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Obamacare 2023 Rates for Portage County

Obamacare > Rates > Ohio > Portage County

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

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

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

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

Obamacare Providers, 120 Plans and 2023 Rates for Portage County, Ohio

Below, you’ll find a summary of the 120 plans for Portage County, Ohio and rates for each of these providers. This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Anthem Blue Cross and Blue Shield

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

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

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$305.00
$346.18
$389.79
$544.73
$827.77
$538.33
$579.51
$623.12
$778.06
$771.66
$812.84
$856.45
$1,011.39
$1,004.99
$1,046.17
$1,089.78
$1,244.72
$233.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$610.00
$692.36
$779.58
$1,089.46
$1,655.54
$843.33
$925.69
$1,012.91
$1,322.79
$1,076.66
$1,159.02
$1,246.24
$1,556.12
$1,309.99
$1,392.35
$1,479.57
$1,789.45
$233.33
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.08
$326.97
$368.17
$514.51
$781.85
$508.46
$547.35
$588.55
$734.89
$728.84
$767.73
$808.93
$955.27
$949.22
$988.11
$1,029.31
$1,175.65
$220.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$576.16
$653.94
$736.34
$1,029.02
$1,563.70
$796.54
$874.32
$956.72
$1,249.40
$1,016.92
$1,094.70
$1,177.10
$1,469.78
$1,237.30
$1,315.08
$1,397.48
$1,690.16
$220.38
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$384.28
$436.16
$491.11
$686.32
$1,042.94
$678.25
$730.13
$785.08
$980.29
$972.22
$1,024.10
$1,079.05
$1,274.26
$1,266.19
$1,318.07
$1,373.02
$1,568.23
$293.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$768.56
$872.32
$982.22
$1,372.64
$2,085.88
$1,062.53
$1,166.29
$1,276.19
$1,666.61
$1,356.50
$1,460.26
$1,570.16
$1,960.58
$1,650.47
$1,754.23
$1,864.13
$2,254.55
$293.97
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309.43
$351.20
$395.45
$552.64
$839.79
$546.14
$587.91
$632.16
$789.35
$782.85
$824.62
$868.87
$1,026.06
$1,019.56
$1,061.33
$1,105.58
$1,262.77
$236.71
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.86
$702.40
$790.90
$1,105.28
$1,679.58
$855.57
$939.11
$1,027.61
$1,341.99
$1,092.28
$1,175.82
$1,264.32
$1,578.70
$1,328.99
$1,412.53
$1,501.03
$1,815.41
$236.71
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$386.70
$438.90
$494.20
$690.65
$1,049.50
$682.53
$734.73
$790.03
$986.48
$978.36
$1,030.56
$1,085.86
$1,282.31
$1,274.19
$1,326.39
$1,381.69
$1,578.14
$295.83
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$773.40
$877.80
$988.40
$1,381.30
$2,099.00
$1,069.23
$1,173.63
$1,284.23
$1,677.13
$1,365.06
$1,469.46
$1,580.06
$1,972.96
$1,660.89
$1,765.29
$1,875.89
$2,268.79
$295.83
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$313.48
$355.80
$400.63
$559.88
$850.78
$553.29
$595.61
$640.44
$799.69
$793.10
$835.42
$880.25
$1,039.50
$1,032.91
$1,075.23
$1,120.06
$1,279.31
$239.81
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$626.96
$711.60
$801.26
$1,119.76
$1,701.56
$866.77
$951.41
$1,041.07
$1,359.57
$1,106.58
$1,191.22
$1,280.88
$1,599.38
$1,346.39
$1,431.03
$1,520.69
$1,839.19
$239.81
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.44
$446.55
$502.82
$702.68
$1,067.80
$694.42
$747.53
$803.80
$1,003.66
$995.40
$1,048.51
$1,104.78
$1,304.64
$1,296.38
$1,349.49
$1,405.76
$1,605.62
$300.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$786.88
$893.10
$1,005.64
$1,405.36
$2,135.60
$1,087.86
$1,194.08
$1,306.62
$1,706.34
$1,388.84
$1,495.06
$1,607.60
$2,007.32
$1,689.82
$1,796.04
$1,908.58
$2,308.30
$300.98
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$393.64
$446.78
$503.07
$703.04
$1,068.34
$694.77
$747.91
$804.20
$1,004.17
$995.90
$1,049.04
$1,105.33
$1,305.30
$1,297.03
$1,350.17
$1,406.46
$1,606.43
$301.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$787.28
$893.56
$1,006.14
$1,406.08
$2,136.68
$1,088.41
$1,194.69
$1,307.27
$1,707.21
$1,389.54
$1,495.82
$1,608.40
$2,008.34
$1,690.67
$1,796.95
$1,909.53
$2,309.47
$301.13
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$7,950 $15,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$379.07
$430.24
$484.45
$677.02
$1,028.80
$669.06
$720.23
$774.44
$967.01
$959.05
$1,010.22
$1,064.43
$1,257.00
$1,249.04
$1,300.21
$1,354.42
$1,546.99
$289.99
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$758.14
$860.48
$968.90
$1,354.04
$2,057.60
$1,048.13
$1,150.47
$1,258.89
$1,644.03
$1,338.12
$1,440.46
$1,548.88
$1,934.02
$1,628.11
$1,730.45
$1,838.87
$2,224.01
$289.99
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Catastrophic

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$227.98
$258.76
$291.36
$407.17
$618.74
$402.38
$433.16
$465.76
$581.57
$576.78
$607.56
$640.16
$755.97
$751.18
$781.96
$814.56
$930.37
$174.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$455.96
$517.52
$582.72
$814.34
$1,237.48
$630.36
$691.92
$757.12
$988.74
$804.76
$866.32
$931.52
$1,163.14
$979.16
$1,040.72
$1,105.92
$1,337.54
$174.40
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$381.52
$433.03
$487.58
$681.39
$1,035.45
$673.38
$724.89
$779.44
$973.25
$965.24
$1,016.75
$1,071.30
$1,265.11
$1,257.10
$1,308.61
$1,363.16
$1,556.97
$291.86
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$763.04
$866.06
$975.16
$1,362.78
$2,070.90
$1,054.90
$1,157.92
$1,267.02
$1,654.64
$1,346.76
$1,449.78
$1,558.88
$1,946.50
$1,638.62
$1,741.64
$1,850.74
$2,238.36
$291.86
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$309.13
$350.86
$395.07
$552.11
$838.98
$545.61
$587.34
$631.55
$788.59
$782.09
$823.82
$868.03
$1,025.07
$1,018.57
$1,060.30
$1,104.51
$1,261.55
$236.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$618.26
$701.72
$790.14
$1,104.22
$1,677.96
$854.74
$938.20
$1,026.62
$1,340.70
$1,091.22
$1,174.68
$1,263.10
$1,577.18
$1,327.70
$1,411.16
$1,499.58
$1,813.66
$236.48
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$293.73
$333.38
$375.39
$524.60
$797.18
$518.43
$558.08
$600.09
$749.30
$743.13
$782.78
$824.79
$974.00
$967.83
$1,007.48
$1,049.49
$1,198.70
$224.70
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$587.46
$666.76
$750.78
$1,049.20
$1,594.36
$812.16
$891.46
$975.48
$1,273.90
$1,036.86
$1,116.16
$1,200.18
$1,498.60
$1,261.56
$1,340.86
$1,424.88
$1,723.30
$224.70
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$288.73
$327.71
$369.00
$515.67
$783.61
$509.61
$548.59
$589.88
$736.55
$730.49
$769.47
$810.76
$957.43
$951.37
$990.35
$1,031.64
$1,178.31
$220.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$577.46
$655.42
$738.00
$1,031.34
$1,567.22
$798.34
$876.30
$958.88
$1,252.22
$1,019.22
$1,097.18
$1,179.76
$1,473.10
$1,240.10
$1,318.06
$1,400.64
$1,693.98
$220.88
Toc - Plan #15 Anthem Blue Cross and Blue Shield
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.11
$358.78
$403.99
$564.57
$857.92
$557.93
$600.60
$645.81
$806.39
$799.75
$842.42
$887.63
$1,048.21
$1,041.57
$1,084.24
$1,129.45
$1,290.03
$241.82
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.22
$717.56
$807.98
$1,129.14
$1,715.84
$874.04
$959.38
$1,049.80
$1,370.96
$1,115.86
$1,201.20
$1,291.62
$1,612.78
$1,357.68
$1,443.02
$1,533.44
$1,854.60
$241.82
Toc - Plan #16 Anthem Blue Cross and Blue Shield
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$376.96
$427.85
$481.75
$673.25
$1,023.07
$665.33
$716.22
$770.12
$961.62
$953.70
$1,004.59
$1,058.49
$1,249.99
$1,242.07
$1,292.96
$1,346.86
$1,538.36
$288.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$753.92
$855.70
$963.50
$1,346.50
$2,046.14
$1,042.29
$1,144.07
$1,251.87
$1,634.87
$1,330.66
$1,432.44
$1,540.24
$1,923.24
$1,619.03
$1,720.81
$1,828.61
$2,211.61
$288.37
Toc - Plan #17 Anthem Blue Cross and Blue Shield
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$547.18
$621.05
$699.30
$977.26
$1,485.05
$965.77
$1,039.64
$1,117.89
$1,395.85
$1,384.36
$1,458.23
$1,536.48
$1,814.44
$1,802.95
$1,876.82
$1,955.07
$2,233.03
$418.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,094.36
$1,242.10
$1,398.60
$1,954.52
$2,970.10
$1,512.95
$1,660.69
$1,817.19
$2,373.11
$1,931.54
$2,079.28
$2,235.78
$2,791.70
$2,350.13
$2,497.87
$2,654.37
$3,210.29
$418.59

