$2,961.76
$1,508.70
$1,656.04
$1,812.08
$2,366.46
$1,926.12
$2,073.46
$2,229.50
$2,783.88
$2,343.54
$2,490.88
$2,646.92
$3,201.30
$417.42
Toc - Plan #62 MedMutual
Gold

(HMO) Market HMO Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$561.26
$637.03
$717.28
$1,002.40
$1,523.25
$990.62
$1,066.39
$1,146.64
$1,431.76
$1,419.98
$1,495.75
$1,576.00
$1,861.12
$1,849.34
$1,925.11
$2,005.36
$2,290.48
$429.36
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,122.52
$1,274.06
$1,434.56
$2,004.80
$3,046.50
$1,551.88
$1,703.42
$1,863.92
$2,434.16
$1,981.24
$2,132.78
$2,293.28
$2,863.52
$2,410.60
$2,562.14
$2,722.64
$3,292.88
$429.36
Toc - Plan #63 MedMutual
Silver

(HMO) Market HMO 3850

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

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$499.98
$567.48
$638.97
$892.96
$1,356.94
$882.46
$949.96
$1,021.45
$1,275.44
$1,264.94
$1,332.44
$1,403.93
$1,657.92
$1,647.42
$1,714.92
$1,786.41
$2,040.40
$382.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$999.96
$1,134.96
$1,277.94
$1,785.92
$2,713.88
$1,382.44
$1,517.44
$1,660.42
$2,168.40
$1,764.92
$1,899.92
$2,042.90
$2,550.88
$2,147.40
$2,282.40
$2,425.38
$2,933.36
$382.48
Toc - Plan #64 MedMutual
Silver

(HMO) Market HMO 4000 HSA

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
$510.13
$578.99
$651.94
$911.09
$1,384.48
$900.38
$969.24
$1,042.19
$1,301.34
$1,290.63
$1,359.49
$1,432.44
$1,691.59
$1,680.88
$1,749.74
$1,822.69
$2,081.84
$390.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,020.26
$1,157.98
$1,303.88
$1,822.18
$2,768.96
$1,410.51
$1,548.23
$1,694.13
$2,212.43
$1,800.76
$1,938.48
$2,084.38
$2,602.68
$2,191.01
$2,328.73
$2,474.63
$2,992.93
$390.25
Toc - Plan #65 MedMutual
Silver

(HMO) Market HMO Select Silver

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
$530.81
$602.47
$678.38
$948.03
$1,440.62
$936.88
$1,008.54
$1,084.45
$1,354.10
$1,342.95
$1,414.61
$1,490.52
$1,760.17
$1,749.02
$1,820.68
$1,896.59
$2,166.24
$406.07
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,061.62
$1,204.94
$1,356.76
$1,896.06
$2,881.24
$1,467.69
$1,611.01
$1,762.83
$2,302.13
$1,873.76
$2,017.08
$2,168.90
$2,708.20
$2,279.83
$2,423.15
$2,574.97
$3,114.27
$406.07
Toc - Plan #66 MedMutual
Silver

(HMO) Market HMO Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$497.64
$564.82
$635.98
$888.78
$1,350.59
$878.33
$945.51
$1,016.67
$1,269.47
$1,259.02
$1,326.20
$1,397.36
$1,650.16
$1,639.71
$1,706.89
$1,778.05
$2,030.85
$380.69
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$995.28
$1,129.64
$1,271.96
$1,777.56
$2,701.18
$1,375.97
$1,510.33
$1,652.65
$2,158.25
$1,756.66
$1,891.02
$2,033.34
$2,538.94
$2,137.35
$2,271.71
$2,414.03
$2,919.63
$380.69
Toc - Plan #67 MedMutual
Silver

(HMO) Market HMO 6900

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

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$492.95
$559.50
$629.99
$880.41
$1,337.87
$870.06
$936.61
$1,007.10
$1,257.52
$1,247.17
$1,313.72
$1,384.21
$1,634.63
$1,624.28
$1,690.83
$1,761.32
$2,011.74
$377.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$985.90
$1,119.00
$1,259.98
$1,760.82
$2,675.74
$1,363.01
$1,496.11
$1,637.09
$2,137.93
$1,740.12
$1,873.22
$2,014.20
$2,515.04
$2,117.23
$2,250.33
$2,391.31
$2,892.15
$377.11
Toc - Plan #68 MedMutual
Expanded Bronze