ADVERTISEMENT

Ambetter from Buckeye Health Plan

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

Toc - Plan #18 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$310.16
$352.02
$396.38
$553.93
$841.76
$547.43
$589.29
$633.65
$791.20
$784.70
$826.56
$870.92
$1,028.47
$1,021.97
$1,063.83
$1,108.19
$1,265.74
$237.27
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$620.32
$704.04
$792.76
$1,107.86
$1,683.52
$857.59
$941.31
$1,030.03
$1,345.13
$1,094.86
$1,178.58
$1,267.30
$1,582.40
$1,332.13
$1,415.85
$1,504.57
$1,819.67
$237.27
Toc - Plan #19 Ambetter from Buckeye Health Plan
Silver

(HMO) Everyday Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307.34
$348.82
$392.77
$548.89
$834.10
$542.45
$583.93
$627.88
$784.00
$777.56
$819.04
$862.99
$1,019.11
$1,012.67
$1,054.15
$1,098.10
$1,254.22
$235.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614.68
$697.64
$785.54
$1,097.78
$1,668.20
$849.79
$932.75
$1,020.65
$1,332.89
$1,084.90
$1,167.86
$1,255.76
$1,568.00
$1,320.01
$1,402.97
$1,490.87
$1,803.11
$235.11
Toc - Plan #20 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$331.87
$376.67
$424.12
$592.71
$900.68
$585.75
$630.55
$678.00
$846.59
$839.63
$884.43
$931.88
$1,100.47
$1,093.51
$1,138.31
$1,185.76
$1,354.35
$253.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$663.74
$753.34
$848.24
$1,185.42
$1,801.36
$917.62
$1,007.22
$1,102.12
$1,439.30
$1,171.50
$1,261.10
$1,356.00
$1,693.18
$1,425.38
$1,514.98
$1,609.88
$1,947.06
$253.88
Toc - Plan #21 Ambetter from Buckeye Health Plan
Bronze

(HMO) Clear Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$249.37
$283.03
$318.69
$445.36
$676.77
$440.13
$473.79
$509.45
$636.12
$630.89
$664.55
$700.21
$826.88
$821.65
$855.31
$890.97
$1,017.64
$190.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$498.74
$566.06
$637.38
$890.72
$1,353.54
$689.50
$756.82
$828.14
$1,081.48
$880.26
$947.58
$1,018.90
$1,272.24
$1,071.02
$1,138.34
$1,209.66
$1,463.00
$190.76
Toc - Plan #22 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$273.01
$309.85
$348.89
$487.57
$740.91
$481.85
$518.69
$557.73
$696.41
$690.69
$727.53
$766.57
$905.25
$899.53
$936.37
$975.41
$1,114.09
$208.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$546.02
$619.70
$697.78
$975.14
$1,481.82
$754.86
$828.54
$906.62
$1,183.98
$963.70
$1,037.38
$1,115.46
$1,392.82
$1,172.54
$1,246.22
$1,324.30
$1,601.66
$208.84
Toc - Plan #23 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$265.78
$301.65
$339.65
$474.67
$721.30
$469.09
$504.96
$542.96
$677.98
$672.40
$708.27
$746.27
$881.29
$875.71
$911.58
$949.58
$1,084.60
$203.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$531.56
$603.30
$679.30
$949.34
$1,442.60
$734.87
$806.61
$882.61
$1,152.65
$938.18
$1,009.92
$1,085.92
$1,355.96
$1,141.49
$1,213.23
$1,289.23
$1,559.27
$203.31
Toc - Plan #24 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$297.54
$337.70
$380.24
$531.39
$807.50
$525.15
$565.31
$607.85
$759.00
$752.76
$792.92
$835.46
$986.61
$980.37
$1,020.53
$1,063.07
$1,214.22
$227.61
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$595.08
$675.40
$760.48
$1,062.78
$1,615.00
$822.69
$903.01
$988.09
$1,290.39
$1,050.30
$1,130.62
$1,215.70
$1,518.00
$1,277.91
$1,358.23
$1,443.31
$1,745.61
$227.61
Toc - Plan #25 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$304.12
$345.16
$388.65
$543.13
$825.34
$536.76
$577.80
$621.29
$775.77
$769.40
$810.44
$853.93
$1,008.41
$1,002.04
$1,043.08
$1,086.57
$1,241.05
$232.64
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$608.24
$690.32
$777.30
$1,086.26
$1,650.68
$840.88
$922.96
$1,009.94
$1,318.90
$1,073.52
$1,155.60
$1,242.58
$1,551.54
$1,306.16
$1,388.24
$1,475.22
$1,784.18
$232.64
Toc - Plan #26 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$306.32
$347.66
$391.46
$547.07
$831.32
$540.65
$581.99
$625.79
$781.40
$774.98
$816.32
$860.12
$1,015.73
$1,009.31
$1,050.65
$1,094.45
$1,250.06
$234.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$612.64
$695.32
$782.92
$1,094.14
$1,662.64
$846.97
$929.65
$1,017.25
$1,328.47
$1,081.30
$1,163.98
$1,251.58
$1,562.80
$1,315.63
$1,398.31
$1,485.91
$1,797.13
$234.33
Toc - Plan #27 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$318.60
$361.60
$407.16
$569.00
$864.65
$562.32
$605.32
$650.88
$812.72
$806.04
$849.04
$894.60
$1,056.44
$1,049.76
$1,092.76
$1,138.32
$1,300.16
$243.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$637.20
$723.20
$814.32
$1,138.00
$1,729.30
$880.92
$966.92
$1,058.04
$1,381.72
$1,124.64
$1,210.64
$1,301.76
$1,625.44
$1,368.36
$1,454.36
$1,545.48
$1,869.16
$243.72
Toc - Plan #28 Ambetter from Buckeye Health Plan
Silver

(HMO) Enhanced Silver

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

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$305.60
$346.85
$390.55
$545.79
$829.38
$539.38
$580.63
$624.33
$779.57
$773.16
$814.41
$858.11
$1,013.35
$1,006.94
$1,048.19
$1,091.89
$1,247.13
$233.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$611.20
$693.70
$781.10
$1,091.58
$1,658.76
$844.98
$927.48
$1,014.88
$1,325.36
$1,078.76
$1,161.26
$1,248.66
$1,559.14
$1,312.54
$1,395.04
$1,482.44
$1,792.92
$233.78
Toc - Plan #29 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold

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

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314.47
$356.92
$401.89
$561.63
$853.46
$555.04
$597.49
$642.46
$802.20
$795.61
$838.06
$883.03
$1,042.77
$1,036.18
$1,078.63
$1,123.60
$1,283.34
$240.57
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.94
$713.84
$803.78
$1,123.26
$1,706.92
$869.51
$954.41
$1,044.35
$1,363.83
$1,110.08
$1,194.98
$1,284.92
$1,604.40
$1,350.65
$1,435.55
$1,525.49
$1,844.97
$240.57
Toc - Plan #30 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) CMS Standard Expanded Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$260.66
$295.84
$333.11
$465.53
$707.41
$460.06
$495.24
$532.51
$664.93
$659.46
$694.64
$731.91
$864.33
$858.86
$894.04
$931.31
$1,063.73
$199.40
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$521.32
$591.68
$666.22
$931.06
$1,414.82
$720.72
$791.08
$865.62
$1,130.46
$920.12
$990.48
$1,065.02
$1,329.86
$1,119.52
$1,189.88
$1,264.42
$1,529.26
$199.40
Toc - Plan #31 Ambetter from Buckeye Health Plan
Silver

(HMO) CMS Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.68
$344.67
$388.09
$542.36
$824.16
$535.99
$576.98
$620.40
$774.67
$768.30
$809.29
$852.71
$1,006.98
$1,000.61
$1,041.60
$1,085.02
$1,239.29
$232.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607.36
$689.34
$776.18
$1,084.72
$1,648.32
$839.67
$921.65
$1,008.49
$1,317.03
$1,071.98
$1,153.96
$1,240.80
$1,549.34
$1,304.29
$1,386.27
$1,473.11
$1,781.65
$232.31
Toc - Plan #32 Ambetter from Buckeye Health Plan
Gold

(HMO) CMS Standard Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.40
$359.10
$404.34
$565.07
$858.68
$558.44
$601.14
$646.38
$807.11
$800.48
$843.18
$888.42
$1,049.15
$1,042.52
$1,085.22
$1,130.46
$1,291.19
$242.04
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.80
$718.20
$808.68
$1,130.14
$1,717.36
$874.84
$960.24
$1,050.72
$1,372.18
$1,116.88
$1,202.28
$1,292.76
$1,614.22
$1,358.92
$1,444.32
$1,534.80
$1,856.26
$242.04
Toc - Plan #33 Ambetter from Buckeye Health Plan
Silver

(HMO) Everyday Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.53
$360.38
$405.79
$567.09
$861.75
$560.43
$603.28
$648.69
$809.99
$803.33
$846.18
$891.59
$1,052.89
$1,046.23
$1,089.08
$1,134.49
$1,295.79
$242.90
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$635.06
$720.76
$811.58
$1,134.18
$1,723.50
$877.96
$963.66
$1,054.48
$1,377.08
$1,120.86
$1,206.56
$1,297.38
$1,619.98
$1,363.76
$1,449.46
$1,540.28
$1,862.88
$242.90
Toc - Plan #34 Ambetter from Buckeye Health Plan
Silver

(HMO) Complete Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.44
$363.69
$409.52
$572.30
$869.66
$565.57
$608.82
$654.65
$817.43
$810.70
$853.95
$899.78
$1,062.56
$1,055.83
$1,099.08
$1,144.91
$1,307.69
$245.13
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$640.88
$727.38
$819.04
$1,144.60
$1,739.32
$886.01
$972.51
$1,064.17
$1,389.73
$1,131.14
$1,217.64
$1,309.30
$1,634.86
$1,376.27
$1,462.77
$1,554.43
$1,879.99
$245.13
Toc - Plan #35 Ambetter from Buckeye Health Plan
Gold

(HMO) Complete Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.88
$389.15
$438.18
$612.36
$930.54
$605.17
$651.44
$700.47
$874.65
$867.46
$913.73
$962.76
$1,136.94
$1,129.75
$1,176.02
$1,225.05
$1,399.23
$262.29
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$685.76
$778.30
$876.36
$1,224.72
$1,861.08
$948.05
$1,040.59
$1,138.65
$1,487.01
$1,210.34
$1,302.88
$1,400.94
$1,749.30
$1,472.63
$1,565.17
$1,663.23
$2,011.59
$262.29
Toc - Plan #36 Ambetter from Buckeye Health Plan
Bronze

(HMO) Clear Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$257.64
$292.41
$329.25
$460.13
$699.21
$454.73
$489.50
$526.34
$657.22
$651.82
$686.59
$723.43
$854.31
$848.91
$883.68
$920.52
$1,051.40
$197.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$515.28
$584.82
$658.50
$920.26
$1,398.42
$712.37
$781.91
$855.59
$1,117.35
$909.46
$979.00
$1,052.68
$1,314.44
$1,106.55
$1,176.09
$1,249.77
$1,511.53
$197.09
Toc - Plan #37 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Choice Bronze HSA + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$282.06
$320.12
$360.46
$503.74
$765.47
$497.83
$535.89
$576.23
$719.51
$713.60
$751.66
$792.00
$935.28
$929.37
$967.43
$1,007.77
$1,151.05
$215.77
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$564.12
$640.24
$720.92
$1,007.48
$1,530.94
$779.89
$856.01
$936.69
$1,223.25
$995.66
$1,071.78
$1,152.46
$1,439.02
$1,211.43
$1,287.55
$1,368.23
$1,654.79
$215.77
Toc - Plan #38 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Everyday Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$274.59
$311.65
$350.91
$490.40
$745.21
$484.64
$521.70
$560.96
$700.45
$694.69
$731.75
$771.01
$910.50
$904.74
$941.80
$981.06
$1,120.55
$210.05
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$549.18
$623.30
$701.82
$980.80
$1,490.42
$759.23
$833.35
$911.87
$1,190.85
$969.28
$1,043.40
$1,121.92
$1,400.90
$1,179.33
$1,253.45
$1,331.97
$1,610.95
$210.05
Toc - Plan #39 Ambetter from Buckeye Health Plan
Expanded Bronze

(HMO) Elite Bronze + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$307.40
$348.89
$392.85
$549.00
$834.27
$542.56
$584.05
$628.01
$784.16
$777.72
$819.21
$863.17
$1,019.32
$1,012.88
$1,054.37
$1,098.33
$1,254.48
$235.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614.80
$697.78
$785.70
$1,098.00
$1,668.54
$849.96
$932.94
$1,020.86
$1,333.16
$1,085.12
$1,168.10
$1,256.02
$1,568.32
$1,320.28
$1,403.26
$1,491.18
$1,803.48
$235.16
Toc - Plan #40 Ambetter from Buckeye Health Plan
Silver

(HMO) Clear Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314.20
$356.60
$401.53
$561.14
$852.70
$554.55
$596.95
$641.88
$801.49
$794.90
$837.30
$882.23
$1,041.84
$1,035.25
$1,077.65
$1,122.58
$1,282.19
$240.35
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.40
$713.20
$803.06
$1,122.28
$1,705.40
$868.75
$953.55
$1,043.41
$1,362.63
$1,109.10
$1,193.90
$1,283.76
$1,602.98
$1,349.45
$1,434.25
$1,524.11
$1,843.33
$240.35
Toc - Plan #41 Ambetter from Buckeye Health Plan
Silver

(HMO) Focused Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$316.47
$359.18
$404.44
$565.20
$858.88
$558.56
$601.27
$646.53
$807.29
$800.65
$843.36
$888.62
$1,049.38
$1,042.74
$1,085.45
$1,130.71
$1,291.47
$242.09
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$632.94
$718.36
$808.88
$1,130.40
$1,717.76
$875.03
$960.45
$1,050.97
$1,372.49
$1,117.12
$1,202.54
$1,293.06
$1,614.58
$1,359.21
$1,444.63
$1,535.15
$1,856.67
$242.09
Toc - Plan #42 Ambetter from Buckeye Health Plan
Gold

(HMO) Everyday Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$329.16
$373.59
$420.65
$587.86
$893.32
$580.96
$625.39
$672.45
$839.66
$832.76
$877.19
$924.25
$1,091.46
$1,084.56
$1,128.99
$1,176.05
$1,343.26
$251.80
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$658.32
$747.18
$841.30
$1,175.72
$1,786.64
$910.12
$998.98
$1,093.10
$1,427.52
$1,161.92
$1,250.78
$1,344.90
$1,679.32
$1,413.72
$1,502.58
$1,596.70
$1,931.12
$251.80
Toc - Plan #43 Ambetter from Buckeye Health Plan
Silver

(HMO) Enhanced Silver + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$3,850 $7,700 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$315.73
$358.35
$403.50
$563.88
$856.88
$557.26
$599.88
$645.03
$805.41
$798.79
$841.41
$886.56
$1,046.94
$1,040.32
$1,082.94
$1,128.09
$1,288.47
$241.53
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$631.46
$716.70
$807.00
$1,127.76
$1,713.76
$872.99
$958.23
$1,048.53
$1,369.29
$1,114.52
$1,199.76
$1,290.06
$1,610.82
$1,356.05
$1,441.29
$1,531.59
$1,852.35
$241.53
Toc - Plan #44 Ambetter from Buckeye Health Plan
Gold

(HMO) Clear Gold + Vision + Adult Dental

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

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.90
$368.75
$415.21
$580.25
$881.75
$573.44
$617.29
$663.75
$828.79
$821.98
$865.83
$912.29
$1,077.33
$1,070.52
$1,114.37
$1,160.83
$1,325.87
$248.54
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.80
$737.50
$830.42
$1,160.50
$1,763.50
$898.34
$986.04
$1,078.96
$1,409.04
$1,146.88
$1,234.58
$1,327.50
$1,657.58
$1,395.42
$1,483.12
$1,576.04
$1,906.12
$248.54
Toc - Plan #45 Ambetter from Buckeye Health Plan
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$260.29
$295.42
$332.64
$464.86
$706.40
$459.40
$494.53
$531.75
$663.97
$658.51
$693.64
$730.86
$863.08
$857.62
$892.75
$929.97
$1,062.19
$199.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$520.58
$590.84
$665.28
$929.72
$1,412.80
$719.69
$789.95
$864.39
$1,128.83
$918.80
$989.06
$1,063.50
$1,327.94
$1,117.91
$1,188.17
$1,262.61
$1,527.05
$199.11
Toc - Plan #46 Ambetter from Buckeye Health Plan
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$300.55
$341.11
$384.09
$536.76
$815.66
$530.46
$571.02
$614.00
$766.67
$760.37
$800.93
$843.91
$996.58
$990.28
$1,030.84
$1,073.82
$1,226.49
$229.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$601.10
$682.22
$768.18
$1,073.52
$1,631.32
$831.01
$912.13
$998.09
$1,303.43
$1,060.92
$1,142.04
$1,228.00
$1,533.34
$1,290.83
$1,371.95
$1,457.91
$1,763.25
$229.91
Toc - Plan #47 Ambetter from Buckeye Health Plan
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.00
$362.06
$407.67
$569.72
$865.75
$563.03
$606.09
$651.70
$813.75
$807.06
$850.12
$895.73
$1,057.78
$1,051.09
$1,094.15
$1,139.76
$1,301.81
$244.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$638.00
$724.12
$815.34
$1,139.44
$1,731.50
$882.03
$968.15
$1,059.37
$1,383.47
$1,126.06
$1,212.18
$1,303.40
$1,627.50
$1,370.09
$1,456.21
$1,547.43
$1,871.53
$244.03