(HMO) Market HMO 7300 HSA

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

Annual Out of Pocket Expenses:

Individual Family
$7,300 $14,600 Annual Deductible
$7,300 $14,600 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
$361.03
$409.77
$461.40
$644.80
$979.84
$637.22
$685.96
$737.59
$920.99
$913.41
$962.15
$1,013.78
$1,197.18
$1,189.60
$1,238.34
$1,289.97
$1,473.37
$276.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$722.06
$819.54
$922.80
$1,289.60
$1,959.68
$998.25
$1,095.73
$1,198.99
$1,565.79
$1,274.44
$1,371.92
$1,475.18
$1,841.98
$1,550.63
$1,648.11
$1,751.37
$2,118.17
$276.19
Toc - Plan #69 MedMutual
Expanded Bronze

(HMO) Market HMO 8300

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

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$346.59
$393.38
$442.94
$619.01
$940.64
$611.73
$658.52
$708.08
$884.15
$876.87
$923.66
$973.22
$1,149.29
$1,142.01
$1,188.80
$1,238.36
$1,414.43
$265.14
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$693.18
$786.76
$885.88
$1,238.02
$1,881.28
$958.32
$1,051.90
$1,151.02
$1,503.16
$1,223.46
$1,317.04
$1,416.16
$1,768.30
$1,488.60
$1,582.18
$1,681.30
$2,033.44
$265.14
Toc - Plan #70 MedMutual
Expanded Bronze

(HMO) Market HMO Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$373.13
$423.50
$476.86
$666.41
$1,012.67
$658.57
$708.94
$762.30
$951.85
$944.01
$994.38
$1,047.74
$1,237.29
$1,229.45
$1,279.82
$1,333.18
$1,522.73
$285.44
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$746.26
$847.00
$953.72
$1,332.82
$2,025.34
$1,031.70
$1,132.44
$1,239.16
$1,618.26
$1,317.14
$1,417.88
$1,524.60
$1,903.70
$1,602.58
$1,703.32
$1,810.04
$2,189.14
$285.44
Toc - Plan #71 MedMutual
Bronze

(HMO) Market HMO 9450

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.47
$389.83
$438.95
$613.43
$932.17
$606.22
$652.58
$701.70
$876.18
$868.97
$915.33
$964.45
$1,138.93
$1,131.72
$1,178.08
$1,227.20
$1,401.68
$262.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.94
$779.66
$877.90
$1,226.86
$1,864.34
$949.69
$1,042.41
$1,140.65
$1,489.61
$1,212.44
$1,305.16
$1,403.40
$1,752.36
$1,475.19
$1,567.91
$1,666.15
$2,015.11
$262.75
Toc - Plan #72 MedMutual
Expanded Bronze

(HMO) Market HMO Select Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$409.04
$464.26
$522.75
$730.54
$1,110.13
$721.95
$777.17
$835.66
$1,043.45
$1,034.86
$1,090.08
$1,148.57
$1,356.36
$1,347.77
$1,402.99
$1,461.48
$1,669.27
$312.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$818.08
$928.52
$1,045.50
$1,461.08
$2,220.26
$1,130.99
$1,241.43
$1,358.41
$1,773.99
$1,443.90
$1,554.34
$1,671.32
$2,086.90
$1,756.81
$1,867.25
$1,984.23
$2,399.81
$312.91
Toc - Plan #73 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$224.42
$254.72
$286.81
$400.82
$609.09
$396.10
$426.40
$458.49
$572.50
$567.78
$598.08
$630.17
$744.18
$739.46
$769.76
$801.85
$915.86
$171.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$448.84
$509.44
$573.62
$801.64
$1,218.18
$620.52
$681.12
$745.30
$973.32
$792.20
$852.80
$916.98
$1,145.00
$963.88
$1,024.48
$1,088.66
$1,316.68
$171.68

‡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 Licking County here.

Licking County is in “Rating Area 9” of Ohio.

Currently, there are 73 plans offered in Rating Area 9.

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