ADVERTISEMENT

Oscar Insurance Corporation of Ohio

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

Toc - Plan #48 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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
$361.55
$410.35
$462.05
$645.72
$981.23
$638.13
$686.93
$738.63
$922.30
$914.71
$963.51
$1,015.21
$1,198.88
$1,191.29
$1,240.09
$1,291.79
$1,475.46
$276.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$723.10
$820.70
$924.10
$1,291.44
$1,962.46
$999.68
$1,097.28
$1,200.68
$1,568.02
$1,276.26
$1,373.86
$1,477.26
$1,844.60
$1,552.84
$1,650.44
$1,753.84
$2,121.18
$276.58
Toc - Plan #49 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- PCP Saver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$368.32
$418.03
$470.70
$657.80
$999.59
$650.08
$699.79
$752.46
$939.56
$931.84
$981.55
$1,034.22
$1,221.32
$1,213.60
$1,263.31
$1,315.98
$1,503.08
$281.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$736.64
$836.06
$941.40
$1,315.60
$1,999.18
$1,018.40
$1,117.82
$1,223.16
$1,597.36
$1,300.16
$1,399.58
$1,504.92
$1,879.12
$1,581.92
$1,681.34
$1,786.68
$2,160.88
$281.76
Toc - Plan #50 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic

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
$363.72
$412.81
$464.82
$649.58
$987.10
$641.96
$691.05
$743.06
$927.82
$920.20
$969.29
$1,021.30
$1,206.06
$1,198.44
$1,247.53
$1,299.54
$1,484.30
$278.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$727.44
$825.62
$929.64
$1,299.16
$1,974.20
$1,005.68
$1,103.86
$1,207.88
$1,577.40
$1,283.92
$1,382.10
$1,486.12
$1,855.64
$1,562.16
$1,660.34
$1,764.36
$2,133.88
$278.24
Toc - Plan #51 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Elite- Deductible+PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,100 $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
$420.87
$477.67
$537.85
$751.65
$1,142.20
$742.82
$799.62
$859.80
$1,073.60
$1,064.77
$1,121.57
$1,181.75
$1,395.55
$1,386.72
$1,443.52
$1,503.70
$1,717.50
$321.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$841.74
$955.34
$1,075.70
$1,503.30
$2,284.40
$1,163.69
$1,277.29
$1,397.65
$1,825.25
$1,485.64
$1,599.24
$1,719.60
$2,147.20
$1,807.59
$1,921.19
$2,041.55
$2,469.15
$321.95
Toc - Plan #52 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.11
$502.92
$566.28
$791.37
$1,202.57
$782.08
$841.89
$905.25
$1,130.34
$1,121.05
$1,180.86
$1,244.22
$1,469.31
$1,460.02
$1,519.83
$1,583.19
$1,808.28
$338.97
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.22
$1,005.84
$1,132.56
$1,582.74
$2,405.14
$1,225.19
$1,344.81
$1,471.53
$1,921.71
$1,564.16
$1,683.78
$1,810.50
$2,260.68
$1,903.13
$2,022.75
$2,149.47
$2,599.65
$338.97
Toc - Plan #53 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple

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
$434.54
$493.19
$555.33
$776.07
$1,179.32
$766.96
$825.61
$887.75
$1,108.49
$1,099.38
$1,158.03
$1,220.17
$1,440.91
$1,431.80
$1,490.45
$1,552.59
$1,773.33
$332.42
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$869.08
$986.38
$1,110.66
$1,552.14
$2,358.64
$1,201.50
$1,318.80
$1,443.08
$1,884.56
$1,533.92
$1,651.22
$1,775.50
$2,216.98
$1,866.34
$1,983.64
$2,107.92
$2,549.40
$332.42
Toc - Plan #54 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,650 $17,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$443.02
$502.82
$566.17
$791.22
$1,202.34
$781.93
$841.73
$905.08
$1,130.13
$1,120.84
$1,180.64
$1,243.99
$1,469.04
$1,459.75
$1,519.55
$1,582.90
$1,807.95
$338.91
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$886.04
$1,005.64
$1,132.34
$1,582.44
$2,404.68
$1,224.95
$1,344.55
$1,471.25
$1,921.35
$1,563.86
$1,683.46
$1,810.16
$2,260.26
$1,902.77
$2,022.37
$2,149.07
$2,599.17
$338.91
Toc - Plan #55 Oscar Insurance Corporation of Ohio
Catastrophic

(HMO) Secure

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$262.12
$297.50
$334.98
$468.13
$711.37
$462.63
$498.01
$535.49
$668.64
$663.14
$698.52
$736.00
$869.15
$863.65
$899.03
$936.51
$1,069.66
$200.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$524.24
$595.00
$669.96
$936.26
$1,422.74
$724.75
$795.51
$870.47
$1,136.77
$925.26
$996.02
$1,070.98
$1,337.28
$1,125.77
$1,196.53
$1,271.49
$1,537.79
$200.51
Toc - Plan #56 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Elite- Deductible+Specialist Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$421.33
$478.20
$538.45
$752.48
$1,143.46
$743.64
$800.51
$860.76
$1,074.79
$1,065.95
$1,122.82
$1,183.07
$1,397.10
$1,388.26
$1,445.13
$1,505.38
$1,719.41
$322.31
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$842.66
$956.40
$1,076.90
$1,504.96
$2,286.92
$1,164.97
$1,278.71
$1,399.21
$1,827.27
$1,487.28
$1,601.02
$1,721.52
$2,149.58
$1,809.59
$1,923.33
$2,043.83
$2,471.89
$322.31
Toc - Plan #57 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic

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
$503.18
$571.09
$643.05
$898.66
$1,365.59
$888.10
$956.01
$1,027.97
$1,283.58
$1,273.02
$1,340.93
$1,412.89
$1,668.50
$1,657.94
$1,725.85
$1,797.81
$2,053.42
$384.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,006.36
$1,142.18
$1,286.10
$1,797.32
$2,731.18
$1,391.28
$1,527.10
$1,671.02
$2,182.24
$1,776.20
$1,912.02
$2,055.94
$2,567.16
$2,161.12
$2,296.94
$2,440.86
$2,952.08
$384.92
Toc - Plan #58 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$5,200 $10,400 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$395.94
$449.39
$506.00
$707.14
$1,074.56
$698.83
$752.28
$808.89
$1,010.03
$1,001.72
$1,055.17
$1,111.78
$1,312.92
$1,304.61
$1,358.06
$1,414.67
$1,615.81
$302.89
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$791.88
$898.78
$1,012.00
$1,414.28
$2,149.12
$1,094.77
$1,201.67
$1,314.89
$1,717.17
$1,397.66
$1,504.56
$1,617.78
$2,020.06
$1,700.55
$1,807.45
$1,920.67
$2,322.95
$302.89
Toc - Plan #59 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- Specialist Saver

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

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 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
$437.29
$496.32
$558.85
$780.99
$1,186.79
$771.81
$830.84
$893.37
$1,115.51
$1,106.33
$1,165.36
$1,227.89
$1,450.03
$1,440.85
$1,499.88
$1,562.41
$1,784.55
$334.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$874.58
$992.64
$1,117.70
$1,561.98
$2,373.58
$1,209.10
$1,327.16
$1,452.22
$1,896.50
$1,543.62
$1,661.68
$1,786.74
$2,231.02
$1,878.14
$1,996.20
$2,121.26
$2,565.54
$334.52
Toc - Plan #60 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,400 $16,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$451.03
$511.91
$576.40
$805.52
$1,224.07
$796.06
$856.94
$921.43
$1,150.55
$1,141.09
$1,201.97
$1,266.46
$1,495.58
$1,486.12
$1,547.00
$1,611.49
$1,840.61
$345.03
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$902.06
$1,023.82
$1,152.80
$1,611.04
$2,448.14
$1,247.09
$1,368.85
$1,497.83
$1,956.07
$1,592.12
$1,713.88
$1,842.86
$2,301.10
$1,937.15
$2,058.91
$2,187.89
$2,646.13
$345.03
Toc - Plan #61 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Deductible Saver

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

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$9,000 $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
$472.01
$535.72
$603.22
$842.99
$1,281.01
$833.09
$896.80
$964.30
$1,204.07
$1,194.17
$1,257.88
$1,325.38
$1,565.15
$1,555.25
$1,618.96
$1,686.46
$1,926.23
$361.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$944.02
$1,071.44
$1,206.44
$1,685.98
$2,562.02
$1,305.10
$1,432.52
$1,567.52
$2,047.06
$1,666.18
$1,793.60
$1,928.60
$2,408.14
$2,027.26
$2,154.68
$2,289.68
$2,769.22
$361.08
Toc - Plan #62 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- PCP Saver Plus

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

Annual Out of Pocket Expenses:

Individual Family
$8,500 $17,000 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
$378.23
$429.28
$483.37
$675.50
$1,026.50
$667.57
$718.62
$772.71
$964.84
$956.91
$1,007.96
$1,062.05
$1,254.18
$1,246.25
$1,297.30
$1,351.39
$1,543.52
$289.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$756.46
$858.56
$966.74
$1,351.00
$2,053.00
$1,045.80
$1,147.90
$1,256.08
$1,640.34
$1,335.14
$1,437.24
$1,545.42
$1,929.68
$1,624.48
$1,726.58
$1,834.76
$2,219.02
$289.34
Toc - Plan #63 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- Deductible Saver

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
$385.31
$437.32
$492.41
$688.15
$1,045.71
$680.07
$732.08
$787.17
$982.91
$974.83
$1,026.84
$1,081.93
$1,277.67
$1,269.59
$1,321.60
$1,376.69
$1,572.43
$294.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$770.62
$874.64
$984.82
$1,376.30
$2,091.42
$1,065.38
$1,169.40
$1,279.58
$1,671.06
$1,360.14
$1,464.16
$1,574.34
$1,965.82
$1,654.90
$1,758.92
$1,869.10
$2,260.58
$294.76
Toc - Plan #64 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- PCP Saver

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

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 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
$428.74
$486.61
$547.92
$765.72
$1,163.58
$756.72
$814.59
$875.90
$1,093.70
$1,084.70
$1,142.57
$1,203.88
$1,421.68
$1,412.68
$1,470.55
$1,531.86
$1,749.66
$327.98
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.48
$973.22
$1,095.84
$1,531.44
$2,327.16
$1,185.46
$1,301.20
$1,423.82
$1,859.42
$1,513.44
$1,629.18
$1,751.80
$2,187.40
$1,841.42
$1,957.16
$2,079.78
$2,515.38
$327.98
Toc - Plan #65 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- HSA

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

Annual Out of Pocket Expenses:

Individual Family
$4,850 $9,700 Annual Deductible
$4,850 $9,700 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
$466.18
$529.11
$595.77
$832.58
$1,265.19
$822.80
$885.73
$952.39
$1,189.20
$1,179.42
$1,242.35
$1,309.01
$1,545.82
$1,536.04
$1,598.97
$1,665.63
$1,902.44
$356.62
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$932.36
$1,058.22
$1,191.54
$1,665.16
$2,530.38
$1,288.98
$1,414.84
$1,548.16
$2,021.78
$1,645.60
$1,771.46
$1,904.78
$2,378.40
$2,002.22
$2,128.08
$2,261.40
$2,735.02
$356.62
Toc - Plan #66 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$453.75
$515.00
$579.88
$810.38
$1,231.46
$800.86
$862.11
$926.99
$1,157.49
$1,147.97
$1,209.22
$1,274.10
$1,504.60
$1,495.08
$1,556.33
$1,621.21
$1,851.71
$347.11
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$907.50
$1,030.00
$1,159.76
$1,620.76
$2,462.92
$1,254.61
$1,377.11
$1,506.87
$1,967.87
$1,601.72
$1,724.22
$1,853.98
$2,314.98
$1,948.83
$2,071.33
$2,201.09
$2,662.09
$347.11
Toc - Plan #67 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite- Deductible Saver Plus

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$550.27
$624.54
$703.23
$982.76
$1,493.39
$971.22
$1,045.49
$1,124.18
$1,403.71
$1,392.17
$1,466.44
$1,545.13
$1,824.66
$1,813.12
$1,887.39
$1,966.08
$2,245.61
$420.95
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,100.54
$1,249.08
$1,406.46
$1,965.52
$2,986.78
$1,521.49
$1,670.03
$1,827.41
$2,386.47
$1,942.44
$2,090.98
$2,248.36
$2,807.42
$2,363.39
$2,511.93
$2,669.31
$3,228.37
$420.95
Toc - Plan #68 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Elite

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

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$5,500 $11,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$525.70
$596.66
$671.83
$938.88
$1,426.72
$927.85
$998.81
$1,073.98
$1,341.03
$1,330.00
$1,400.96
$1,476.13
$1,743.18
$1,732.15
$1,803.11
$1,878.28
$2,145.33
$402.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,051.40
$1,193.32
$1,343.66
$1,877.76
$2,853.44
$1,453.55
$1,595.47
$1,745.81
$2,279.91
$1,855.70
$1,997.62
$2,147.96
$2,682.06
$2,257.85
$2,399.77
$2,550.11
$3,084.21
$402.15
Toc - Plan #69 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Simple- For Diabetes

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$434.10
$492.69
$554.77
$775.29
$1,178.13
$766.18
$824.77
$886.85
$1,107.37
$1,098.26
$1,156.85
$1,218.93
$1,439.45
$1,430.34
$1,488.93
$1,551.01
$1,771.53
$332.08
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$868.20
$985.38
$1,109.54
$1,550.58
$2,356.26
$1,200.28
$1,317.46
$1,441.62
$1,882.66
$1,532.36
$1,649.54
$1,773.70
$2,214.74
$1,864.44
$1,981.62
$2,105.78
$2,546.82
$332.08
Toc - Plan #70 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Specialist Saver

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
$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
$435.89
$494.72
$557.05
$778.48
$1,182.98
$769.34
$828.17
$890.50
$1,111.93
$1,102.79
$1,161.62
$1,223.95
$1,445.38
$1,436.24
$1,495.07
$1,557.40
$1,778.83
$333.45
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$871.78
$989.44
$1,114.10
$1,556.96
$2,365.96
$1,205.23
$1,322.89
$1,447.55
$1,890.41
$1,538.68
$1,656.34
$1,781.00
$2,223.86
$1,872.13
$1,989.79
$2,114.45
$2,557.31
$333.45
Toc - Plan #71 Oscar Insurance Corporation of Ohio
Expanded Bronze

(HMO) Bronze Classic- Standard

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

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $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
$378.93
$430.08
$484.27
$676.76
$1,028.40
$668.81
$719.96
$774.15
$966.64
$958.69
$1,009.84
$1,064.03
$1,256.52
$1,248.57
$1,299.72
$1,353.91
$1,546.40
$289.88
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$757.86
$860.16
$968.54
$1,353.52
$2,056.80
$1,047.74
$1,150.04
$1,258.42
$1,643.40
$1,337.62
$1,439.92
$1,548.30
$1,933.28
$1,627.50
$1,729.80
$1,838.18
$2,223.16
$289.88
Toc - Plan #72 Oscar Insurance Corporation of Ohio
Bronze

(HMO) Bronze Simple- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.39
$401.08
$451.62
$631.13
$959.07
$623.72
$671.41
$721.95
$901.46
$894.05
$941.74
$992.28
$1,171.79
$1,164.38
$1,212.07
$1,262.61
$1,442.12
$270.33
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$706.78
$802.16
$903.24
$1,262.26
$1,918.14
$977.11
$1,072.49
$1,173.57
$1,532.59
$1,247.44
$1,342.82
$1,443.90
$1,802.92
$1,517.77
$1,613.15
$1,714.23
$2,073.25
$270.33
Toc - Plan #73 Oscar Insurance Corporation of Ohio
Silver

(HMO) Silver Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$428.96
$486.86
$548.20
$766.11
$1,164.17
$757.11
$815.01
$876.35
$1,094.26
$1,085.26
$1,143.16
$1,204.50
$1,422.41
$1,413.41
$1,471.31
$1,532.65
$1,750.56
$328.15
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$857.92
$973.72
$1,096.40
$1,532.22
$2,328.34
$1,186.07
$1,301.87
$1,424.55
$1,860.37
$1,514.22
$1,630.02
$1,752.70
$2,188.52
$1,842.37
$1,958.17
$2,080.85
$2,516.67
$328.15
Toc - Plan #74 Oscar Insurance Corporation of Ohio
Gold

(HMO) Gold Classic- Standard

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$484.61
$550.02
$619.32
$865.50
$1,315.21
$855.33
$920.74
$990.04
$1,236.22
$1,226.05
$1,291.46
$1,360.76
$1,606.94
$1,596.77
$1,662.18
$1,731.48
$1,977.66
$370.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$969.22
$1,100.04
$1,238.64
$1,731.00
$2,630.42
$1,339.94
$1,470.76
$1,609.36
$2,101.72
$1,710.66
$1,841.48
$1,980.08
$2,472.44
$2,081.38
$2,212.20
$2,350.80
$2,843.16
$370.72

ADVERTISEMENT

SummaCare

Local: 1-330-996-8675 | Toll Free: 1-888-996-8675 | TTY: 1-800-750-0750

Toc - Plan #75 SummaCare
Catastrophic

(HMO) SummaCare Value with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$191.10
$216.89
$244.22
$341.30
$518.63
$337.29
$363.08
$390.41
$487.49
$483.48
$509.27
$536.60
$633.68
$629.67
$655.46
$682.79
$779.87
$146.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$382.20
$433.78
$488.44
$682.60
$1,037.26
$528.39
$579.97
$634.63
$828.79
$674.58
$726.16
$780.82
$974.98
$820.77
$872.35
$927.01
$1,121.17
$146.19
Toc - Plan #76 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 9100 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$257.20
$291.91
$328.69
$459.35
$698.02
$453.95
$488.66
$525.44
$656.10
$650.70
$685.41
$722.19
$852.85
$847.45
$882.16
$918.94
$1,049.60
$196.75
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$514.40
$583.82
$657.38
$918.70
$1,396.04
$711.15
$780.57
$854.13
$1,115.45
$907.90
$977.32
$1,050.88
$1,312.20
$1,104.65
$1,174.07
$1,247.63
$1,508.95
$196.75
Toc - Plan #77 SummaCare
Silver

(HMO) SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$354.94
$402.84
$453.60
$633.90
$963.27
$626.46
$674.36
$725.12
$905.42
$897.98
$945.88
$996.64
$1,176.94
$1,169.50
$1,217.40
$1,268.16
$1,448.46
$271.52
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$709.88
$805.68
$907.20
$1,267.80
$1,926.54
$981.40
$1,077.20
$1,178.72
$1,539.32
$1,252.92
$1,348.72
$1,450.24
$1,810.84
$1,524.44
$1,620.24
$1,721.76
$2,082.36
$271.52
Toc - Plan #78 SummaCare
Silver

(HMO) SummaCare Silver 5000 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$343.11
$389.41
$438.48
$612.77
$931.16
$605.58
$651.88
$700.95
$875.24
$868.05
$914.35
$963.42
$1,137.71
$1,130.52
$1,176.82
$1,225.89
$1,400.18
$262.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$686.22
$778.82
$876.96
$1,225.54
$1,862.32
$948.69
$1,041.29
$1,139.43
$1,488.01
$1,211.16
$1,303.76
$1,401.90
$1,750.48
$1,473.63
$1,566.23
$1,664.37
$2,012.95
$262.47
Toc - Plan #79 SummaCare
Silver

(HMO) SummaCare Silver 5000 40 with SCConnect Network and 3 Free PCP Visits +Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$320.99
$364.31
$410.21
$573.27
$871.13
$566.54
$609.86
$655.76
$818.82
$812.09
$855.41
$901.31
$1,064.37
$1,057.64
$1,100.96
$1,146.86
$1,309.92
$245.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$641.98
$728.62
$820.42
$1,146.54
$1,742.26
$887.53
$974.17
$1,065.97
$1,392.09
$1,133.08
$1,219.72
$1,311.52
$1,637.64
$1,378.63
$1,465.27
$1,557.07
$1,883.19
$245.55
Toc - Plan #80 SummaCare
Gold

(HMO) SummaCare Gold 2000 with SCConnect Network and 3 Free PCP Visits + Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.77
$426.49
$480.22
$671.11
$1,019.81
$663.23
$713.95
$767.68
$958.57
$950.69
$1,001.41
$1,055.14
$1,246.03
$1,238.15
$1,288.87
$1,342.60
$1,533.49
$287.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$751.54
$852.98
$960.44
$1,342.22
$2,039.62
$1,039.00
$1,140.44
$1,247.90
$1,629.68
$1,326.46
$1,427.90
$1,535.36
$1,917.14
$1,613.92
$1,715.36
$1,822.82
$2,204.60
$287.46
Toc - Plan #81 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 7000 HSA with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$285.24
$323.73
$364.52
$509.42
$774.11
$503.44
$541.93
$582.72
$727.62
$721.64
$760.13
$800.92
$945.82
$939.84
$978.33
$1,019.12
$1,164.02
$218.20
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$570.48
$647.46
$729.04
$1,018.84
$1,548.22
$788.68
$865.66
$947.24
$1,237.04
$1,006.88
$1,083.86
$1,165.44
$1,455.24
$1,225.08
$1,302.06
$1,383.64
$1,673.44
$218.20
Toc - Plan #82 SummaCare
Silver

(HMO) SummaCare Silver 6000 with SCConnect Network and 3 Free PCP Visits +Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,600 $15,200 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
$307.87
$349.42
$393.45
$549.84
$835.53
$543.38
$584.93
$628.96
$785.35
$778.89
$820.44
$864.47
$1,020.86
$1,014.40
$1,055.95
$1,099.98
$1,256.37
$235.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$615.74
$698.84
$786.90
$1,099.68
$1,671.06
$851.25
$934.35
$1,022.41
$1,335.19
$1,086.76
$1,169.86
$1,257.92
$1,570.70
$1,322.27
$1,405.37
$1,493.43
$1,806.21
$235.51
Toc - Plan #83 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 9100 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$256.43
$291.04
$327.71
$457.97
$695.93
$452.59
$487.20
$523.87
$654.13
$648.75
$683.36
$720.03
$850.29
$844.91
$879.52
$916.19
$1,046.45
$196.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$512.86
$582.08
$655.42
$915.94
$1,391.86
$709.02
$778.24
$851.58
$1,112.10
$905.18
$974.40
$1,047.74
$1,308.26
$1,101.34
$1,170.56
$1,243.90
$1,504.42
$196.16
Toc - Plan #84 SummaCare
Bronze

(HMO) SummaCare Bronze 8000 with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$238.94
$271.19
$305.36
$426.73
$648.46
$421.72
$453.97
$488.14
$609.51
$604.50
$636.75
$670.92
$792.29
$787.28
$819.53
$853.70
$975.07
$182.78
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$477.88
$542.38
$610.72
$853.46
$1,296.92
$660.66
$725.16
$793.50
$1,036.24
$843.44
$907.94
$976.28
$1,219.02
$1,026.22
$1,090.72
$1,159.06
$1,401.80
$182.78
Toc - Plan #85 SummaCare
Silver

(HMO) SummaCare Silver 5000 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$342.08
$388.25
$437.16
$610.93
$928.37
$603.76
$649.93
$698.84
$872.61
$865.44
$911.61
$960.52
$1,134.29
$1,127.12
$1,173.29
$1,222.20
$1,395.97
$261.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$684.16
$776.50
$874.32
$1,221.86
$1,856.74
$945.84
$1,038.18
$1,136.00
$1,483.54
$1,207.52
$1,299.86
$1,397.68
$1,745.22
$1,469.20
$1,561.54
$1,659.36
$2,006.90
$261.68
Toc - Plan #86 SummaCare
Silver

(HMO) SummaCare Silver 5000 40 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$5,000 $10,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$319.96
$363.14
$408.89
$571.43
$868.34
$564.72
$607.90
$653.65
$816.19
$809.48
$852.66
$898.41
$1,060.95
$1,054.24
$1,097.42
$1,143.17
$1,305.71
$244.76
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$639.92
$726.28
$817.78
$1,142.86
$1,736.68
$884.68
$971.04
$1,062.54
$1,387.62
$1,129.44
$1,215.80
$1,307.30
$1,632.38
$1,374.20
$1,460.56
$1,552.06
$1,877.14
$244.76
Toc - Plan #87 SummaCare
Gold

(HMO) SummaCare Gold 2000 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$374.48
$425.03
$478.58
$668.81
$1,016.32
$660.95
$711.50
$765.05
$955.28
$947.42
$997.97
$1,051.52
$1,241.75
$1,233.89
$1,284.44
$1,337.99
$1,528.22
$286.47
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$748.96
$850.06
$957.16
$1,337.62
$2,032.64
$1,035.43
$1,136.53
$1,243.63
$1,624.09
$1,321.90
$1,423.00
$1,530.10
$1,910.56
$1,608.37
$1,709.47
$1,816.57
$2,197.03
$286.47
Toc - Plan #88 SummaCare
Expanded Bronze

(HMO) SummaCare Bronze 7000 HSA with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$284.21
$322.57
$363.21
$507.58
$771.32
$501.62
$539.98
$580.62
$724.99
$719.03
$757.39
$798.03
$942.40
$936.44
$974.80
$1,015.44
$1,159.81
$217.41
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$568.42
$645.14
$726.42
$1,015.16
$1,542.64
$785.83
$862.55
$943.83
$1,232.57
$1,003.24
$1,079.96
$1,161.24
$1,449.98
$1,220.65
$1,297.37
$1,378.65
$1,667.39
$217.41
Toc - Plan #89 SummaCare
Silver

(HMO) SummaCare Silver 3500 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$353.91
$401.67
$452.28
$632.06
$960.48
$624.64
$672.40
$723.01
$902.79
$895.37
$943.13
$993.74
$1,173.52
$1,166.10
$1,213.86
$1,264.47
$1,444.25
$270.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$707.82
$803.34
$904.56
$1,264.12
$1,920.96
$978.55
$1,074.07
$1,175.29
$1,534.85
$1,249.28
$1,344.80
$1,446.02
$1,805.58
$1,520.01
$1,615.53
$1,716.75
$2,076.31
$270.73
Toc - Plan #90 SummaCare
Silver

(HMO) SummaCare Silver 6000 with SCConnect Network and 3 Free PCP Visits

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$7,600 $15,200 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
$307.10
$348.55
$392.46
$548.46
$833.44
$542.02
$583.47
$627.38
$783.38
$776.94
$818.39
$862.30
$1,018.30
$1,011.86
$1,053.31
$1,097.22
$1,253.22
$234.92
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$614.20
$697.10
$784.92
$1,096.92
$1,666.88
$849.12
$932.02
$1,019.84
$1,331.84
$1,084.04
$1,166.94
$1,254.76
$1,566.76
$1,318.96
$1,401.86
$1,489.68
$1,801.68
$234.92
Toc - Plan #91 SummaCare
Bronze

(HMO) SummaCare Standard Bronze with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$242.29
$274.98
$309.63
$432.71
$657.54
$427.63
$460.32
$494.97
$618.05
$612.97
$645.66
$680.31
$803.39
$798.31
$831.00
$865.65
$988.73
$185.34
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$484.58
$549.96
$619.26
$865.42
$1,315.08
$669.92
$735.30
$804.60
$1,050.76
$855.26
$920.64
$989.94
$1,236.10
$1,040.60
$1,105.98
$1,175.28
$1,421.44
$185.34
Toc - Plan #92 SummaCare
Bronze

(HMO) SummaCare Bronze 8000 with SCConnect Network and Travel Assistance + Adult Vision Exam

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$239.71
$272.06
$306.34
$428.11
$650.56
$423.08
$455.43
$489.71
$611.48
$606.45
$638.80
$673.08
$794.85
$789.82
$822.17
$856.45
$978.22
$183.37
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$479.42
$544.12
$612.68
$856.22
$1,301.12
$662.79
$727.49
$796.05
$1,039.59
$846.16
$910.86
$979.42
$1,222.96
$1,029.53
$1,094.23
$1,162.79
$1,406.33
$183.37
Toc - Plan #93 SummaCare
Silver

(HMO) SummaCare Standard Silver with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$314.04
$356.43
$401.33
$560.86
$852.29
$554.28
$596.67
$641.57
$801.10
$794.52
$836.91
$881.81
$1,041.34
$1,034.76
$1,077.15
$1,122.05
$1,281.58
$240.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$628.08
$712.86
$802.66
$1,121.72
$1,704.58
$868.32
$953.10
$1,042.90
$1,361.96
$1,108.56
$1,193.34
$1,283.14
$1,602.20
$1,348.80
$1,433.58
$1,523.38
$1,842.44
$240.24
Toc - Plan #94 SummaCare
Gold

(HMO) SummaCare Standard Gold with SCConnect Network

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-996-8675

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$392.49
$445.46
$501.59
$700.96
$1,065.18
$692.73
$745.70
$801.83
$1,001.20
$992.97
$1,045.94
$1,102.07
$1,301.44
$1,293.21
$1,346.18
$1,402.31
$1,601.68
$300.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$784.98
$890.92
$1,003.18
$1,401.92
$2,130.36
$1,085.22
$1,191.16
$1,303.42
$1,702.16
$1,385.46
$1,491.40
$1,603.66
$2,002.40
$1,685.70
$1,791.64
$1,903.90
$2,302.64
$300.24

ADVERTISEMENT

CareSource

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

Toc - Plan #95 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
$328.26
$372.57
$419.52
$586.27
$890.90
$579.38
$623.69
$670.64
$837.39
$830.50
$874.81
$921.76
$1,088.51
$1,081.62
$1,125.93
$1,172.88
$1,339.63
$251.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$656.52
$745.14
$839.04
$1,172.54
$1,781.80
$907.64
$996.26
$1,090.16
$1,423.66
$1,158.76
$1,247.38
$1,341.28
$1,674.78
$1,409.88
$1,498.50
$1,592.40
$1,925.90
$251.12
Toc - Plan #96 CareSource
Gold

(HMO) CareSource Marketplace Gold

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$464.35
$527.04
$593.44
$829.33
$1,260.25
$819.58
$882.27
$948.67
$1,184.56
$1,174.81
$1,237.50
$1,303.90
$1,539.79
$1,530.04
$1,592.73
$1,659.13
$1,895.02
$355.23
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$928.70
$1,054.08
$1,186.88
$1,658.66
$2,520.50
$1,283.93
$1,409.31
$1,542.11
$2,013.89
$1,639.16
$1,764.54
$1,897.34
$2,369.12
$1,994.39
$2,119.77
$2,252.57
$2,724.35
$355.23
Toc - Plan #97 CareSource
Silver

(HMO) CareSource Marketplace Standard Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$335.27
$380.52
$428.47
$598.78
$909.91
$591.75
$637.00
$684.95
$855.26
$848.23
$893.48
$941.43
$1,111.74
$1,104.71
$1,149.96
$1,197.91
$1,368.22
$256.48
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$670.54
$761.04
$856.94
$1,197.56
$1,819.82
$927.02
$1,017.52
$1,113.42
$1,454.04
$1,183.50
$1,274.00
$1,369.90
$1,710.52
$1,439.98
$1,530.48
$1,626.38
$1,967.00
$256.48
Toc - Plan #98 CareSource
Expanded Bronze

(HMO) CareSource Marketplace Bronze First

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$243.47
$276.33
$311.15
$434.83
$660.77
$429.72
$462.58
$497.40
$621.08
$615.97
$648.83
$683.65
$807.33
$802.22
$835.08
$869.90
$993.58
$186.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$486.94
$552.66
$622.30
$869.66
$1,321.54
$673.19
$738.91
$808.55
$1,055.91
$859.44
$925.16
$994.80
$1,242.16
$1,045.69
$1,111.41
$1,181.05
$1,428.41
$186.25
Toc - Plan #99 CareSource
Bronze

(HMO) CareSource Marketplace Bronze

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$238.16
$270.30
$304.36
$425.34
$646.35
$420.35
$452.49
$486.55
$607.53
$602.54
$634.68
$668.74
$789.72
$784.73
$816.87
$850.93
$971.91
$182.19
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$476.32
$540.60
$608.72
$850.68
$1,292.70
$658.51
$722.79
$790.91
$1,032.87
$840.70
$904.98
$973.10
$1,215.06
$1,022.89
$1,087.17
$1,155.29
$1,397.25
$182.19
Toc - Plan #100 CareSource
Silver

(HMO) CareSource Marketplace Essential Silver

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$375.33
$425.99
$479.67
$670.33
$1,018.63
$662.45
$713.11
$766.79
$957.45
$949.57
$1,000.23
$1,053.91
$1,244.57
$1,236.69
$1,287.35
$1,341.03
$1,531.69
$287.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$750.66
$851.98
$959.34
$1,340.66
$2,037.26
$1,037.78
$1,139.10
$1,246.46
$1,627.78
$1,324.90
$1,426.22
$1,533.58
$1,914.90
$1,612.02
$1,713.34
$1,820.70
$2,202.02
$287.12
Toc - Plan #101 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
$333.54
$378.57
$426.26
$595.70
$905.23
$588.70
$633.73
$681.42
$850.86
$843.86
$888.89
$936.58
$1,106.02
$1,099.02
$1,144.05
$1,191.74
$1,361.18
$255.16
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$667.08
$757.14
$852.52
$1,191.40
$1,810.46
$922.24
$1,012.30
$1,107.68
$1,446.56
$1,177.40
$1,267.46
$1,362.84
$1,701.72
$1,432.56
$1,522.62
$1,618.00
$1,956.88
$255.16
Toc - Plan #102 CareSource
Gold

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$470.75
$534.30
$601.61
$840.75
$1,277.60
$830.87
$894.42
$961.73
$1,200.87
$1,190.99
$1,254.54
$1,321.85
$1,560.99
$1,551.11
$1,614.66
$1,681.97
$1,921.11
$360.12
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$941.50
$1,068.60
$1,203.22
$1,681.50
$2,555.20
$1,301.62
$1,428.72
$1,563.34
$2,041.62
$1,661.74
$1,788.84
$1,923.46
$2,401.74
$2,021.86
$2,148.96
$2,283.58
$2,761.86
$360.12
Toc - Plan #103 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$340.54
$386.51
$435.20
$608.20
$924.21
$601.05
$647.02
$695.71
$868.71
$861.56
$907.53
$956.22
$1,129.22
$1,122.07
$1,168.04
$1,216.73
$1,389.73
$260.51
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$681.08
$773.02
$870.40
$1,216.40
$1,848.42
$941.59
$1,033.53
$1,130.91
$1,476.91
$1,202.10
$1,294.04
$1,391.42
$1,737.42
$1,462.61
$1,554.55
$1,651.93
$1,997.93
$260.51
Toc - Plan #104 CareSource
Expanded Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$248.20
$281.70
$317.19
$443.27
$673.60
$438.07
$471.57
$507.06
$633.14
$627.94
$661.44
$696.93
$823.01
$817.81
$851.31
$886.80
$1,012.88
$189.87
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$496.40
$563.40
$634.38
$886.54
$1,347.20
$686.27
$753.27
$824.25
$1,076.41
$876.14
$943.14
$1,014.12
$1,266.28
$1,066.01
$1,133.01
$1,203.99
$1,456.15
$189.87
Toc - Plan #105 CareSource
Bronze

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$242.61
$275.36
$310.05
$433.30
$658.44
$428.20
$460.95
$495.64
$618.89
$613.79
$646.54
$681.23
$804.48
$799.38
$832.13
$866.82
$990.07
$185.59
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$485.22
$550.72
$620.10
$866.60
$1,316.88
$670.81
$736.31
$805.69
$1,052.19
$856.40
$921.90
$991.28
$1,237.78
$1,041.99
$1,107.49
$1,176.87
$1,423.37
$185.59
Toc - Plan #106 CareSource
Silver

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

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$380.43
$431.78
$486.18
$679.44
$1,032.47
$671.45
$722.80
$777.20
$970.46
$962.47
$1,013.82
$1,068.22
$1,261.48
$1,253.49
$1,304.84
$1,359.24
$1,552.50
$291.02
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$760.86
$863.56
$972.36
$1,358.88
$2,064.94
$1,051.88
$1,154.58
$1,263.38
$1,649.90
$1,342.90
$1,445.60
$1,554.40
$1,940.92
$1,633.92
$1,736.62
$1,845.42
$2,231.94
$291.02

ADVERTISEMENT

MedMutual

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

Toc - Plan #107 MedMutual
Silver

(HMO) Market HMO 3500 - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.64
$472.89
$532.46
$744.12
$1,130.76
$735.37
$791.62
$851.19
$1,062.85
$1,054.10
$1,110.35
$1,169.92
$1,381.58
$1,372.83
$1,429.08
$1,488.65
$1,700.31
$318.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833.28
$945.78
$1,064.92
$1,488.24
$2,261.52
$1,152.01
$1,264.51
$1,383.65
$1,806.97
$1,470.74
$1,583.24
$1,702.38
$2,125.70
$1,789.47
$1,901.97
$2,021.11
$2,444.43
$318.73
Toc - Plan #108 MedMutual
Silver

(HMO) Market HMO 4000 HSA - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$416.64
$472.89
$532.46
$744.12
$1,130.76
$735.37
$791.62
$851.19
$1,062.85
$1,054.10
$1,110.35
$1,169.92
$1,381.58
$1,372.83
$1,429.08
$1,488.65
$1,700.31
$318.73
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$833.28
$945.78
$1,064.92
$1,488.24
$2,261.52
$1,152.01
$1,264.51
$1,383.65
$1,806.97
$1,470.74
$1,583.24
$1,702.38
$2,125.70
$1,789.47
$1,901.97
$2,021.11
$2,444.43
$318.73
Toc - Plan #109 MedMutual
Expanded Bronze

(HMO) Market HMO 7000 HSA - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$317.09
$359.90
$405.25
$566.33
$860.59
$559.67
$602.48
$647.83
$808.91
$802.25
$845.06
$890.41
$1,051.49
$1,044.83
$1,087.64
$1,132.99
$1,294.07
$242.58
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$634.18
$719.80
$810.50
$1,132.66
$1,721.18
$876.76
$962.38
$1,053.08
$1,375.24
$1,119.34
$1,204.96
$1,295.66
$1,617.82
$1,361.92
$1,447.54
$1,538.24
$1,860.40
$242.58
Toc - Plan #110 MedMutual
Bronze

(HMO) Market HMO 9100 - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$299.95
$340.45
$383.34
$535.72
$814.07
$529.41
$569.91
$612.80
$765.18
$758.87
$799.37
$842.26
$994.64
$988.33
$1,028.83
$1,071.72
$1,224.10
$229.46
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$599.90
$680.90
$766.68
$1,071.44
$1,628.14
$829.36
$910.36
$996.14
$1,300.90
$1,058.82
$1,139.82
$1,225.60
$1,530.36
$1,288.28
$1,369.28
$1,455.06
$1,759.82
$229.46
Toc - Plan #111 MedMutual
Catastrophic

(HMO) Market HMO Young Adult Essentials - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$198.10
$224.85
$253.17
$353.81
$537.65
$349.65
$376.40
$404.72
$505.36
$501.20
$527.95
$556.27
$656.91
$652.75
$679.50
$707.82
$808.46
$151.55
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$396.20
$449.70
$506.34
$707.62
$1,075.30
$547.75
$601.25
$657.89
$859.17
$699.30
$752.80
$809.44
$1,010.72
$850.85
$904.35
$960.99
$1,162.27
$151.55
Toc - Plan #112 MedMutual
Silver

(HMO) Market HMO 6500 - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$415.32
$471.39
$530.78
$741.76
$1,127.18
$733.04
$789.11
$848.50
$1,059.48
$1,050.76
$1,106.83
$1,166.22
$1,377.20
$1,368.48
$1,424.55
$1,483.94
$1,694.92
$317.72
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$830.64
$942.78
$1,061.56
$1,483.52
$2,254.36
$1,148.36
$1,260.50
$1,379.28
$1,801.24
$1,466.08
$1,578.22
$1,697.00
$2,118.96
$1,783.80
$1,895.94
$2,014.72
$2,436.68
$317.72
Toc - Plan #113 MedMutual
Expanded Bronze

(HMO) Market HMO Select Bronze - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$357.97
$406.29
$457.48
$639.33
$971.52
$631.81
$680.13
$731.32
$913.17
$905.65
$953.97
$1,005.16
$1,187.01
$1,179.49
$1,227.81
$1,279.00
$1,460.85
$273.84
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$715.94
$812.58
$914.96
$1,278.66
$1,943.04
$989.78
$1,086.42
$1,188.80
$1,552.50
$1,263.62
$1,360.26
$1,462.64
$1,826.34
$1,537.46
$1,634.10
$1,736.48
$2,100.18
$273.84
Toc - Plan #114 MedMutual
Silver

(HMO) Market HMO Select Silver - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$447.95
$508.43
$572.48
$800.04
$1,215.74
$790.63
$851.11
$915.16
$1,142.72
$1,133.31
$1,193.79
$1,257.84
$1,485.40
$1,475.99
$1,536.47
$1,600.52
$1,828.08
$342.68
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$895.90
$1,016.86
$1,144.96
$1,600.08
$2,431.48
$1,238.58
$1,359.54
$1,487.64
$1,942.76
$1,581.26
$1,702.22
$1,830.32
$2,285.44
$1,923.94
$2,044.90
$2,173.00
$2,628.12
$342.68
Toc - Plan #115 MedMutual
Expanded Bronze

(HMO) Market HMO 8000 - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.91
$344.94
$388.40
$542.78
$824.81
$536.40
$577.43
$620.89
$775.27
$768.89
$809.92
$853.38
$1,007.76
$1,001.38
$1,042.41
$1,085.87
$1,240.25
$232.49
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607.82
$689.88
$776.80
$1,085.56
$1,649.62
$840.31
$922.37
$1,009.29
$1,318.05
$1,072.80
$1,154.86
$1,241.78
$1,550.54
$1,305.29
$1,387.35
$1,474.27
$1,783.03
$232.49
Toc - Plan #116 MedMutual
Gold

(HMO) Market HMO 2500 - Northern Ohio

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

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$5,750 $11,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$554.75
$629.64
$708.97
$990.78
$1,505.59
$979.13
$1,054.02
$1,133.35
$1,415.16
$1,403.51
$1,478.40
$1,557.73
$1,839.54
$1,827.89
$1,902.78
$1,982.11
$2,263.92
$424.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,109.50
$1,259.28
$1,417.94
$1,981.56
$3,011.18
$1,533.88
$1,683.66
$1,842.32
$2,405.94
$1,958.26
$2,108.04
$2,266.70
$2,830.32
$2,382.64
$2,532.42
$2,691.08
$3,254.70
$424.38
Toc - Plan #117 MedMutual
Gold

(HMO) Market HMO Standard Gold - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$533.65
$605.70
$682.01
$953.11
$1,448.34
$941.90
$1,013.95
$1,090.26
$1,361.36
$1,350.15
$1,422.20
$1,498.51
$1,769.61
$1,758.40
$1,830.45
$1,906.76
$2,177.86
$408.25
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$1,067.30
$1,211.40
$1,364.02
$1,906.22
$2,896.68
$1,475.55
$1,619.65
$1,772.27
$2,314.47
$1,883.80
$2,027.90
$2,180.52
$2,722.72
$2,292.05
$2,436.15
$2,588.77
$3,130.97
$408.25
Toc - Plan #118 MedMutual
Silver

(HMO) Market HMO Standard Silver - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$413.34
$469.14
$528.25
$738.23
$1,121.81
$729.55
$785.35
$844.46
$1,054.44
$1,045.76
$1,101.56
$1,160.67
$1,370.65
$1,361.97
$1,417.77
$1,476.88
$1,686.86
$316.21
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$826.68
$938.28
$1,056.50
$1,476.46
$2,243.62
$1,142.89
$1,254.49
$1,372.71
$1,792.67
$1,459.10
$1,570.70
$1,688.92
$2,108.88
$1,775.31
$1,886.91
$2,005.13
$2,425.09
$316.21
Toc - Plan #119 MedMutual
Expanded Bronze

(HMO) Market HMO Standard Expanded Bronze - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$324.68
$368.51
$414.94
$579.87
$881.17
$573.06
$616.89
$663.32
$828.25
$821.44
$865.27
$911.70
$1,076.63
$1,069.82
$1,113.65
$1,160.08
$1,325.01
$248.38
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$649.36
$737.02
$829.88
$1,159.74
$1,762.34
$897.74
$985.40
$1,078.26
$1,408.12
$1,146.12
$1,233.78
$1,326.64
$1,656.50
$1,394.50
$1,482.16
$1,575.02
$1,904.88
$248.38
Toc - Plan #120 MedMutual
Bronze

(HMO) Market HMO Standard Bronze - Northern Ohio

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

Annual Out of Pocket Expenses:

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

Monthly Premiums:

[show premiums]
Age Individual
Individual
1 Child
Individual
2 Children
Individual
3+ Children
Child
0-14
21
30
40
50
60
$303.58
$344.56
$387.97
$542.19
$823.92
$535.82
$576.80
$620.21
$774.43
$768.06
$809.04
$852.45
$1,006.67
$1,000.30
$1,041.28
$1,084.69
$1,238.91
$232.24
Age Couple
Couple
1 Child
Couple
2 Chidren
Couple
3+ Children
Child
0-14
21
30
40
50
60
$607.16
$689.12
$775.94
$1,084.38
$1,647.84
$839.40
$921.36
$1,008.18
$1,316.62
$1,071.64
$1,153.60
$1,240.42
$1,548.86
$1,303.88
$1,385.84
$1,472.66
$1,781.10
$232.24

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

Portage County is in “Rating Area 12” of Ohio.

Currently, there are 120 plans offered in Rating Area 12.

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